Hirsuitism which hormones to order

Which hormone to test in  case of hirsuitism?

A).Total testosterone, SHBG, and albumin level should ideally measured. When laboratory testing for the assessment of hirsutism is indicated, either a bioavailable testosterone level (includes a total testosterone, SHBG, and albumin level) or

B) or  a calculated free testosterone level (if albumin levels are assumed to be normal) provides the most accurate assessment of the androgen effect derived from testosterone.

 C) then In such clinical situations requiring a testosterone evaluation, the addition of 17-hydroxyprogesterone will screen for adult onset adrenal hyperplasia, when indicated (Table 31.2).

D) IN Oligomeno/infertility:- When hirsutism is accompanied by absent or abnormal menstrual periods, assessment of prolactin and thyroid-stimulating hormone (TSH) values are required to diagnose an ovulatory disorder.

E) In obvious male type Hirsutism:-:- then,  because increased testosterone production is not reliably reflected by total testosterone levels, the clinician may chose to rely on typical male pattern hirsutism as confirmation of its presence, or may elect measures that reflect levels of free or unbound testosterone (bioavailable or calculated free testosterone levels). Total testosterone does serve as a reliable marker for testosterone-producing neoplasms. Total testosterone levels greater than 200 ng/dL should prompt a workup for ovarian or adrenal tumors

Hypothyroidism and hyperprolactinemia may result in reduced levels of SHBG and may increase the fraction of unbound testosterone levels, occasionally resulting in hirsutism.

 Cushing syndrome:-In cases of suspected Cushing syndrome, patients should undergo screening with a 24-hour urinary cortisol (most sensitive and specific) assessment or an overnight dexamethasone suppression test. For this test, the patient takes 1 mg of dexamethasone at 11 p.m, and a blood cortisol assessment is performed at 8 a.m. the next day. Cortisol levels of 2μg/dL or higher after overnight dexamethasone suppression requires a further workup for evaluation of Cushing syndrome.

Elevated 17-hydroxyprogesterone (17-OHP) levels identify patients who may have AOAH, found in 1% to 5% of hirsute women. The 17-OHP levels can vary significantly within the menstrual cycle, increasing in the periovulatory period and luteal phase, and may be modestly elevated in PCOS. Standardized testing requires early morning testing during the follicular phase.

According to the Endocrine Society clinical guideline, patients with morning follicular phase 17-OHP levels of less than 300 ng/dL (10 nmol/L) are likely unaffected .When levels are greater than 300 ng/dL but less than 10,000 ng/dL (300 nmol/L), ACTH testing should be performed to distinguish between PCOS and AOAH. Levels greater than 10,000 ng/dL (300 nmol/L) are virtually diagnostic of congenital adrenal hyperplasia.

Evaluation of hirsute women for hyperandrogenism. Evaluation includes more than the assessment of the degree of hirsutism. When hirsutism is moderate (>9) or severe or if mild hirsutism is accompanied by features that suggest an underlying disorder, elevated androgen levels should be ruled out. Disorders to be considered include endocrinopathies, of which PCOS is the most common, and neoplasms. Plasma testosterone is best assessed in the early morning on day 4 to 10 in regularly cycling women. A 17-hydroxyprogesterone is also indicated when symptoms warrant a bioavailable testosterone measurement