Algorithm for the Evaluation and Differential Diagnosis of Hirsutism - Flowchart
Algorithm for the Evaluation and Differential Diagnosis of Hirsutism - Flowchart
«Flowchart»

Start

Start

Start

Hirsutism significant

Hirsutism significant

Hirsutism

Virilization
Rapid progression

Virilization
Rapid progression


Virilization

Laboratory Evaluation


Total, free testosterone
DHEAS

Laboratory Evaluation


Total, free testosterone
DHEAS

Laboratory Evaluation


Total, free testosterone
DHEAS


Total, free testosterone
DHEAS

Reassurance
Nonpharmacologic approaches

Reassurance
Nonpharmacologic approaches

Reassurance
Nonpharmacologic approaches


Treat empirically
or
Consider further testing


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

Treat empirically
or
Consider further testing


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

Treat empirically
or
Consider further testing




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


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

End

End

End

Normal

Normal

Normal

Increased

Increased

Increased

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

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

Rule out ovarian or adrenal neoplasm

Rule out ovarian or adrenal neoplasm

Final diagnosis

Final diagnosis

Final diagnosis

Idiopathic

Idiopathic

Idiopathic


Nonclassic CAH
Functional adrenal hyperandrogenism


Nonclassic CAH
Functional adrenal hyperandrogenism


Nonclassic CAH
Functional adrenal hyperandrogenism Nonclassic CAH


PCOS
Functional ovarian hyperandrogenism


PCOS
Functional ovarian hyperandrogenism


PCOS
Functional ovarian hyperandrogenism PCOS

Yes

Yes

Yes

No

No

No

R/O ovarian or adrenal neoplasm

R/O ovarian or adrenal neoplasm

R/O

ACTH, adrenocorticotropic hormone; CAH, congenital adrenal hyperplasia; DHEAS, sulfated form of dehydroepiandrosterone; PCOS, polycystic ovarian syndrome; R/O, rule out.

ACTH, adrenocorticotropic hormone; CAH, congenital adrenal hyperplasia; DHEAS, sulfated form of dehydroepiandrosterone; PCOS, polycystic ovarian syndrome; R/O, rule out.

ACTH, adrenocorticotropic hormone; CAH, congenital adrenal hyperplasia; DHEAS, sulfated form of dehydroepiandrosterone; PCOS, polycystic ovarian syndrome; R/O, rule out.