Endocrine Society GUIDELINES Bundle (free trial)

Figure 2 Notes • Local sexual hair growth (i.e., in the absence of an abnormal hirsutism score) that is not accompanied by clinical evidence of a hyperandrogenic endocrine disorder does not require an endocrine workup before embarking on dermatologic therapy (cosmetic or direct hair removal measures). • Elevated androgen levels should be ruled out in women with hirsutism or any degree of sexual hair growth who also have clinical evidence of a hyperandrogenic endocrine disorder. • Clinical evidence of menstrual irregularity, infertility, galactorrhea, signs or symptoms of hypothyroidism, Cushing syndrome, acromegaly, central obesity, acanthosis nigricans, clitoromegaly, or sudden-onset or rapid-progression hirsutism suggests the presence of a hyperandrogenic endocrine disorder. • PCOS is the most common hyperandrogenic disorder associated with hirsutism. However, androgen-secreting tumors and NCCAH are other major causes that clinicians should consider. • Drugs that cause hirsutism include anabolic or androgenic steroids (a consideration in athletes, users of dietary supplements, patients with sexual dysfunction, or in patients with a partner who uses testosterone gel) and valproic acid (a consideration in patient with neurologic disorders). • An accurate and specific assay, such as mass spectrometry, is the best choice for assessing serum total testosterone concentrations. • Norms are standardized for early morning, when levels are the highest, and for days 4–10 of the menstrual cycle a when ovarian follicle development is the most comparable to that of women with hyperandrogenic anovulation; clinicians should interpret marginal values obtained at other times accordingly. • Women with mild hirsutism, a normal total testosterone level, a pelvic ultrasound showing normal ovarian morpholog y (if performed), and no clinical evidence of other hyperandrogenic endocrine disorders have idiopathic hirsutism, which may be responsive to OC therapy. However, if the serum total testosterone is normal in the presence of moderate or severe hirsutism or if there is clinical evidence of PCOS or other endocrine disorder, clinicians should test serum-free testosterone levels. • Assessing free testosterone levels using high-quality testosterone and SHBG or equilibrium dialysis assays with well-defined reference intervals is the single most useful, clinically sensitive marker of androgen excess in women. ◆ A simultaneous assay of early-morning 17-hydroxyprogesterone is indicated in subjects at high risk for NCCAH. a ◆ Progression of hyperandrogenism in the presence of a normal serum-free testosterone is very unusual, and clinicians should thoroughly reevaluate these patients. • Unless fertility is an issue, demonstrating polycystic ovary morpholog y to diagnose ovulatory PCOS is unlikely to affect management. a See Section 5, Androgen Testing Remarks in the full text guideline. Adapted from Martin KA et al. J Clin Endocrinol Metab. 2008;93(4):1105–1120. Diagnosis

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