What is the best approach to the evaluation of hirsutism?
A retrospective study of 84 consecutive women presenting to an endocrinology clinic in the Netherlands was conducted to determine hormone level sensitivity and specificity to identify virilizing adrenal tumors.4 Hormone levels of 14 women with either an adrenal carcinoma (n=12) or an adrenal adenoma (n=2) were compared with the hormone levels of the women with hirsutism (n=73) as well as to the controls (n=31). Serum levels of total testosterone, androstenedione, DHEAS, DHEA, and cortisol were measured. A 24-hour urinary 17-ketosteroid excretion was also measured. A 5-day dexamethasone suppression study was conducted and a urinary sample was obtained between 8 and 9 A.M. on Day 6. An elevated basal total testosterone (normal range, 29–84 ng/dL) or DHEAS level (normal range, 118–431 ng/dL) detected all 14 women with adrenal carcinomas or adenomas and 36 of 73 women with hirsutism of non-neoplastic origin. The combined test sensitivity was 100% (95% confidence interval [CI], 77–100) and specificity was 50% (95% CI, 38–62) for the detection of adrenal tumors.
A prospective study of the incidence of late-onset CAH among hirsute women evaluated 83 consecutive patients with hirsutism from an endocrinology clinic in California with an ACTH stimulation test.5 They found 1 patient with late-onset CAH. Because CAH had an incidence of only 1.2% (95% CI, 0.0–3.4), the authors concluded that routine testing with the ACTH stimulation test is not cost-effective for the evaluation of hirsutism.
Recommendations from others
The American College of Obstetrics and Gynecology 1995 technical bulletin recommended using the clinical examination to guide the evaluation, and laboratory testing to rule out androgen-producing tumors including a serum total testosterone and DHEAS.6 The Society of Obstetricians and Gynaecologists of Canada advised using the clinical examination to guide the assessment, and a total serum testosterone level and a DHEAS level.7
Referral is recommended in the presence of virilism or if the total testosterone or DHEAS level is over twice the upper limit of normal or if there are signs of Cushing’s disease.
Early work on expectations by physician and patient leads to a better outcome
Tim Huber, MD
Naval Hospital, Camp Pendleton, Calif
Primary care physicians field questions about nonspecific findings on a day-to-day basis. Hirsutism is a common complaint and physical finding in women. Most diagnoses related to hirsutism are not life-threatening and have a relatively straightforward workup. There is the occasional patient with a zebra-type diagnosis that demands more detailed evaluation. As with most physical findings that have a large subjective component, I find that early management of expectations both on the part of the physician and patient leads to a better outcome whether or not a million-dollar workup shows any definitive pathology.
