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An approach to testing for androgen excess is depicted in Fig. 175-2. PCOS is a relatively common cause of hirsutism. The dexamethasone androgen-suppression test (0.5 mg PO every 6 h × 4 days, with free testosterone levels obtained before and after administration of dexamethasone) may distinguish ovarian from adrenal overproduction. Incomplete suppression suggests ovarian androgen excess. Congenital adrenal hyperplasia due to 21-hydroxylase deficiency can be excluded by a 17-hydroxyprogesterone level that is <6 nmol/L (<2 µg/L) either in the morning during the follicular phase or 1 h after administration of 250 µg of cosyntropin. CT may localize an adrenal mass, and ultrasound may identify an ovarian mass, if evaluation suggests these possibilities.

Treatment: Hirsutism

Treatment of a remediable underlying cause (e.g., Cushing's syndrome, adrenal or ovarian tumor) also improves hirsutism. In idiopathic hirsutism or PCOS, symptomatic physical or pharmacologic treatment is indicated. Nonpharmacologic treatments include (1) bleaching; (2) depilatory such as shaving and chemical treatments; and (3) epilatory such as plucking, waxing, electrolysis, and laser therapy. Pharmacologic therapy includes oral contraceptives with a low androgenic progestin and spironolactone (100-200 mg/d PO), often in combination. Flutamide is also effective as an antiandrogen, but its use is limited by hepatotoxicity. Glucocorticoids (dexamethasone, 0.25-0.5 mg at bedtime, or prednisone, 5-10 mg at bedtime) are the mainstay of treatment in pts with congenital adrenal hyperplasia. Attenuation of hair growth with pharmacologic therapy is typically not evident until 6 months after initiation of medical treatment and therefore should be used in conjunction with nonpharmacologic treatments.

Outline

Section 13. Endocrinology and Metabolism