Internal Medicine

0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:13

Hirsutism (Endocrinology) 715

tests

Laboratory

■Basic blood tests:

➣None if mild and nonprogressive

➣Testosterone, >2 ng/mL (7 nmol/L) characteristic of ovarian

tumor

➣DHEAS: adrenal source:

>8 mcg/mL (22 mcmol/L): tumor

Modest elevation: consider 17-hydroxyprogesterone for CAH

■Specific Diagnostic Tests

➣Fasting insulin:

Glucose/insulin <4.5: insulin resistance

C-peptide level

Free testosterone may be elevated when total testosterone nor-

mal, but rarely helpful

Imaging

■Ovarian US usually unnecessary

■CT or MRI of the adrenals and ovaries when neoplasm suspected

differential diagnosis

Differential Diagnosis

■Rare:

➣Children: CAH or tumor, especially adrenal carcinoma

➣With rapid onset or virilization (deep voice, male musculature,

temporal balding, clitoromegaly): Ovarian (>80%) or adrenal

tumor

■PCOS

■Idiopathic hirsutism (diagnosis of exclusion)

■Medication effect

■Late-onset CAH (21-hydroxylase, 11-hydroxylase, or 3-beta-

hydroxysteroid dehydrogenase deficiency)

■Ovarian or adrenal androgen-producing tumor (ovarian tumors

often large, adrenal adenomas usually small, large virilizing adrenal

tumor may be malignant)

■Cushing syndrome

■Hypothyroidism, acromegaly, or hyperprolactinemia

management

What to Do First

■Establish cause