|Year : 2020 | Volume
| Issue : 2 | Page : 123-127
A study of clinical and investigational profile of hirsute women at a tertiary care center in Western India
Priyanka G Dhanotia1, Bela J Shah2, Suyog S Dhamale3
1 Niramaya Skin and Orthopaedic Clinic, Indore, Madhya Pradesh, India
2 B.J. Medical College, Ahmedabad, Gujarat, India
3 Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
|Date of Submission||08-Oct-2018|
|Date of Acceptance||21-Nov-2018|
|Date of Web Publication||18-Aug-2020|
Suyog S Dhamale
G7/8 Omkar Garden, Manikbaug, Sinhagad Road, Pune - 411 051, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Hirsutism is defined as a male pattern of hair distribution in a female. The interplay of androgens as well as other non androgenic hormones has an important role in the causation of hirsutism. Objectives: The objective of this study was to investigate the prevalent causes for hirsutism and to study the clinical profile of patients presenting with hirsutism. Methodology: Patients who came with features of hirsutism were screened by the modified Ferriman–Gallwey (mFG) scale and those with mFG ≥8 were included in the study. Patient's clinical history, family history, body mass index, general examination, dermatological examination, and systemic examination were carried out. Serum total testosterone, serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH: FSH ratio, dehydroepiandrosterone sulfate (DHEAS), thyroid-stimulating hormone, blood sugar levels (fasting and postprandial), and abdomino-pelvic ultrasound were performed for all patients. Serum prolactin, free testosterone, 17 hydroxyprogesterone, T3level, T4level, serum cortisol level, and serum fasting insulin levels were performed in selected patients depending on the clinical scenario. Results: A total of 44 patients were studied during the study. About 95.45% of patients were categorized under mild mFG, whereas 4.55% of patients had moderate mFG score. Idiopathic hirsutism (IH) was the most common cause in our patients which accounted for 43.18% of patients followed by polycystic ovarian syndrome (PCOS) which was the reason for hirsutism in 38.64% of patients. Total testosterone was raised in 25% of patients. Free testosterone levels were performed for 25 patients and found to be raised in six patients. Five patients had elevated DHEAS levels of which four had PCOS and one had late-onset congenital adrenal hyperplasia. Conclusion: IH was the most common cause of hirsutism in our patients which was followed by PCOS.
Keywords: Hirsutism, idiopathic hirsutism, polycystic ovarian syndrome
|How to cite this article:|
Dhanotia PG, Shah BJ, Dhamale SS. A study of clinical and investigational profile of hirsute women at a tertiary care center in Western India. Clin Dermatol Rev 2020;4:123-7
|How to cite this URL:|
Dhanotia PG, Shah BJ, Dhamale SS. A study of clinical and investigational profile of hirsute women at a tertiary care center in Western India. Clin Dermatol Rev [serial online] 2020 [cited 2021 Jan 19];4:123-7. Available from: https://www.cdriadvlkn.org/text.asp?2020/4/2/123/292477
| Introduction|| |
Hirsutism is defined as a male pattern of hair distribution in a female, with the hair being transferred to visible, coarse, terminal hair under the influence of androgens.
Hirsutism can be due to the increased levels of the circulating androgens or increased sensitivity of the end organ toward the androgens.
The interplay of androgens as well as other non androgenic hormones has an important role in the causation of hirsutism.
Hirsutism is usually benign; however, in rare cases, it may be associated with virilism due to ovarian or adrenal tumors which may be malignant and at times may be life-threatening. The diagnosis of the cause of hirsutism depends on the assessment of coexisting clinical signs and laboratory testing for various endocrinological parameters.
Very few studies are available in literature on hirsutism in the Indian context. Being an entity which is determined by factors such as race, genetics, ethnicity, culture, and social norms; it is important to have the clear picture of the problem in country such as India where the population is diverse.
Among the available literature on the subject polycystic ovarian syndrome (PCOS) and idiopathic hirsutism (IH) are the two most common causes of hirsutism.
The objective of this study was
- To investigate the prevalent causes for hirsutism in our study population
- To study the clinical profile of patients presenting with hirsutism
- To assess the investigational profile in patients of hirsutism.
| Methodology|| |
This study was conducted at the tertiary care setup in Western India.
After valid permission of the Institutional Ethics Committee, patients were recruited, investigated, followed up, and collection of data was done in the intervening period of April 2016–August 2016.
The patients who came with features of hirsutism in study duration were screened by the modified Ferriman–Gallwey (mFG) scale, and those who had the mFG ≥8 were included in the study.
The patients who were on drugs which were likely to modify the hormonal pattern as well as patients who were pregnant or lactating were excluded from the study.
Patient's clinical history was recorded using a pro forma which included the age of onset and duration of hirsutism, rate of progression, history of weight gain/loss, symptoms of virilization if any (increase in muscle mass, deepening of voice, hair loss, and oligomenorrhea), sleep disturbances, bowel and bladder habits, menstrual history, marital status, and method of contraception if any with duration. History also asked for endocrine disorders such as hyperprolactinemia (galactorrhea and amenorrhea), symptoms suggestive of diabetes mellitus (polyuria, polydipsia, and polyphagia).
Menstrual history of the patient was noted which took note of menarche, menstrual irregularity, history of oligomenorrhea, and dysmenorrhea if any. Family history if any was recorded. History of any surgical or gynecological operations was asked if any.
On clinical examination, patients' height and weight were noted, and body mass index (BMI) was calculated to classify patients into underweight, normal, overweight, or obese as per South Asian BMI standards.
Patient's general examination, dermatological examination, and systemic examination were carried out to find the associated dermatological and systemic comorbidities such as acanthosis nigricans, acne, androgenetic alopecia, seborrhea, and hypertension. Signs of virilization and any other endocrinopathy if present were noted.
Hormonal evaluation was carried out by taking blood samples between the 3rd and 5th days of the menstrual cycle at 8 am after overnight fasting. Serum total testosterone, serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH: FSH ratio, dehydroepiandrosterone sulfate (DHEAS), thyroid-stimulating hormone (TSH), fasting blood sugar (FBS), and postprandial blood sugar levels were performed for all patients.
All patients were evaluated with abdomino-pelvic ultrasound between day 3 and day 5 of the cycle. The ultrasound (USG) definition of polycystic ovarian morphology is the presence of ≥12 follicles with a 2–9-mm diameter in the ovary. An ovarian volume >40 ml is also suggestive. To diagnose the PCOS, Rotterdam criteria were adopted which required the presence of at least two out of three of hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology.
Additional laboratory investigations were carried out in selected patients based on symptom clues and included free testosterone level, T3 level, T4 level, serum prolactin, 17 hydroxyprogesterone (17-OHP), serum cortisol level, and fasting insulin levels.
To find the insulin resistance, homeostasis model assessment of insulin resistance (HOMA-IR) was utilized, and cutoff reference value was taken as 1.55 and >40.55 is suggestive of insulin resistance.
| Observations and Results|| |
A total number of patients who presented with the complaint of hirsutism during the study period were 52 of which 44 patients were included in our study which could fulfill inclusion criteria.
Age of these patients was between 17 and 50 years. Maximum members of the study population were in the age range of 20–29 years of age and the mean age of the study group was 25.45 ± 9.06.
The mean duration of hirsutism was 3.289 years, and majority of the patients (n = 25, i.e., 56.82%) had a duration of 3 or more years.
Nearly 95.45% of our patients (n = 42) were categorized under mild mFG (mFG score 8–16), whereas only 4.55% (n = 2) of patients had moderate mFG score (mFG score 17–24). None of the patients in our study had severe mFG score (mFG score 25–36).
The mean mFG was maximum for upper lip which was found to be 1.81, followed by lower abdomen which counted 1.79, while upper arms had the lowest mFG of 0.11.
The most common associated clinical manifestation in our patients was alopecia in 45.45% of patients (n = 20) followed by various menstrual cycle irregularities such as oligomenorrhea, menorrhagia, and dysmenorrhea in 40.90% of patients (n = 18). Rest of the clinical associations of hirsutism in our patients were acne, acanthosis nigricans, voice changes, sleep disturbances, polyuria, polyphagia, and weight gain. [Table 1] demonstrates the presence and prevalence of various clinical associations of hirsutism.
IH was the most common cause of hirsutism in our patients which accounted for 43.18% of patients (n = 19) followed by PCOS which was the reason of hirsutism in 38.64% (n = 17) of patients.
Of 44 patients, four patients were menopausal while one of them had undergone hysterectomy, thus we had 39 patients who were in reproductive age group of which 18 patients had irregular menses (46.15% of reproductive age group). Of these 18 patients, 17 patients were diagnosed with having PCOS, and one patient had late-onset congenital adrenal hyperplasia (LOCAH). Nineteen patients of IH had normal menstrual cycles. One patient of hypothyroidism and diabetes mellitus each also had normal menstruation.
Of 44 patients, 22.72% were overweight, 18.18% were obese, and 59.09% of patients were normal as determined by BMI calculation. Thus, 40.9% of patients (n = 18) had BMI above normal.
Total testosterone was raised in 11 out of 44 patients (25%). Ten out of 11 who had raised total testosterone had PCOS, and one patient was of LOCAH.
Free testosterone levels were performed for 25 patients and found to be raised in six patients. Out of these six patients, five patients had PCOS while one patient had LOCAH.
Five patients (11.36%) had elevated DHEAS levels, of which four had PCOS and one was having LOCAH.
LH/FSH ratio was ≥1 in 15 patients, of which 14 had PCOS and one had diabetes mellitus with hypothyroidism. The mean LH/FSH ratio was 1.180 for entire study population while that of PCOS patients it was found to be 1.89.
TSH was performed for all patients; however, T3 and T4 levels were performed only for selected patients. A total of five patients were found to be hypothyroid while TSH was raised in four of these patients and normal in one patient.
Serum prolactin levels were performed in 19 of our patients of which four had raised values. Thus, out of the studied population for prolactin, 21.05% of patients had hyperprolactinemia. Out of 19 in whom serum prolactin was done 10 had IH, 8 had PCOS and 1 had hypothyroidism. Out of four patients with hyperprolactinemia, three patients were of PCOS while one patient was hypothyroid.
17-OHP studies were carried out in four patients in this study out of which one patient showed values suggestive of LOCAH.
Fasting insulin levels and determination of insulin resistance by HOMA-IR criteria could be performed for 11 patients out of whom five patients were of PCOS. All 11 patients had insulin resistance as per the cutoff value of >40.55. Only three patients were found to have insulin resistance when we considered the cutoff value of 2.77 as suggested by Geloneze et al., and these three patients were of PCOS.
All patients underwent ultrasound study and 15 patients out of 44 recorded positive findings of polycystic ovarian morphology by radiological examination alone while a total number of patients diagnosed with PCOS were 17 when Rotterdam criterion was employed. No other pathology apart from PCOS was apparent on USG of patients of PCOS.
Two patients of ours had hyperandrogenism-insulin resistance-acanthosis nigricans (HAIR-AN) syndrome.
Both of them were diagnosed as a case of PCOS. First patient had serum testosterone level 84 ng/dl, DHEAS level 496 μg/dl, HOMA-IR value 6.28, All these values were above normal. Second patient had raised serum total testosterone level of 92ng/dl, HOMA-IR value was 2.62. This patient had borderline FBS and was overweight. Symptoms of virilization were not observed in these patients.
[Table 2] summarizes the hormonal profile of the entire study population.
| Discussion|| |
The degree of hairiness of a woman depends on her place in the normal spectrum of hairiness in that community, and hence, the social norms can dictate the prevalence of females likely to report with complaint of hirsutism.
Maximum number of our study population belonged to the 20–29 years of age group and the mean age was 25.45 ± 9.06. This compares very well with the finding by other researchers. The mean age of the study population of Sharma et al. was 25.84 while it was 24.18 in a study by Chhabra et al. though it is also a significant problem among elderly and postmenopausal women.
The mean duration of hirsutism in our study was 3.289 years. This could be attributed to the fact that none of our patients had tumors of adrenals or ovaries which would result in more acute presentation.
About 95.45% of patients in our study had mild hirsutism as per mFG scale and 4.55% had moderate hirsutism, whereas none of the patients had severe features. This again can be explained by the absence of any neoplastic condition in our patients which usually result in severe hirsutism.
Our findings correlate well with the findings of Zargar et al. who determined 484 cases (96.03%) of mild hirsutism and 20 cases (3.96%) of moderate hirsutism among 504 cases of hirsutism studied by Ferriman–Gallwey scaling.
In a study by Chhabra et al., the authors recorded the incidence of mild, moderate, and severe hirsutism was 32.5%, 52.5%, and 15%, respectively. While accounting for increased finding of severe hirsutism authors have suggested that there was a statistically significant relationship between the duration and severity of hirsutism. The mean duration of hirsutism was more in the above-mentioned study (6.1 ± 3.38 years) as compared to the present study (3.289 ± 2.47 years). This may explain the difference in findings of severe hirsutism among our studies.
Although various authors have encountered noncoherent results while measuring the prevalence of mild, moderate, and severe hirsutism, there seems to be convergence upon the rarity of severe hirsutism as evident from [Table 3]. [Table 3] shows a comparison of findings of degree of hirsutism by various researchers.
Literature suggests PCOS to be the leading underlying cause of hirsutism. IH also appears to be one of the most important causes. In this study, we found IH as a leading cause among our patients.
Among the various Indian studies reviewed by us, we found that the prevalence of IH ranging from 80% in a study by Ahmad et al. to as low as 15% in study by Chhabra et al. [Table 4] collates together the findings by various researchers in this regard.
Chhabra et al. reported 70% incidence of PCOS in their study while in our study it was 38.64%. The difference in these findings can be explained on the basis of differences in the methodology. Chhabra et al. used the modified National Institute of Health criteria for the diagnosis of PCOS. Furthermore, polycystic ovarian morphology criteria were defined as the presence of 10 or more intermediate follicles each measuring 2–9 mm and/or increased ovarian volume of more than 10 ml. While acknowledging the increased incidence of PCOS, in their study, the authors mentioned that inclusion of patient sample referred from endocrinology clinic and increased number of obese participants in the study population may have increased the incidence of PCOS in the study.
In a study by Sharma et al., the authors reported the incidence of PCOS as 34% which appears in agreement with findings of our study. Another finding reported by authors was 15 patients had polycystic ovarian morphology on USG while 17 patients fulfilled Rotterdam criteria for PCOS. Incidentally, in this study, we also had 15 patients having polycystic ovarian morphology on USG out of 17 patients fulfilling Rotterdam criteria. Thus, the findings of our study are in agreement with the findings of Sharma et al.
Zargar et al. carried out the study on hirsutism in Kashmir. This study reported the IH as the most common cause of hirsutism (similar to the present study) in 38.7% of patients while PCOS was the second most common cause in their study (37.7%). Their study also reported 9.2% of patients with postmenopausal hirsutism which was not taken in account in other similar studies. However, the findings of our study are in agreement with this study with respect to the underlying cause.
In another study on hirsutism in Kashmir by Ahmed et al., investigators reported IH as the most common cause in 80% of participants while PCOS was observed in 11.43% of patients. While the most common cause of hirsutism remains similar to the present study, the percentage of patients suffering from IH does not correlate with the findings of our study. The diagnostic criteria employed by authors have not been mentioned in manuscript; hence, analysis as to why the findings differ is not possible with available data.
Hair loss was the most common clinical association in our study in 45.45% of patients while it was found to be 27.5% by Chhabra et al. This greater number in our study can be explained based on the fact that a study by Chhabra et al. included only androgenetic alopecia while we chose to include all cases of hair loss including telogen effluvium as it may also have significant endocrinal correlation such as hypothyroidism or hyperthyroidism.,
Though majority of patients came to dermatology consultation regarding hirsutism menstrual irregularity was also one of the chief complaints of patients.
Our study found hyperprolactinemia in four patients. PCOS was associated in three of these patients and hypothyroidism in remaining one patient. Hence, in these cases, hirsutism appears more due to the associated PCOS rather than due to the role of prolactin barring one patient.
Fifteen out of 17 patients of PCOS (88.23%) showed polycystic ovarian morphology on USG, and in addition, two patients were diagnosed with PCOS when Rotterdam criteria were applied. Thus, when used alone USG has 88.23% sensitivity in detection of PCOS in our study.
Limited sample size, short duration of the observation, and collection of data from the single center can be cited as the limitations of our study.
| Conclusion|| |
Idiopathic hirsutism was the most common cause of hirsutism in our study which was followed by polycystic ovarian syndrome. However, before categorizing the patient as a case of IH, it is necessary to completely investigate the patient for all possible causes to manage the patient effectively.
Furthermore, the definition of IH is evolving constantly which is a principal source of confusion as there are no concrete set of guidelines for it. As our knowledge of various androgen disorders will evolve, we may encounter the new hidden contributors for hirsutism leading to change in the incidence of IH.
It remains to be seen whether the findings of our study are applicable to other national regions or not. As more studies in this regard are carried out from various regions will help to complete the picture of the problem.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, et al.
Evaluation and treatment of hirsutism in premenopausal women: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008;93:1105-20.
Hatch R, Rosenfield RL, Kim MH, Tredway D. Hirsutism: Implications, etiology, and management. Am J Obstet Gynecol 1981;140:815-30.
Sharma NL, Mahajan VK, Jindal R, Gupta M, Lath A. Hirsutism: Clinico-investigative profile of 50 Indian patients. Indian J Dermatol 2008;53:111-4.
] [Full text]
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157-63.
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19-25.
Do HD, Lohsoonthorn V, Jiamjarasrangsi W, Lertmaharit S, Williams MA. Prevalence of insulin resistance and its relationship with cardiovascular disease risk factors among Thai adults over 35 years old. Diabetes Res Clin Pract 2010;89:303-8.
Geloneze B, Repetto EM, Geloneze SR, Tambascia MA, Ermetice MN. The threshold value for insulin resistance (HOMA-IR) in an admixtured population IR in the Brazilian metabolic syndrome study. Diabetes Res Clin Pract 2006;72:219-20.
Beek CH. A study on extension and distribution of the human body-hair. Dermatologica 1950;101:317-31.
Chhabra S, Gautam RK, Kulshreshtha B, Prasad A, Sharma N. Hirsutism: A clinico-investigative study. Int J Trichology 2012;4:246-50.
Zargar AH, Wani AI, Masoodi SR, Laway BA, Bashir MI, Salahuddin M, et al.
Epidemiologic and etiologic aspects of hirsutism in Kashmiri women in the Indian subcontinent. Fertil Steril 2002;77:674-8.
Ahmad QM, Shah IH, Sameem F, Kamili QU, Sultan J. Hirsutism in Kashmir: An etiological study. Indian J Dermatol 2009;54:80-2.
] [Full text]
Vinay K, Sawatkar GU, Dogra S. Hair manifestations of endocrine diseases: A brief review. Indian J Dermatol Venereol Leprol 2018;84:528-38.
] [Full text]
Malkud S. Telogen effluvium: A review. J Clin Diagn Res 2015;9:WE01-3.
Azziz R, Carmina E, Sawaya ME. Idiopathic Hirsutism. Endocr Rev 2000;21:347-62.
[Table 1], [Table 2], [Table 3], [Table 4]