Approach to the premenopausal patient with hirsutism

This algorithm is intended for patients with hirsutism without evidence of virilization or rare endocrine disorders such as Cushing's syndrome.

OCs: oral estrogen-progestin contraceptives; T: testosterone; 17-OHP: 17-hydroxyprogesterone; hCG: human chorionic gonadotropin; PRL: prolactin; TSH: thyroid-stimulating hormone; FSH: follicle-stimulating hormone; PCOS: polycystic ovary syndrome; IH: idiopathic hirsutism; NCCAH: nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency; ACTH: corticotropin.

* Hirsutism should be distinguished from ((1) hypertrichosis (generalized excessive hair growth [vellus] that may be hereditary or result from certain medications [eg, phenytoin], not caused by excess androgen) and (2) "unwanted hair" – light, unpigmented facial hair that the patient finds bothersome. Signs of virilization include balding, lowering of the voice, and clitoromegaly.

¶ Criteria for diagnosis of PCOS include 2 of 3 of the following:

Clinical or biochemical evidence of hyperandrogenism
Oligomenorrhea
Polycystic ovaries on pelvic ultrasound

In addition, other endocrine disorders that cause hirsutism and/or oligomenorrhea must be ruled out.

Δ Idiopathic hirsutism is hirsutism without hyperandrogenemia or other signs or symptoms indicative of a hyperandrogenic endocrine disorder.

◊ 8 AM serum 17-OHP: Measure at 8 AM on a random day if amenorrhea or infrequent menses; otherwise, day 3 of a menstrual cycle.

Graphic 115056 Version 2.0

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Approach to the premenopausal patient with hirsutism