Causes of hirsutism in women

Etiology	Clinical features
Common
PCOS	Peripubertal onset of symptoms, oligomenorrhea, obesity, polycystic ovaries on ultrasound.
Nonclassic 21-hydroxylase deficiency	Similar presentation to PCOS, high serum 17-hydroxyprogesterone concentration, more common in certain ethnic groups.
Uncommon
Classic 21-hydroxylase deficiency	Diagnosed during infancy, ambiguous genitalia.
Androgen-secreting ovarian tumors (Sertoli-Leydig cell, granulosa-theca cell, hilus cell)	Onset in third decade or later (usually postmenopausal), rapidly progressive hirsutism, virilization.
Androgen-secreting adrenal tumors	Some women with adrenocortical cancer present with just virilization, but a mixed Cushing's and virilization syndrome is more common.
Ovarian hyperthecosis	Onset in third decade or later (usually postmenopausal), rapidly progressive hirsutism, virilization.
Severe insulin-resistance syndromes	Virilization, amenorrhea, infertility, and the ovary shows histologic changes of hyperthecosis.
Cushing's disease	Corticotroph adenoma secreting ACTH results in excess cortisol and adrenal androgens.
Drugs	Use of exogenous androgens (testosterone or DHEA) can cause hirsutism and acne.
Acromegaly	Enlarged jaw (macrognathia) and enlarged, swollen hands and feet, which result in increasing shoe, glove, and ring sizes. Patients with large pituitary tumors may have headaches, visual field defects, and cranial nerve palsies.

PCOS: polycystic ovary syndrome; ACTH: corticotropin; DHEA: dehydroepiandrosterone.

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