MODULE 6: REPRODUCTIVE ENDOCRONOLOGY

TOPIC 2: HIRSUTISM AND VIRILIZATION

A. Recognize normal variations and abnormalities in secondary sexual characteristics

B. Define hirsutism and virilization
C. Describe pathophysiology and identify etiologies of hirsutism
D. Describe the steps in the evaluation and initial management options for hirsutism and
virilization
E. Describe how hirsutism and virilization are manifested in other medical disorders

CLINICAL CASE:

A 25-year-old G0 woman presents with complaints of increased hair growth on the face, particularly the
upper lip, chin and neck. Her menses started about age 13 and she has never had regular cycles. Her
periods come every 2-4 months. She saw a physician when she was 14 who stated that it was not
uncommon to have irregular cycles initially and she has not seen a physician since. She noted the onset
of facial hair around the onset of menses and it has gradually worsened. She has not noticed any recent
increase in severity; however, she is seriously dating someone and is interested in getting rid of this hair
growth. Currently, she has been using a combination of shaving twice a week and electrolysis when she
can afford it. Her electrologist recommended this evaluation. She would like to be able to conceive in
the near future and wonders about her fertility.

Allergy and Medications:

None

Ob-Gyn History:
G0P0. LMP: 2 months ago. Menarche: 13 years old. Cycle length: every 2-4 months. Duration: 7-10 days
with heavy flow for the first 3 days. No STD history. She has been sexually active and has used condoms
for contraception. No prior pap smear.

Past Medical and Surgical History:

None

Social History:
She smokes 1⁄2 pack of cigarettes per day for 8 years. Occasional alcohol. No street drugs. She works as a
bus driver.

Family History:
A number of family members are obese. Mother has irregular cycles, obesity, diabetes, hypertension
and similar facial hair growth. Her father had some balding, obesity, hypertension and died of a heart
attack at age 50. Her sister is obese, has irregular cycles, similar facial hair growth and she has 2
children. Her 2 brothers are healthy, except for being overweight.
VS: Ht: 5’3” Wt: 204 pounds, BP=120/80, Pulse=88, Respirations=18 Obese African-American woman in
no apparent distress.
Physical Examination:
HEENT: NC/AT

Terminal hair is noted on the upper outer 1/3 of lip, few sparse hairs in the sideburn area and chin, neck
with hair recently shaved.

Neck: No thyromegaly palpable. Supple and no lymphadenopathy

Lungs: Clear to auscultation and percussion

Heart: Nl S1 and S2. No murmurs
Chest: Few midline terminal hairs
Breasts: Few periareolar hairs. No palpable masses, discharge or nipple inversions.
Abdomen: NT, ND, obese, No hepatosplenomegaly and No striae. Terminal hair noted in a vertical
band below the umbilicus.
Extremities: Non-tender. No edema. DTRs: 2+/= bilaterally. Upper inner thighs with sparse terminal hair.

Pelvic exam:
 Normal external genitalia
 Vagina: moist, pink with rugae
 Cervix: Nullipara, non-tender, no lesions
 Pap smear was done
 Uterus: anteflexed, anteverted, midline and normal size
 Adnexae: no palpable masses and non-tender
 Rectal: peri-anal tuft of hair noted
 Ferriman-Gallwey Score: 10 (Normal <8)

Laboratory or studies:
 Urine hCG: negative
 Hgb: 11.0
 Hct: 33.6
 Total Testosterone: 84 ng/dl (Normal range: 20-80)
 DHEA-S: 247 uG/dl (Normal range: 62-615 uG/dl)
 Prolactin: 15 ng/dL (Normal range <20) -TSH: 2.6 uIU/mL (Normal range: 0.4-4.0)
 17-hydroxyprogesterone: 120 ng/dl (Normal range < 200)
 Fasting glucose: 86 (Normal: 60-110)
 Pap smear: Normal
 Endometrial biopsy: Hyperplasia without atypia

DISCUSSION:

A. Recognize normal variations and abnormalities in secondary sexual characteristics

B. Define hirsutism and virilization
C. Describe pathophysiology and identify etiologies of hirsutism
D. Describe the steps in the evaluation and initial management options for hirsutism and
virilization
E. Describe how hirsutism and virilization are manifested in other medical disorders