Hirsutism: evaluation and treatment: a reader's dilemma.

Sir,

I have read with interest the review article ′Hirsutism: Evaluation and treatment′ published in your journal (Year: 2010, Volume: 55, Issue: 1, Page: 3-7).[1] Unfortunately, this review on a common and important condition contains a few inconsistencies that I would like to bring to your notice.

The definition of hirsutism stated in the article is perhaps not appropriate. The author has defined hirsutism as, “the presence of terminal coarse hair in females in a male-like distribution”. However, the mere presence of terminal hair is not diagnostic of hirsutism. It is the presence of ′excessive′ terminal hair in females in a male-like distribution that signifies hirsutism.[23] The actual threshold for excessiveness varies widely according to ethnicity and individual perception. The Ferriman-Gallwey scale recognizes this fact by putting the cut-off value at 8, which means that some terminal hair in women in male-like distribution is normal.

In the etiology section, it was mentioned that ′Hirsutism can also occur in some premenopausal women and continue for a few years after menopause.′ It would have been more appropriate if the term ′premenopausal′ were replaced with ′perimenopausal′. The author has quoted a reference (ref. no 8 in the article and ref. no 3 in our letter) that dealt with the management of hirsutism in premenopausal women, which did not contain anything supporting the author's statement regarding the etiology of perimenopausal hirsutism.

Contrary to the statement in the pathogenesis section that a ′majority of Tst is secreted either by the ovaries or adrenals (80%)′, 50 – 65% testosterone in normal women is synthesized in the peripheral tissues from the precursor molecules.[45]

In the ‘Clinical Feature’ section, the author has mentioned that due to subjective variation, the ’Ferriman and Gallwey’ scoring was not universally adopted. However, the causes of non-acceptance are multiple. Other than subjective variation they are, racial variation in cut-off value, not paying due attention to other androgen-dependent sites like sideburns and buttocks, and neglecting focal hirsutism.[6] In India, with its multi-ethnic background, the inter-racial variation of the cut-off value is very important. The other important scoring system devised by Lorenzo has not been mentioned at all.

Factors such as family history, body mass index, waist-hip ratio, skin tag, acanthosis nigricans, and galactorrhea are missing in the section on evaluation.

The cut-off value of total testosterone, to signify adrenal or ovarian neoplasm, is off the mark. It should be 2 ng / ml and any value more than this will signify an adrenal or ovarian neoplasm, both benign and malignant (not malignant only as claimed by the author). There is no mention of the free testosterone level and its importance, in the whole article. The timing of testosterone estimation (early morning, day four to day ten)[6] is also missing.

The author should have mentioned the depilatory and epilatory methods separately. Plucking and waxing removes hair, including their roots and hence they are the epilatory methods. Shaving and hair removing cream (not mentioned in the article) only remove hair from the skin surface and they are the depilatory methods.[46]

The author has mentioned that the LASER works on a selective photothermolysis principle destroying the target melanin. Actually, melanin is the chromophore that absorbs the light, and the actual target for destruction is the hair follicle and its stem cells.[7] Intense pulse light as a tool of hair removal has been overlooked.

Contrary to the statement that ′Drugs are indicated for treatment when hyperandrogenism is confirmed by various laboratory tests′, drugs are used with success in idiopathic hirsutism (IH), which by definition includes cases of hirsutism without the laboratory feature of hyperandrogenism. Multiple studies confirm the role of medical treatment in IH.[89]

The importance of the progestin content in oral contraceptive pills (OCP) and their specific role in hirsutism has been overlooked. Drospirenone, one of the two antiandrogenic progesterones (the other is cyproterone acetate) has not even been mentioned.

In the section on adrenal suppression by glucocorticoids, the author wrote, “The main use of corticosteroids has been to treat hirsutism associated with congenital adrenal hyperplasia (CAH).” Actually, the non-classical or late-onset CAH (NCCAH) is the most important variant of CAH, from a dermatologist's point of view. In hirsutism, in NCCAH, cyproterone acetate is more effective in reducing hirsutism than hydrocortisone.[1011] In the published guidelines, this view has also been supported and dexamethasone is only advised to be added if a patient with hirsutism, with NCCAH, has an inadequate response to OCPs and / or antiandrogens, and develops intolerance to those agents or asks for ovulation induction.[6] The other study quoted by the author regarding bedtime dosing of dexamethasone (ref no 25 in the article and ref no 10 in this letter) was not studied in CAH patients at all (excluded in the initiation of study) and so its reference in context with CAH means the author had possibly not gone through the complete study while quoting it.

The role and significance of metformin and thiazolidinediones in hirsutism have not been discussed (although some authors recommend against their use,[6] others have found their use encouraging, particularly in PCOS[12]). Bromocriptine also remains unmentioned.