hirsutism case presentation
TRANSCRIPT
HIRSUTISM-CASE PRESENTATION
Department of Streeroga & Prasutitantra
HODDr.Mrs.S.S.Chaudhari
Name: xyzSex: femaleAge: 35 YearsOPD No.:27380
Chief Complaints: On Dt.14 May 2009 Irregular menses Scanty menses Since 4 years Hirsutism Weight gain
Menarche: At 14th years of agePast Menstrual History (Before 4 Yrs.):3 day/28-30 day -Reg./Med./PainlessPresent Menstrual History (Since 4 Yrs.):3 day/2-2½Month -Irreg./Scanty/PainlessMarital Status: Married since 16 Yrs.Obstetric History: G₅ P₂ A₃ L₂ D₀
1)Mch-15 yr-FTND2)Mch-12 yr-FTNDThree MTP done.
H/O Tubectomy done 10 yrs back.Personal History: NADFamily History: NAD
Examination:
Pulse- 90/minBlood Pressure- 120/80 mmHgTemperature- 98.6 F⁰Build- ObeseHeight- 145cmWeight- 65kgBMI- 31F & G Score - 10
STROTAS PARIKSHAN:Rasawaha- Twak-SnigdhaRaktawaha- Yakrit
Pleeha Not Palpable
Mansawaha- Snaya- PrabhutTwak- SnigdhaRoma- Atiloma
Medowaha- Vrikka- No tendernessKati- KatishulaSweda- Prabhut
Asthiwaha- Dant- Prakrut Nakh- Prakrut
Kesh-Krishna
Majjawaha- Akshisneha- AlpaTwakasneha- PrabhutVitsneha- Alpa
Stanyawaha- Stana- PrakrutPranawaha- Nasa- Prakrut
Kantha- PrakrutAnnawaha- Ostha- Prakrut
Jivha- SamaDanta- Prakut
Udakawaha- Talu- PrakrutJivha- SamaTrishna- Prabhut
Purishawaha- Pakwashaya- Prakrut Sthulaguda- Prakrut
Mutrawaha- Vankshana- PrakrutBasti- Prakrut
Swedowaha- Sweda- PrabhutMeda- Prabhut
ABDOMINAL EXAMINATION:INSPECTION- Fat distribution over abdominal region(Android Obesity)PALPATION-L S K⁰ ⁰ ⁰Soft Abdomen
SYSTEMIC EXAMINATION: RS- ClearCVS- S₁S₂ NormalCNS- Well conscious & oriented
GNAECOLOGICAL EXAMINATION:Per Speculum- Cx & Os-Normal
Vagina- HealthyPer Vaginal- Uterus - AV & NS
Rt. Fx- TendernessLt. Fx- Clear
INVESTIGATIONS:Hb%- 8.9 Gm%Urine- NADHIV- NRVDRL- NRUSG- Uterus-Normal size
Ovary-Normal size e/o Right Hydrosalpinx of size 7x4cm
BSL®- 85.5mg/dl
Total Testosterone- 93.51ng/dl (↑ ) (Dt.09/09/09)Total Testosterone- 68.39ng/dl (N) (Dt.09/01/10)TFT- T3 -87.7ng/dl
T4 -5.2ug/dlTSH -27.94uIU/mL(↑) ?subclinical hypothyroidism
Ayurvedic ConceptHair- Mala of Asthidhatu
Upadhatu of Majjadhatu
Pitruja Avayava
Good quality of loma mentioned in Twaksar
A person with Aloma & Atiloma mentioned in Astha Nindit
Cycle growth of hair
Several months 2 weeks 3 months
Types of hairLanugo
Fetal hair
VellusShort,fine, UnpigmentedBefore puberty
TerminalLong, coarse, pigmented arises from vellus hair
Non sexual Ambi-sexual Male sexual
Sites Lower parts of the scalp, eye brow, lashes, fore-arms, lower legs
Temporal & vertical parts of the scalp, axilla, lower pubic hair.
Ears, nasal tip, chin, sternum, upper pubic triangle, back.
Depend on Growth hormone from pituitary
Androgen in low concentration from the adrenals & ovaries in females & adrenals in male
Androgen in high concentration
Sites of hair
Androgen production Androstenedione
Testosterone
Adrenal DHEA Ovary
DHEAS
50% 50%50%
25% 25%
90% 10%
100%
Hypertrichosis Excessive growth ofLanugo, vellus or terminal hair in non-sexual sites (James et al, 2005)•CongAcquired•LocalizedGeneralized
Congenital hypertrichosis lanuginosa Drug-induced hypertrichosis
Hirsutism: Latin hirsutus = shaggy, hairy
Excessive growth of terminal hair in male sexual sites. Excessive: Socially unacceptable to the patient F& G score >8
Hirsutism is a consequence of several
factors. An increase in: 1. Androgen production
2. The sensitivity of the androgen receptors at the level of the hair follicle.
3. The activity of 5œ-reductase.
CAUSES
A. Ovarian:.PCOS: 90% {hyperandrogenism, oligo-ovulation, PCO}
.Virilizing ovarian tumors {arrhenoblastoma, hilus cell tumor, lipod cell tumor, granulosa cell tumor}
.Luteoma of pregnancy { Not true tumor but an exaggerated reaction of ovarian stroma to chorionic gonadotropins. It is solid, usually unilateral & regress after labour}
.Ovarian dysgenesis
Turner’s syndrome
B. Adrenal:•Cong adrenal hyperplasia•Tumors•Cushing syndrome
Congenital adrenal hyperplasia
C. PERIPHERAL•Idiopathic: Regular ovulation & normal androgen levels
•Insulin resistance– HAIRAN syndrome: HyperAndrogenicInsulin-Resistant Acanthosis Nigricans– 5H syndrome
acanthosis nigricans.
•Aromatase deficiency•Glucocorticoid resistance•Hyperprolactinema can cause an increase in DHEAS. TT with bromocriptin: dec PRL & DHEAS
HirsutismAnabolic steroidsDanazolMetoclopramideMethyldopaPhenothiazinesProgestinsReserpineTestosterone
HypertrichosisCyclosporineDiazoxideHydrocortisoneMinoxidilPenicillaminePhenytoinPsoralensStreptomycin
Hunter, 2003
D. Drugs
Degree of hirsutism Photography or scoring systemsa. Ferriman & Gallwey(1961): 9 areas upper lip, chin, chestupper abdomen, lower abdomen, upper arm, thighs, upper back,lower back/buttocks
minimal=1, mild=2, moderate=3, severe=4
>8 = hirsutism
Degree of hair growth (Ferriman & Gallwey,1961)
TREATMENT
Principle of Treatment-
A. To Remove the Source of Androgen
B. To Supress the Action of Androgen
C. Removal of Excess Hair
A. To Remove the Source of Androgen
Vamana Karma
Weight Reduction
B. To Supress the Action of Androgen
Hyponidd Tablets-Yashad BhasmaKarvellakaExtracts-Haridra, Tarwar, Amalaki, Jambu, Mamajavo, Meshashringi, Vijaysaar, Guduchi, Neem, Kirattikta.
To Decrease Insulin Resistance
C. Removal of Excess Hair
Lomashatan Yoga-(Sharangdhar)
Shudha Shankha Churna- 2 partShudha Hartal -1 partShudha Manahashila - ½ partShudha Swarjika kshar - 1 part
Mixed together, pasted in water & applied after waxing for 7 times.
"Once the Black Terminal Hair is produced, the changes persist even in the absence of a continuing androgen excess"