Case :- Obesity and hirsutism

History:

Age of Onset at menarche suggests PCOS, idiopathic hirsutism or 21-hydroxylase deficiency. Onset distinct from menarche suggests tumor

Progression - Rapid progression of hirsutism or other symptoms suggests tumor

Menstrual disorder

Drug intake like Phenytoin, Minoxidil, Cyclosporin

Clinical findings and lab tests

Hirsutism, Acne - PCOS or idiopathic hirsutism

Virilisation - Ovarian or adrenal tumor, hyperthecosis

Evidence of ovulation

Ovarian ultrasound - Confirm polycystic ovaries, rule out ovarian tumor

Total and free Testosterone and LH levels

Evidence of insulin resistance

17 OH progesterone levels

Lipid profile

Prolactin, TSH

CT of adrenal glands - If ovarian ultrasound is normal and tumor is suspected

Dexamethasone suppression test

Differential Diagnosis ~

PCOS

Ovarian hyperthecosis

Idiopathic hirsutism

Adrenal/Ovarian steroidogenic enzyme deficiency

Late onset 21 Hydroxylase deficiency

 3 β Hydroxy steroid dehydrogenase or 11 Hydroxy deficiency

Adrenal/ovarian tumors

Drug induced

Non Surgical Treatment

 Treatment of Hirsutism

Aim of medical therapy - suppress androgen production, block androgen receptors or decrease the conversion of testosterone to dihydrotestosterone by inhibition of the enzyme 5a-reductase

Oral Contraceptive Pills

Gonadotropin Releasing Hormone Agonists

Glucocorticoids - Hirsutism secondary to late-onset congenital adrenal

hyperplasia or functional adrenal hyperandrogenism

Androgen Receptor Antagonists - cyproterone acetate

Spironolactone - OCP is often used in conjunction

Flutarnide is a nonsteroidal anti androgen - works at the androgen receptor

5a-reductase Inhibitors - Finasteride

Insulin Sensitizing Agents

Metformin

Eflornithine HCL( difluriomethyl ornithine)

Non-Medical Therapy - different means of mechanical hair removal have been employed in combination with medical therapy

Shaving

Epilation

Chemical depilatories Electrolysis Lasers

Photodynamic therapy - aminolevulinic acid

Treatment of Insulin Resistance and Other Metabolic Abnormalities

Weight loss

Insulin-sensitizing agent - Thiazolodinediones . rosiglitazone and pioglitazone, Metformin

OCPs and anti antiandrogens - spironolactone flutamide and GnRH agonist

Treatment of Anovulation

Clomiphene citrate

Aduvant therapy like Metformin, Dexamethasone and dopamine agonists Gonadotropins

Surgical Treatment

Bilateral ovarian wedge resection

Laparoscopic drilling

Surgical removal of tumors