Practice Rational testing

Investigating hirsutism

BMJ 2009; 338 doi: (Published 28 April 2009) Cite this as: BMJ 2009;338:b912
  1. T Sathyapalan, specialist registrar in diabetes1,
  2. Stephen L Atkin, professor of academic endocrinology2
  1. 1Endocrinology and General Medicine, Michael White Diabetes Centre, Hull Royal Infirmary, Hull HU3 2RW
  2. 2Diabetes and Metabolism, Hull-York Medical School, Hull Royal Infirmary
  1. Correspondence to: S L Atkin Stephen.Atkin{at}

    When should we test for clinical hyperandrogenism and what are the best tests?

    Learning points

    • Clinical hirsutism is usually caused by polycystic ovary syndrome or is idiopathic (has no other clinical or biochemical abnormality)

    • Initial tests should: assess biochemical hyperandrogenaemia by measuring total testosterone, sex hormone binding globulin, and free androgen index; include thyroid function tests and prolactin measurements; and if clinically indicated, rule out non-classic congenital adrenal hyperplasia by measuring 17-hydroxyprogesterone and Cushing’s syndrome by measuring 24 hour urinary cortisol

    • Ultrasonographic imaging of ovaries is not needed to diagnose polycystic ovary syndrome in patients with menstrual disturbances and clinical or biochemical evidence of hyperandrogenism

    The patient

    A 29 year old woman presented to her general practitioner because of facial hair that had worsened over the past three years. Her menarche had been at the age of 13 and her menstrual cycle was regular at 30 days. Her weight had been stable over the past two years, but she had previously put on 10 kg in weight over 18 months. She had an unremarkable medical history and was not taking any drugs. She had a body mass index of 34 and coarse terminal hair on her upper lip, chin, and stomach. No signs of virilisation (deepening of the voice, clitoromegaly, and loss of female body shape) were seen.

    What is the next investigation?

    Hirsutism is the presence of excess hair growth in women as a result of increased androgen production or increased skin sensitivity to androgens, or both. It should be distinguished from hypertrichosis, which is androgen independent and causes uniform growth of non-terminal (vellus) hair over the body, particularly in non-sexual areas; this condition can be familial, related to drugs …

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