HIRSUTISMCASE PRESENTATION

Department of Streeroga & Prasutitantra HOD

Dr.Mrs.S.S.Chaudhari

Name: xyz Sex: female Age: 35 Years OPD No.:27380

Chief Complaints: On Dt.14 May 2009 Irregular menses Scanty menses Since 4 years Hirsutism Weight gain

Menarche: At 14th years of age Past Menstrual History (Before 4 Yrs.): 3 day/28-30 day -Reg./Med./Painless Present Menstrual History (Since 4 Yrs.): 3 day/2-2Month -Irreg./Scanty/Painless Marital Status: Married since 16 Yrs. Obstetric History: G P A L D 1)Mch-15 yr-FTND 2)Mch-12 yr-FTND Three MTP done. H/O Tubectomy done 10 yrs back. Personal History: NAD Family History: NAD

Examination:

Pulse- 90/min Blood Pressure- 120/80 mmHg Temperature- 98.6F Build- Obese Height- 145cm Weight- 65kg BMI- 31 F & G Score - 10

STROTAS PARIKSHAN: RasawahaTwak-Snigdha RaktawahaYakrit Pleeha Not Palpable MansawahaSnaya- Prabhut Twak- Snigdha Roma- Atiloma Vrikka- No tenderness Kati- Katishula Sweda- Prabhut Dant- Prakrut Nakh- Prakrut Kesh-Krishna

Medowaha-

Asthiwaha-

Majjawaha-

StanyawahaPranawahaAnnawaha-

Udakawaha-

PurishawahaMutrawahaSwedowaha-

Akshisneha- Alpa Twakasneha- Prabhut Vitsneha- Alpa Stana- Prakrut Nasa- Prakrut Kantha- Prakrut Ostha- Prakrut Jivha- Sama Danta- Prakut Talu- Prakrut Jivha- Sama Trishna- Prabhut Pakwashaya- Prakrut Sthulaguda- Prakrut Vankshana- Prakrut Basti- Prakrut Sweda- Prabhut Meda- Prabhut

ABDOMINAL EXAMINATION: INSPECTIONFat distribution over abdominal region(Android Obesity) PALPATIONLSK Soft Abdomen SYSTEMIC EXAMINATION: RS- Clear CVS- SS Normal CNS- Well conscious & oriented GNAECOLOGICAL EXAMINATION: Per SpeculumCx & Os-Normal Vagina- Healthy Per VaginalUterus - AV & NS Rt. Fx- Tenderness Lt. Fx- Clear

INVESTIGATIONS: Hb%8.9 Gm% UrineNAD HIVNR VDRLNR USG- Uterus-Normal size Ovary-Normal size e/o Right Hydrosalpinx of size 7x4cm BSL85.5mg/dl Total Testosterone- 93.51ng/dl ( ) (Dt.09/09/09) Total Testosterone- 68.39ng/dl (N) (Dt.09/01/10) TFT- T3 -87.7ng/dl T4 -5.2ug/dl TSH -27.94uIU/mL() ?subclinical hypothyroidism

Ayurvedic Concept
Hair Mala of Asthidhatu Upadhatu of Majjadhatu Pitruja Avayava

 Good quality of loma mentioned in Twaksar

A person with Aloma & Atiloma mentioned in Astha Nindit

Cycle growth of hair

Several months

2 weeks

3 months

Types of hair
Lanugo

Fetal hair

Vellus Short, fine,

Unpigmented
Before puberty

Terminal Long, coarse, pigmented arises from vellus hair

Sites of hair
Non sexual Ambi-sexual Male sexual
Ears, nasal tip, chin, sternum,
upper pubic triangle,

Sites

Lower parts of the scalp, eye brow, lashes, fore-arms, lower legs

Temporal & vertical parts of the scalp, axilla, lower pubic hair.

back.

Depend on Growth hormone Androgen in low concentration from from pituitary

the adrenals & ovaries in females & adrenals in male

Androgen in high concentration

Androgen production
Androstenedione
50% 25% 50%

Testosterone
25%

50%

Adrenal
90%
100%

DHEA
10%

Ovary

DHEAS

Hypertrichosis
Excessive growth of Lanugo, vellus or terminal hair in non-sexual sites (James et al, 2005)
Cong Acquired Localized Generalized
Drug-induced hypertrichosis

Congenital hypertrichosis lanuginosa

Hirsutism: Latin hirsutus = shaggy, hairy

Excessive growth of terminal hair in male sexual sites.

Excessive: Socially unacceptable to the patient F& G score >8

Hirsutism is a consequence of several factors.

An increase in:

1. Androgen production
2. The sensitivity of the androgen receptors at the level of the hair follicle. 3. The activity of 5-reductase.

CAUSES

A. Ovarian:
.PCOS: 90%
{hyperandrogenism, oligo-ovulation, PCO}

.Virilizing ovarian tumors

{arrhenoblastoma, hilus cell tumor, lipod cell tumor, granulosa cell tumor}

.Luteoma of pregnancy
{ Not true tumor but an exaggerated reaction of ovarian stroma to chorionic gonadotropins. It is solid, usually unilateral & regress after labour}

.Ovarian dysgenesis

Turners syndrome

B. Adrenal:
Cong adrenal hyperplasia Tumors Cushing syndrome

Congenital adrenal hyperplasia

C. PERIPHERAL Idiopathic: Regular ovulation & normal androgen levels Insulin resistance HAIRAN syndrome: HyperAndrogenic
Insulin-Resistant Acanthosis Nigricans 5H syndrome

acanthosis nigricans.

Aromatase deficiency Glucocorticoid resistance Hyperprolactinema can cause an increase in DHEAS. TT with bromocriptin: dec PRL & DHEAS

D. Drugs
Hirsutism Anabolic steroids Danazol Metoclopramide Methyldopa Phenothiazines Progestins Reserpine Testosterone
Hunter, 2003

Hypertrichosis Cyclosporine Diazoxide Hydrocortisone Minoxidil Penicillamine Phenytoin Psoralens Streptomycin

Degree of hirsutism Photography or scoring systems a. Ferriman & Gallwey(1961): 9 areas

upper lip, chin, chest upper abdomen, lower abdomen, upper arm, thighs, upper back, lower back/buttocks minimal=1, mild=2, moderate=3, severe=4

>8 = hirsutism

Degree of hair growth

(Ferriman & Gallwey,1961)

TREATMENT

Principle of TreatmentA. To Remove the Source of Androgen

B. To Supress the Action of Androgen C. Removal of Excess Hair

A. To Remove the Source of Androgen

Vamana Karma Weight Reduction

B. To Supress the Action of Androgen

To Decrease Insulin Resistance
Hyponidd TabletsYashad Bhasma Karvellaka Extracts-Haridra, Tarwar, Amalaki, Jambu, Mamajavo, Meshashringi, Vijaysaar, Guduchi, Neem, Kirattikta.

C. Removal of Excess Hair

Lomashatan Yoga-(Sharangdhar)
Shudha Shankha Churna- 2 part Shudha Hartal -1 part Shudha Manahashila - part Shudha Swarjika kshar - 1 part

Mixed together, pasted in water & applied after waxing for 7 times.

"Once the Black Terminal Hair is produced, the changes persist even in the absence of a continuing androgen excess"