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==Overview==
==Overview==
Laboratory tests that should be done in hirsutism include testosterone level, DHEAS, and 24-hour cortisol level.


==Laboratory Findings==
==Laboratory Finding==
* Testosterone: The most important assay is the level of serum testosterone, the major circulating androgen. If the total serum testosterone level is normal, measure the free serum level because hyperandrogenism (and insulin resistance, if present) decreases sex steroid-binding globulin, such that the unbound, biologically active testosterone moiety may be elevated even if the total level is unremarkable. Extremely high testosterone levels are likely to be associated with adrenal or ovarian tumors, whereas idiopathic and benign etiologies result in very mild elevations. Indeed, in idiopathic hirsutism, the results from testing androgen levels are often normal. In some of these women, hirsutism is thought to be caused by increased skin sensitivity to androgen or by increased skin 5-alpha-reductase activity. This enzyme is located in the skin near the hair follicle, and it converts plasma testosterone to the androgen metabolite dihydrotestosterone.
===Testosterone===
* Dehydroepiandrosterone sulfate (DHEAS): Because testosterone can originate in either the adrenal cortex or the ovary, an elevated testosterone level does not indicate the gland of origin. Accordingly, measurement of elevated plasma levels of DHEAS, an androgen synthesized almost exclusively by the adrenal cortex, can indicate excess adrenal function. Elevations in both testosterone and DHEAS suggest an adrenal origin, whereas an isolated testosterone elevation indicates an ovarian source.
*Serum testosterone may be normal to increased in case of [[PCOS]] and [[CAH]] but would be definitely raised (>200 ng/ml) in case of [[malignant]] tumor of the [[Adrenal gland|adrenal]] or [[ovary]].<ref name="pmid18574213">{{cite journal |vauthors=Lin-Su K, Nimkarn S, New MI |title=Congenital adrenal hyperplasia in adolescents: diagnosis and management |journal=Ann. N. Y. Acad. Sci. |volume=1135 |issue= |pages=95–8 |year=2008 |pmid=18574213 |doi=10.1196/annals.1429.021 |url=}}</ref>
* Dexamethasone suppression (see the image above): Laboratory testing of testosterone (free or total) and DHEAS can be performed on the initial visit. At the same time, a diagnostic trial of dexamethasone therapy for 7-14 days can be initiated to help exclude adrenocorticotropin hormone (ACTH)–dependent hirsutism. When the patient returns, free testosterone, DHEAS, and plasma cortisol levels are measured. Dexamethasone-mediated suppression of androgens is observed in healthy women who do not have hirsutism and in those with congenital adrenal hyperplasia (CAH) and idiopathic hirsutism.
===DHEAS===
* Adrenocorticotropin stimulation: An ACTH-stimulation test (250 mcg for 30 min) can help differentiate between CAH and idiopathic hirsutism because CAH produces abnormal findings (elevations in metabolic precursors of cortisol).
*[[DHEAS|Dehydroepiandrosterone sulfate (DHEAS)]]: Raised [[DHEAS]] (>700 μg/dl) always indicates an adrenal cause, [[benign]] or [[malignant]].
** Hirsutism caused by CAH is due to 1 of 3 cortisol biosynthetic defects, ie, 21-hydroxylase deficiency, 3 3 β -hydroxysteroid dehydrogenase, or 11-β -hydroxylase deficiency.
===17-Hydroxyprogesterone===
** Because 21-hydroxylase deficiency accounts for the vast majority of cases of CAH (approximately 90%), the discussion is focused on this diagnosis. Investigate possible 21-hydroxylase deficiency by measuring plasma 17-hydroxyprogesterone levels obtained between 0700 and 0900 hours. Values of less than 7 nmol/L exclude the diagnosis, and values of greater than 45 nmol/L (in women who are nongestational) confirm 21-hydroxylase deficiency. When basal values of 17-hydroxyprogesterone are between 7 and 45 nmol/L, an ACTH-stimulated concentration of greater than 45 nmol/L is also diagnostic.
* [[17-Hydroxyprogesterone|17 Hydroxy progesterone]]: Levels less than 200 ng/dl excludes [[CAH]]. Mildly increased levels between 300 and 1,000 ng/dl require an [[ACTH]] stimulation test. [[Cosyntropin]] (synthetic [[ACTH]]), 250 μg, is administered intravenously, and levels of [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] are measured before and one hour after the injection. Post-stimulation values (>1,000 ng/dl) constitute a positive test.<ref name="pmid18574213">{{cite journal |vauthors=Lin-Su K, Nimkarn S, New MI |title=Congenital adrenal hyperplasia in adolescents: diagnosis and management |journal=Ann. N. Y. Acad. Sci. |volume=1135 |issue= |pages=95–8 |year=2008 |pmid=18574213 |doi=10.1196/annals.1429.021 |url=}}</ref>
** Although elevated basal plasma 17-hydroxyprogesterone levels (as high as 17 nmol/L) may be present during the luteal phase of the menstrual cycle and in PCOS, ACTH-stimulated increments are blunted.
===24-hour urinary cortisol===
* Cortisol suppression: Investigation of subnormal dexamethasone suppression of androgens can be guided by the patient’s cortisol level, without the need for an ACTH-stimulation test. PCOS and adrenal and ovarian tumors are associated with normal suppression of cortisol by dexamethasone, whereas cortisol levels in patients with Cushing syndrome are not suppressed.
* Twenty four hour urine free [[cortisol]] should be measured in women with signs and symptoms of [[Cushing's syndrome]].
Other laboratory tests include the following:
===LH/FSH ratio===
* Serum prolactin or FSH: Women with hirsutism and amenorrhea of unknown cause should have a serum prolactin or FSH test to evaluate for either a prolactinoma or ovarian failure.
* [[LH]]/[[FSH]] greater than 3 is indicative of [[PCOS]].<ref name="pmid10352925">{{cite journal |vauthors=Chang RJ, Katz SE |title=Diagnosis of polycystic ovary syndrome |journal=Endocrinol. Metab. Clin. North Am. |volume=28 |issue=2 |pages=397–408, vii |year=1999 |pmid=10352925 |doi= |url=}}</ref>
* Diabetes screening: Women with hirsutism, PCOS, obesity, or acanthosis nigricans may have insulin resistance, and screening for diabetes and hyperlipidemia is warranted. Approximately 50% of these women have increased insulin levels and 5% have undiagnosed diabetes mellitus.
===Serum TSH===
* Prostate-specific antigen (PSA): Ultrasensitive assays can detect PSA in women and is a potential marker for androgen excess. Studies thus far, however, have not shown a good correlation with the change in androgen levels after treatment. Therefore, further studies are needed. <sup>[[null 11]]</sup><ref name="urlHirsutism Workup: Laboratory Studies, Imaging Studies">{{cite web |url=http://emedicine.medscape.com/article/121038-workup |title=Hirsutism Workup: Laboratory Studies, Imaging Studies |format= |work= |accessdate=}}</ref>
* Serum [[TSH]] and [[Prolactin]]: [[Hypothyroidism]] and [[hyperprolactinemia]] can lead to hirsutism.<ref name="pmid1905280">{{cite journal |vauthors=Schmidt JB, Lindmaier A, Spona J |title=[Hyperprolactinemia and hypophyseal hypothyroidism as cofactors in hirsutism and androgen-induced alopecia in women] |language=German |journal=Hautarzt |volume=42 |issue=3 |pages=168–72 |year=1991 |pmid=1905280 |doi= |url=}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Needs content]]
[[Category:Endocrinology]]
[[Category:Integumentary system]]
[[Category:Gynecology]]
[[Category:Dermatology]]
[[Category:Hair-related diseases]]
{{WH}}
{{WS}}

Latest revision as of 13:43, 10 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Rasam Hajiannasab M.D.[2], Ahmed Younes M.B.B.CH [3]

Overview

Laboratory tests that should be done in hirsutism include testosterone level, DHEAS, and 24-hour cortisol level.

Laboratory Finding

Testosterone

  • Serum testosterone may be normal to increased in case of PCOS and CAH but would be definitely raised (>200 ng/ml) in case of malignant tumor of the adrenal or ovary.[1]

DHEAS

17-Hydroxyprogesterone

  • 17 Hydroxy progesterone: Levels less than 200 ng/dl excludes CAH. Mildly increased levels between 300 and 1,000 ng/dl require an ACTH stimulation test. Cosyntropin (synthetic ACTH), 250 μg, is administered intravenously, and levels of 17-hydroxyprogesterone are measured before and one hour after the injection. Post-stimulation values (>1,000 ng/dl) constitute a positive test.[1]

24-hour urinary cortisol

LH/FSH ratio

Serum TSH

References

  1. ↑ 1.0 1.1 Lin-Su K, Nimkarn S, New MI (2008). "Congenital adrenal hyperplasia in adolescents: diagnosis and management". Ann. N. Y. Acad. Sci. 1135: 95–8. doi:10.1196/annals.1429.021. PMID 18574213.
  2. ↑ Chang RJ, Katz SE (1999). "Diagnosis of polycystic ovary syndrome". Endocrinol. Metab. Clin. North Am. 28 (2): 397–408, vii. PMID 10352925.
  3. ↑ Schmidt JB, Lindmaier A, Spona J (1991). "[Hyperprolactinemia and hypophyseal hypothyroidism as cofactors in hirsutism and androgen-induced alopecia in women]". Hautarzt (in German). 42 (3): 168–72. PMID 1905280.
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