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Probability diagnosis

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Constitutional (physiological or familial)

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Polycystic ovary syndrome (PCOS)

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Serious disorders not to be missed

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Cancer/tumour:

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  • virilising ovarian tumour

  • adrenal tumours (cancer and adenoma)

  • ectopic (paraneoplastic) hormone production (e.g. lung cancer, carcinoid)

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Pitfalls (often missed)

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Postmenopausal

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Rarities:

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  • porphyria cutanea tarda

  • congenital adrenal hyperplasia

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Masquerades checklist

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Drugs (many incl. phenytoin, danazol, minoxidil, anabolic steroids, cyclosporin, corticosteroids, OCP, phenothiazines, interferon 〈, penicillamine)

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Thyroid/other endocrine (prolactinaemia, Cushing, acromegaly, hypothyroidism)

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Is the patient trying to tell me something?

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Consider anorexia nervosa

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Key history

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History of age of onset, extent and activity of the hair. Family history and past medical history including endocrine disorders and drugs especially those listed opposite.

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Key examination

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  • General inspection including distribution and character of the hair growth, endocrine abnormalities (e.g. Cushing syndrome), skin, abdomen and breasts

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Key investigations

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  • Consider pituitary hormones (e.g. FSH, LH, ACTH, TSH, prolactin)

  • Serum thyroxine, testosterone, DHEAS

  • Pelvic ultrasound (?PCOS)

  • Urinary porphyrins

  • Imaging of pituitary and adrenal regions

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Diagnostic tips

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  • Mild longstanding hirsutism does not require investigation.

  • Keep in mind possibility of self-medication, especially in athletes (anabolic steroids).

  • Red flags include sudden appearance of hirsutism/virilisation and a pelvic or abdominal mass.

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