{"id":186,"date":"2020-08-13T16:06:59","date_gmt":"2020-08-13T16:06:59","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=186"},"modified":"2021-05-09T20:49:30","modified_gmt":"2021-05-09T20:49:30","slug":"44-hirsutism-and-virilization","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/overview\/44-hirsutism-and-virilization\/","title":{"rendered":"44. Hirsutism and Virilization"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/8IPnPOs3c0s\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration = 7:52<\/p>\n<input type='hidden' bg_collapse_expand='69e9b5801c82f3012262200' value='69e9b5801c82f3012262200'><input type='hidden' id='bg-show-more-text-69e9b5801c82f3012262200' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b5801c82f3012262200' value='Hide Transcript'><button id='bg-showmore-action-69e9b5801c82f3012262200' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b5801c82f3012262200' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic number 44<br \/>\n00:02<br \/>\nhirsutism and viralization hirsutism<br \/>\n00:05<br \/>\noccurs in 7% of women it has an<br \/>\n00:08<br \/>\nestimated economic burden of 600 million<br \/>\n00:10<br \/>\ndollars annually hirsutism and<br \/>\n00:13<br \/>\nviralization can cause significant<br \/>\n00:15<br \/>\nemotional distress for our patients the<br \/>\n00:17<br \/>\nobjectives are to recognize normal<br \/>\n00:19<br \/>\nvariations and abnormalities in<br \/>\n00:20<br \/>\nsecondary sexual characteristics to<br \/>\n00:23<br \/>\ndefine hirsutism and viralization<br \/>\n00:25<br \/>\ndescribe the pathophysiology and<br \/>\n00:27<br \/>\nidentify ideologies of hirsutism<br \/>\n00:29<br \/>\ndescribe the steps in the evaluation and<br \/>\n00:31<br \/>\ninitial management options for hirsutism<br \/>\n00:33<br \/>\nand realization and finally describe how<br \/>\n00:36<br \/>\nhirsutism and viralization are<br \/>\n00:38<br \/>\nmanifested in other medical disorders<br \/>\n00:39<br \/>\nlet&#8217;s start with some basic definitions<br \/>\n00:41<br \/>\nof hirsutism and viralization hirsutism<br \/>\n00:44<br \/>\nis accessed terminal hair in a male<br \/>\n00:47<br \/>\npattern of distribution terminal hair is<br \/>\n00:50<br \/>\ndark and coarse versus vellus hair which<br \/>\n00:52<br \/>\nis soft downy and fine prior to puberty<br \/>\n00:56<br \/>\nall hair is vellus when androgen levels<br \/>\n00:58<br \/>\nrise during puberty Bella&#8217;s follicles<br \/>\n01:01<br \/>\nand specific areas of the body develop<br \/>\n01:03<br \/>\ninto terminal hairs with hirsutism<br \/>\n01:05<br \/>\nterminal hair first appears on the lower<br \/>\n01:07<br \/>\nabdomen around the nipples chin and<br \/>\n01:09<br \/>\nupper lip pictorial scale such as the<br \/>\n01:12<br \/>\npheromone Galway scale have been created<br \/>\n01:14<br \/>\nto help objectify normal versus abnormal<br \/>\n01:17<br \/>\namounts of hair growth<br \/>\n01:18<br \/>\neach of the nine body areas most<br \/>\n01:21<br \/>\nsensitive to androgen are assigned a<br \/>\n01:22<br \/>\nscore from 0 of no hair to 4 of frankly<br \/>\n01:25<br \/>\nvirile these are some to provide a<br \/>\n01:28<br \/>\nhormonal hirsutism score it is important<br \/>\n01:31<br \/>\nto note that different ethnic groups<br \/>\n01:32<br \/>\nwill have different amounts of normal<br \/>\n01:34<br \/>\nhair growth and distributions some<br \/>\n01:36<br \/>\nexperts have recommended using the term<br \/>\n01:37<br \/>\npatient important hirsutism to indicate<br \/>\n01:40<br \/>\nsymptoms that are causing patient<br \/>\n01:41<br \/>\ndistress hirsutism causes 50% are<br \/>\n01:45<br \/>\nidiopathic which will be often<br \/>\n01:47<br \/>\nconstitutional or familial polycystic<br \/>\n01:49<br \/>\novarian syndrome or PCOS is the most<br \/>\n01:52<br \/>\ncommon pathological cause other causes<br \/>\n01:54<br \/>\ninclude congenital adrenal hyperplasia<br \/>\n01:56<br \/>\nviralization refers to masculinization<br \/>\n01:59<br \/>\nof a woman woman will present with<br \/>\n02:01<br \/>\nenlargement of the clitoris temporal<br \/>\n02:03<br \/>\nbalding deepening of the voice<br \/>\n02:04<br \/>\ninvolution of the breasts and remodeling<br \/>\n02:06<br \/>\nof the limb shoulder girdle let&#8217;s now<br \/>\n02:09<br \/>\nmove to androgen production women there<br \/>\n02:12<br \/>\nare three primary androgens that are<br \/>\n02:13<br \/>\nPurdue<br \/>\n02:14<br \/>\nand women dehydroepiandrosterone or DHEA<br \/>\n02:17<br \/>\nandrostenone and testosterone these are<br \/>\n02:20<br \/>\nproduced by the adrenal glands ovaries<br \/>\n02:22<br \/>\nand peripheral tissues DHEA is primarily<br \/>\n02:26<br \/>\nsecreted by the adrenal glands and<br \/>\n02:28<br \/>\novaries let&#8217;s very quickly revisit the<br \/>\n02:31<br \/>\ncortisol synthesis pathway remember that<br \/>\n02:33<br \/>\nin the adrenal gland cholesterol is<br \/>\n02:35<br \/>\nconverted to aldosterone and cortisol<br \/>\n02:37<br \/>\nDHEA is one of the precursor hormones in<br \/>\n02:40<br \/>\nthis pathway we&#8217;ll go back to this<br \/>\n02:41<br \/>\ncortisol synthesis pathway later in the<br \/>\n02:43<br \/>\nvideo<br \/>\n02:43<br \/>\ngoing back to our three primary antigens<br \/>\n02:46<br \/>\nAndres team diode is equally secreted by<br \/>\n02:49<br \/>\nthe adrenal glands and the ovaries<br \/>\n02:50<br \/>\ntestosterone is a potent androgen that<br \/>\n02:53<br \/>\nare secreted from the adrenal glands<br \/>\n02:54<br \/>\novaries and from peripheral tissues<br \/>\n02:57<br \/>\ntestosterone is the primary androgen<br \/>\n02:59<br \/>\nthat causes increased hair growth and<br \/>\n03:01<br \/>\nphysical changes associated with varial<br \/>\n03:02<br \/>\nis asian let&#8217;s now move on to etiology<br \/>\n03:05<br \/>\nx&#8217; for androgen excess polycystic<br \/>\n03:08<br \/>\novarian syndrome or PCOS is the most<br \/>\n03:10<br \/>\ncommon pathological cause for women<br \/>\n03:12<br \/>\npresenting with hirsutism remember that<br \/>\n03:14<br \/>\nthis is a clinical diagnosis the<br \/>\n03:16<br \/>\ndiagnosis involves menstrual<br \/>\n03:18<br \/>\nirregularity clinical or biochemical<br \/>\n03:20<br \/>\nsigns of hyperandrogenism polycystic<br \/>\n03:24<br \/>\novaries on ultrasound here is a classic<br \/>\n03:26<br \/>\npolycystic ovary with the small<br \/>\n03:28<br \/>\nfollicles around the periphery of the<br \/>\n03:30<br \/>\novary measuring less than 9 millimeters<br \/>\n03:32<br \/>\nthis is referred to as the ring of<br \/>\n03:34<br \/>\npearls different organizations have<br \/>\n03:37<br \/>\ndifferent criteria for the diagnosis of<br \/>\n03:38<br \/>\nPCOS but most groups endorse the<br \/>\n03:40<br \/>\ndiagnosis can be made if a patient has<br \/>\n03:42<br \/>\ntwo out of three of these criteria there<br \/>\n03:45<br \/>\nshould also be exclusion of other causes<br \/>\n03:47<br \/>\nof androgen excess or ovulatory<br \/>\n03:49<br \/>\ndisorders polycystic ovarian syndrome is<br \/>\n03:51<br \/>\noften associated with obesity and many<br \/>\n03:54<br \/>\nwomen will describe at the acquisition<br \/>\n03:55<br \/>\nof body fat coincides with the onset of<br \/>\n03:57<br \/>\nPCOS symptoms women will describe<br \/>\n03:59<br \/>\nsituations such as changing to a<br \/>\n04:01<br \/>\nsedentary job gaining weight in college<br \/>\n04:03<br \/>\nor having a baby<br \/>\n04:04<br \/>\nwhy is PCOS related to obesity remember<br \/>\n04:08<br \/>\nthat the pituitary gland secretes LH<br \/>\n04:10<br \/>\nwhich stimulates the collodial cells in<br \/>\n04:12<br \/>\nthe ovary to produce androstenone<br \/>\n04:13<br \/>\nin adipose tissue this and resting<br \/>\n04:16<br \/>\nDioner is converted to ester own which<br \/>\n04:18<br \/>\nis a weak estrogen which positively<br \/>\n04:20<br \/>\nstimulates the pituitary to secrete more<br \/>\n04:23<br \/>\nLH the increased la stimulation leads to<br \/>\n04:26<br \/>\nmore<br \/>\n04:27<br \/>\n\u00e9and I own the androstenone is converted<br \/>\n04:30<br \/>\ntestosterone which leads to acne and<br \/>\n04:31<br \/>\nhirsutism I think the important thing to<br \/>\n04:33<br \/>\nremember is that Esther Owen is a<br \/>\n04:35<br \/>\npositive stimulator of LH let&#8217;s move now<br \/>\n04:39<br \/>\nto more uncommon causes of<br \/>\n04:41<br \/>\nhyperandrogenism congenital adrenal<br \/>\n04:43<br \/>\nhyperplasia accounts for 1.5 to 2.5<br \/>\n04:45<br \/>\npercent of women with hyperandrogenism<br \/>\n04:47<br \/>\nthese enzyme deficiency disorders caused<br \/>\n04:50<br \/>\nsubstrate access which result in<br \/>\n04:51<br \/>\nandrogen excess here again is our<br \/>\n04:53<br \/>\nsimplified version of the cortisol<br \/>\n04:55<br \/>\nsynthesis pathway cholesterol is<br \/>\n04:57<br \/>\nconverted to aldosterone and cortisol<br \/>\n05:00<br \/>\na21 hydroxylase deficiency or 11 beta<br \/>\n05:03<br \/>\nhydroxylase deficiency will lead to<br \/>\n05:05<br \/>\nincreased levels of DHEA for this is one<br \/>\n05:07<br \/>\nof the substrates in the pathway a very<br \/>\n05:10<br \/>\nneoplasms are rare causes of high<br \/>\n05:11<br \/>\nandrogen levels accounting for<br \/>\n05:13<br \/>\napproximately 0.2 percent of women with<br \/>\n05:15<br \/>\nhyperandrogenism sertoli lytic tumors<br \/>\n05:18<br \/>\nare a very neoplasms that secrete<br \/>\n05:20<br \/>\ntestosterone these tumors constitute<br \/>\n05:22<br \/>\n0.4% of ovarian tumors they usually<br \/>\n05:25<br \/>\noccur in women between the ages of 20<br \/>\n05:27<br \/>\nand 30 and women will describe rapid<br \/>\n05:29<br \/>\nonset of acne hirsutism amenorrhea and v<br \/>\n05:32<br \/>\nrealization other medical conditions to<br \/>\n05:35<br \/>\ninclude on the differential diagnosis of<br \/>\n05:37<br \/>\nhigh androgen levels include Cushing&#8217;s<br \/>\n05:38<br \/>\nsyndrome hyperprolactinemia acromegaly<br \/>\n05:41<br \/>\nand thyroid dysfunction let&#8217;s move now<br \/>\n05:44<br \/>\nto evaluation of hirsutism first start<br \/>\n05:47<br \/>\nwith a careful history assess how<br \/>\n05:49<br \/>\nrapidly the symptoms have developed for<br \/>\n05:51<br \/>\nour rapid pace of development should<br \/>\n05:53<br \/>\nraise concerns about an androgen<br \/>\n05:54<br \/>\nsecreting neoplasm the high frequency of<br \/>\n05:57<br \/>\npolycystic ovarian syndrome warrants<br \/>\n05:58<br \/>\nattention to menstrual irregularity ask<br \/>\n06:00<br \/>\nabout viralization symptoms such as<br \/>\n06:03<br \/>\nvoice changes and ask about the hair<br \/>\n06:05<br \/>\npatterns of family members remember to<br \/>\n06:08<br \/>\nask about medications and supplements as<br \/>\n06:10<br \/>\nwell on physical examination a faraman<br \/>\n06:13<br \/>\nGallwey score should be calculated and<br \/>\n06:14<br \/>\nmake sure to perform an abdominal and<br \/>\n06:17<br \/>\nbimanual examination to assess for<br \/>\n06:18<br \/>\nabdominal and pelvic tumors and a<br \/>\n06:20<br \/>\ncareful skin examination to check for<br \/>\n06:22<br \/>\nacne striae or acanthosis nigricans in<br \/>\n06:25<br \/>\naddition make sure to look for a<br \/>\n06:27<br \/>\nrealization sign such as enlargement of<br \/>\n06:29<br \/>\nthe clitoris temporal balding or<br \/>\n06:31<br \/>\ninvolution of the breasts the history<br \/>\n06:33<br \/>\nand physical examination can help you<br \/>\n06:35<br \/>\ndetermine if the patient is low moderate<br \/>\n06:37<br \/>\nor high risk of having an androgen<br \/>\n06:39<br \/>\nsecreting tumor<br \/>\n06:41<br \/>\nfor a low-risk patient therapy can be<br \/>\n06:43<br \/>\ninitiated with a six-month trial of<br \/>\n06:44<br \/>\nhormonal therapy such as oral<br \/>\n06:46<br \/>\ncontraception for moderate to high risk<br \/>\n06:48<br \/>\npatients hormonal evaluation and imaging<br \/>\n06:51<br \/>\nshould be ordered further workup to<br \/>\n06:53<br \/>\nconsider includes thyroid function tests<br \/>\n06:55<br \/>\nprolactin and 17 hydroxy progesterone<br \/>\n06:57<br \/>\nlevels for further evaluation for other<br \/>\n06:59<br \/>\nmedical ideologies of hyperandrogenism<br \/>\n07:02<br \/>\nlet&#8217;s conclude by discussing treatment<br \/>\n07:04<br \/>\nhair removal methods include bleaching<br \/>\n07:07<br \/>\nshaving epilation which is waxing or<br \/>\n07:10<br \/>\nplucking electrolysis or laser<br \/>\n07:12<br \/>\npharmacologic measures include a floor<br \/>\n07:15<br \/>\nnathan hydrochloride which is a cream<br \/>\n07:16<br \/>\nwhich has recently been approved for the<br \/>\n07:18<br \/>\ntreatment of facial hirsutism oral<br \/>\n07:20<br \/>\ncontraception works by suppressing<br \/>\n07:22<br \/>\nplasma testosterone levels by inhibiting<br \/>\n07:24<br \/>\novarian function and finally the<br \/>\n07:27<br \/>\nanti-androgen medications of<br \/>\n07:28<br \/>\nspironolactone and finasteride this<br \/>\n07:31<br \/>\nconcludes the app go video on hirsutism<br \/>\n07:33<br \/>\nand viralization we&#8217;ve defined important<br \/>\n07:35<br \/>\nterms described pathophysiology and<br \/>\n07:37<br \/>\ndescribed steps in the evaluation and<br \/>\n07:39<br \/>\ninitial management of these conditions<br \/>\n07:46<br \/>\nOh<\/p>\n<p><\/div>\n<hr \/>\n","protected":false},"excerpt":{"rendered":"<p>Duration = 7:52<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":46,"menu_order":44,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-186","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/186","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=186"}],"version-history":[{"count":1,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/186\/revisions"}],"predecessor-version":[{"id":2849,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/186\/revisions\/2849"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=186"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}