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| Clinical Practice Guidelines Issued For Hirutism Treatment |
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| SciMed - Healthcare | |||
| TS-Si News Service | |||
| Friday, 25 April 2008 18:00 | |||
University Park, PA, USA. Beliefs about nature and nurture (especially  genetics and God) can affect how patients and their families respond to news about their diagnosis.
Understanding how people might respond to a health pr...New clinical practice guidelines for the treatment of hirsutism in premenopausal women have been released The Endocrine Society. They have been published in the Society's Journal of Clinical Endocrinology & Metabolism (JCEM), its flagship publication.
Clinical assessment of body hair growth in women. Ferriman D and Gallwey JD. Journal of Clinical Endocrinology 1961; 21:1440-1447. This article includes information on the Ferriman-Gallwey (mFG) score, used to evaluate and quantify hirsutism in women, and the newly released guidelines.  “Hirsutism is a potential indication of an underlying medical disorder that may require specific treatment, and such a disorder may have implications for menstrual function, fertility, and metabolic risks,” said Kathryn Martin, MD, of the Reproductive Endocrine Unit at Massachusetts General Hospital (Boston, MA, USA), and member of the Society’s task force that developed the guidelines. “These evidence-based guidelines give healthcare professionals an approach to treating hirsutism based upon a comprehensive review of clinical trials of drug therapy and hair removal techniques such as laser and electrolysis.” For females, hirsutism is a male pattern of body hair (androgenic hair). The hair, known as terminal hair, is defined medically as excessive terminal hair that appears in a male pattern in women. Terminal hair refers to the stiff, pigmented hairs normally seen in men on the face, chest, abdomen, and back, and which are not normal in women.
Prominent among the causes for differing hair growth patterns between males and females are the relative concentrations of male hormones.
There is growing evidence that implicates high circulating levels of insulin in women to the development of hirsutism. This
theory is consistent with the observation that obese (and thus presumably insulin resistant hyperinsulinemic) women are at high risk of becoming hirsute. Further, treatments that lower insulin levels will lead to a reduction in hirsutism. It is speculated that insulin, at high enough concentration, stimulates the ovarian
theca cells to produce androgens. There may also be an effect of high levels of insulin to activate the insulin-like growth factor-I (IGF-1) receptor in those same cells. Again, the result is increased androgen production. Testosterone stimulates hair growth while increasing the size, growth intensity, and pigmentationr. Other symptoms associated with a high level of male hormones include acne, a deepening of the voice, and increased muscle mass.
The guidelines suggest testing for elevated androgen levels in women with moderate or severe hirsutism, or hirsutism of any degree when it is sudden in onset, rapidly progressive, or associated with other abnormalities such as menstrual dysfunction or obesity.
For pharmacological therapy, the guidelines suggest oral contraceptives for the majority of women, adding an antiandrogen after six months if the response in suboptimal. An antiandrogen is a substance that prevents or inhibits the effects of male sex hormones. The guidelines recommend against using antiandrogens alone unless adequate contraception is used, because antiadrogens pose a potential risk to the normal sexual development of a male fetus.
Almost all women with hirsutism use temporary methods of hair removal such as shaving, plucking, and waxing. For those considering more “permanent” methods of hair removal the guidelines suggest photoepilation (laser and intense pulsed light) as first line therapy. Photoepilation methods, when compared to electrolysis, are more expensive per treatment session, but are more efficient, less painful, and may be associated with less scarring.
The guidelines were developed by a task force chaired by Dr. Martin. Other members of the task force included R. Jeffrey Chang of the University of California School of Medicine-San Diego in La Jolla, California; David Ehrmann of the University of Chicago General Clinical Research Center in Chicago, Illinois; Lourdes Ibanez of the University of Barcelona in Barcelona, Spain; Rogerio Lobo of Columbia University Medical Center in New York, New York; Robert Rosenfeld of the University of Chicago Comer Children’s Hospital in Chicago, Illinois; Jerry Shapiro of the University of British Columbia in Vancouver, Canada; and Victor Montori and Brian Swiglo of Mayo Clinic in Rochester, Minnesota. Clinical assessment of body hair growth in women. Ferriman D and Gallwey JD. Journal of Clinical Endocrinology 1961; 21:1440-1447. The Ferriman-Gallwey (mFG) score is a method of evaluating and quantifying hirsutism in women, a condition where there is too much body hair.
Hair growth is rated from 0 (no growth of terminal hair) to 4 (complete and heavy cover), in nine locations, giving a maximum score of 36. In Caucasian women, a score of 8 or higher is regarded as indicative of androgen excess. With other ethnic groups, the amount of hair expected for that race should be considered. The nine locations measured are the upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, the upper arms and the thighs.
Although more objective tools are available (including photographic evaluation, microscopic measurement of hair diameter with extensive counting of shafts, computerized assessment of photographic measures, and others), these are complex, expensive, or difficult to use. The ease of use and low cost of the Ferriman Gallwey system make it a potentially attractive instrument for use in the clinic.
Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. Kathryn A. Martin, R. Jeffrey Chang, David A. Ehrmann, Lourdes Ibanez, Rogerio A. Lobo, Robert L. Rosenfield, Jerry Shapiro, Victor M. Montori, and Brian A. Swiglo. J. Clin. Endocrinol. Metab., Apr 2008; 93: 1105 - 1120. doi: 10.1210 / jc.2007-2437 Appendix: Testosterone And Androgen Testing Abstract
Objective. Our objective was to develop clinical practice guidelines for the evaluation and treatment of hirsutism in premenopausal women.
Participants. The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, two methodologists, and a medical writer. The Task Force received no corporate funding or remuneration.
Evidence. Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations, and "suggest" for weak recommendations.
Consensus Process. Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and e-mail communications. The drafts prepared by the Task Force with the help of a medical writer were reviewed successively by The Endocrine Society’s CGS, Clinical Affairs Core Committee (CACC), and Council. The version approved by the CGS and CACC was placed on The Endocrine Society’s Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes.
Conclusions. We suggest testing for elevated androgen levels in women with moderate or severe hirsutism or hirsutism of any degree when it is sudden in onset, rapidly progressive, or associated with other abnormalities such as menstrual dysfunction, obesity, or clitoromegaly. For women with patient-important hirsutism despite cosmetic measures, we suggest either pharmacological therapy or direct hair removal methods. For pharmacological therapy, we suggest oral contraceptives for the majority of women, adding an antiandrogen after 6 months if the response is suboptimal. We recommend against antiandrogen monotherapy unless adequate contraception is used. We suggest against using insulin-lowering drugs. For women who choose hair removal therapy, we suggest laser/photoepilation.
 The TS-Si News Service is a collaborative effort by TS-Si.org editors, contributors, and corresponding institutions. Sources can include the cited individuals and organizations, as well as TS-Si.org staff contributions. Articles and news reports do not necessarily convey official positions of TS-Si, its partners, or affiliates. We welcome your comments. Use the form below to leave a public comment or send private correspondence via the TS-Si Contact Page. We will not divulge any personal details or place you on a mailing list without your permission.TS-Si is dedicated to the acceptance, medical treatment, and legal protection of individuals correcting the misalignment of their brains and their anatomical sex, while supporting their transition into society as hormonally reconstituted and surgically corrected citizens.
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