Abnormal Hair Growth of hairs u in women

Hirsutism (Androgen Excess Syndrome)

Hirsutism is defined as presence of excessive amount of coarse hair of male distribution seen in a female, causing unacceptable cosmetic concern. Such areas include face, chest, abdomen, thighs and back, etc. A semi-quantitative analysis of hirsutism can be made according to Ferriman D and Gallway JD Nine body areas of hormone sensitivity for hair growth are graded from 1 to 4 (minimal hair to frank virilization) and ultimately the grades in each of these areas are summed together. If the score is more that 8 it indicates hirsutism. The amount of hair growth differs among various ethnic and genetic groups. It is much decreased in Orientals, for example the Chinese and increased in Mediterranean’s. Hirsutism must not be confused with virilization. Hirsutism does not always signify major pathology or serious endocrine disturbance. In several hirsute women the disturbance is due to excessive activity of  5 alpha reductase in the skin. The enzyme releases dihydrotestosterone (DHT) from testosterone carried along with sex hormone binding globulin (SHBG). Hirsutism may also occur due to excessive sensitivity of hair follicles to DHT. This kind of sensitivity is known as constitutional Hirsutism of no serious pathological significance except that it is unacceptable to the patient. But hirsutism can also be the earliest sign of a serious disorder like an androgen producing tumor. Hirsutism of recent organ must be viewed with suspicion particularly if the degree of hirsutism is increasing with time. This is due to androgen levels increasing in the system caused probably by neoplasm. Frank virilization characterized by clitoromegaly deepening of voice and alopecia may all follow this kind of hirsutism.

Androgen excess syndrome can occur due to several causes. Sixty to eighty percent of these women are said to be having PCO syndrome. The syndrome is seen in 5 percent of general population of reproductive age group. They may not all be infertile nor will they all be hirsute. Forty to sixty percent of them are obese 50 to 90 percent are oligomenorrheic and 50 to 70 percent of them may have hirsutism of low or high order. The high level of androgens and cyclical estrogen production causes disruption of HT-HP gonadal axis resulting in elevated LH-FSH ratio. Many women with PCO have metabolic disturbances some showing insulin resistance and compensatory hyperinsulinemia with or without abnormal glucose tolerance (GT). Some of the women with PCOS have dyslipidemia caused both by high levels of insulin and androgens. Hirsutism caused by hyperinsulinemia may show at least a partial response to administration of insulin sensitizing agents like metformin.

HAIR –AN Syndrome: This syndrome connotes a group of symptoms, which include hyperandrogenism, insulin resistance and acanthosis nigricans. In this syndrome, the predominant feature is hyperinsulinemia due to insulin resistance. The mitogenic action of insulin on the basal cells of epididymis causes a velvety hyperpigmented patches or streaks in skin creases. Although PCOS is also along with HAIR-AN syndrome the degree of metabolic disturbance seen in HAIR-AN syndrome can be of a much higher order.

Congenital Adrenal Hyperplasia(CAH) is a disorder caused by deficiency of 21 hydroxylase enzyme

Cushing syndrome: The clinical presentation of this syndrome is primarily that of abnormal fat deposition of the body, thinning of skin with striae, glucose intolerance, osteoporosis, muscle weakness along with all the other signs of PCO syndrome.

Androgenic tumors: Androgens producing tumors of ovary or adrenal gland can cause hirsutism. But they are rare. This should be suspected when the onset of symptoms are sudden and the progression is rapid. Hormone producing tumors are usually of low malignancy. When signs of excessive secretions of cortisol are present associated with virilization one must look for adrenal tumors or secondary androgenism caused by  PCO syndrome, etc. Unlike PCO or Cushingoid pathology, virilising  ovarian tumors exhibit the form of sudden onset of hyper-androgenism with frank virilization. These include Sertoli-Leydig cells and lipoid cell tumors.