Endocrine Abstracts

Introduction: Hirsutism is the presence of terminal hair growth in females with a male distribution pattern. It affects 5-15% of women, being an important sign of androgen excess. The main causes of hirsutism are polycystic ovary syndrome (PCOS) and idiopathic hyperandrogenism. Other significant but less frequent causes of hirsutism include nonclassic congenital adrenal hyperplasia (NCAH), androgen-secreting tumors, and Cushing’s syndrome.

Case report: A 24 year old obese female patient was referred to the Endocrine Department due to marked hirsutism, which began at the age of 15 and worsened from 18 years onwards. She had no other complaints. Menarche occurred at 13 years old. Even though her menstrual cycles were initially regular, she was in amenorrhea for the past 5 years. She had no history of pregnancy and had never taken oral contraceptives. She was medicated with sertraline for depression and topiramate for chronic headaches. There was no known family history of hirsutism. On physical examination, the patient had a BMI of 36.8 kg/m2, acanthosis nigricans, a Ferriman-Gallwey score of 31 and a marked androgenic pattern alopecia. Blood pressure was normal and there were no purple striae, proximal myopathy or other signs of virilization such as acne or voice changes. The blood tests showed normal thyroid function, prolactin and gonadotropin levels, an estradiol of 46.3 pg/ml (NR 12-398), total testosterone 61.9 ng/dl (NR 5-48), free testosterone 3.40 ng/dl (NR <4.2), SDHEA 347 µg/dl (NR 98-340), delta-4-androstenedione 5.13 ng/ml (NR 0.3-3.7) and a basal 17OH-P 1.30 ng/ml (NR <2), which excluded NCAH. The dexamethasone 1 mg suppression test also excluded Cushing’s syndrome, with a cortisol of 0.6 µg/dl. A CT scan of the abdomen showed no changes of the adrenal glands. Pelvic ultrasound showed increased volume of both adnexa (14 and 13cc), globous, with sonolucent formations of both central and peripheral location, features suggestive of micropolycystic ovaries. The diagnosis of PCOS was assumed, and the patient was medicated with daily drospirenone, ethinyl estradiol and ciproterone acetate 10 mg (for 15 days of the menstrual cycle), with no perceived improvement. Mechanical terminal hair removal was encouraged.

Conclusions: Androgen levels correlate poorly with hirsutism severity in PCOS, given that clinical manifestations are dependent on the individual’s pilosebaceus unit response to androgens. Therefore, individuals can present with very exuberant hirsutism, suggesting more serious underlying disease, despite modest androgen levels, as in the case of our patient.