Algorithm for the Evaluation and Differential Diagnosis of Hirsutism

Algorithm for the Evaluation and Differential Diagnosis of Hirsutism - Flowchart

«Flowchart»

Start

Hirsutism significant

Hirsutism

Virilization
Rapid progression

Virilization

Laboratory Evaluation

Total, free testosterone
DHEAS

Laboratory Evaluation

Total, free testosterone
DHEAS

Laboratory Evaluation

Total, free testosterone
DHEAS

Reassurance
Nonpharmacologic approaches

Treat empirically
or
Consider further testing

Dexamethasone suppression → adrenal vs ovarian causes; R/O Cushing's
ACTH stimulation → assess nonclassic CAH

Treat empirically
or
Consider further testing

Dexamethasone suppression → adrenal vs ovarian causes; R/O Cushing's
ACTH stimulation → assess nonclassic CAH

Treat empirically
or
Consider further testing

Dexamethasone suppression → adrenal vs ovarian causes; R/O Cushing's
ACTH stimulation → assess nonclassic CAH

Dexamethasone suppression → adrenal vs ovarian causes; R/O Cushing's → vs vs
ACTH stimulation → assess nonclassic CAH →

End

Yes

Rule out ovarian or adrenal neoplasm

Rule

Yes

Rule out ovarian or adrenal neoplasm

Rule

Normal

Increased

Marked elevation
[Total testosterone >7 nmol/L (>2 ng/mL)
DHEAS >18.5 µmol/L (>7000 µg/L)]

Marked

Rule out ovarian or adrenal neoplasm

Other causes see Table 49-1 in HPIM-18

Final diagnosis^*

^* ^*

Idiopathic

Nonclassic CAH
Functional adrenal hyperandrogenism

Nonclassic CAH
Functional adrenal hyperandrogenism Nonclassic

PCOS
Functional ovarian hyperandrogenism

PCOS
Functional ovarian hyperandrogenism PCOS