Medical History and Physical Examination in Patients With Possible Androgen Excess

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We outline here the basics of the medical history and physical exam in the patient suspected of suffering from androgen excess. Medical History

The timing and pace of pubertal development and its relation to complaints of unwanted hair growth, hair loss, acne, and/or obesity should be established. The onset and progression of these complaints should also be established. Drug or medication use and exposure or use of skin irritants should be elicited. A detailed menstrual history should be obtained, with an emphasis on determining whether evidence of ovulatory function (e.g., premenstrual molimina) is present. Change in skin pigmentation or texture, extremity or head size, and changes in facial contour should be noted. A detailed family history of endocrine, reproductive, or metabolic disorders should be obtained. A family history of similar hyperandrogenic signs and symptoms is a powerful clue to the inherited basis of the disorder, although a familial association can be noted for PCOS, HAIR-AN syndrome, NCAH, and IH patients. Clinicians should note that the etiology of hirsutism can often be suspected from the history alone. For example, rapid progression of androgenization, particularly appearing some time after puberty or in the menopause, is most suggestive of an ASN and not a functional cause of androgen excess.

Modified Ferriman Gallwey Score

Fig. 1. Modified Ferriman-Gallwey scoring method. The total score is obtained by adding up the individual scores in each of nine body areas. If no excess terminal hairs are noted, the area is scored as zero. (Modified from ref. 8.)

Fig. 1. Modified Ferriman-Gallwey scoring method. The total score is obtained by adding up the individual scores in each of nine body areas. If no excess terminal hairs are noted, the area is scored as zero. (Modified from ref. 8.) Physical Exam

During the physical exam it will be important to determine whether hirsutism or other hyperandrogenic features are actually present and whether there are signs or symptoms of related disorders. The type and pattern of excessive hair growth and/or acne should be noted and scored (Fig. 1). Hirsutism is defined as the presence of terminal hairs in a male-like pattern in women. Clinically, terminal hairs are generally pigmented, coarse (secondary to being medullated), and greater than 1 cm in length (if allowed to grow out). However, excessive terminal hair growth affecting only the lower legs or forearms does not constitute hirsutism, because a mixture of terminal and vellus hairs normally covers these areas. Alternatively, the excessive growth of vellus hairs, producing a "fuzzy" appearance, is termed vellus hypertrichosis and should not be considered hirsutism. Although a number of medical problems or medications can lead to vellus hypertrichosis, it is more commonly an ethnic variant (e.g., in individuals of Scandinavian or Mediterranean extraction). The presence of alopecia, acne, acanthosis nigricans, lipodystrophy, clitoromegaly, virilization and/or masculiniza-tion, pelvic and/or abdominal masses, abdominal and generalized obesity, cushingoid features, coarseness or bluntness of facial features, galactorrhea, thyroid enlargement, or signs of systemic illness should also be sought.

If the degree of androgenization is severe, resulting in clitoromegaly, severe male-pattern balding, and masculinization of the body (decrease in breast size, increase in muscle mass, loss of hip-to-waist discordance, etc.), an androgenic tumor or syndrome of severe insulin resistance (i.e., HAIR-AN syndrome) should be suspected. The presence of cushingoid features (i.e., centripetal obesity, muscle wasting of the extremities, moon facies, generalized facial rubor, or purple-red abdominal striae) in association with hirsutism is particularly worrisome, because it suggests the possibility of either an adrenocortical carcinoma or ACTH excess resulting from an ectopic or pituitary ACTH-producing tumor. The presence of acanthosis nigricans signals significant hyperinsulinism, observable in very insulin-resistant women with PCOS or in patients with the HAIR-AN syndrome.

Table 3

Pitfalls in the Biochemical Assessment of Androgen Excess

• Circulating androgen levels measure only one point in time; urinary measures are relatively nonspecific.

• Normal ranges may not be well established, particularly in adolescents and women in the later reproduc tive years.

• Wide variability in androgens levels in the normal population.

• The quality of most assays for total testosterone (T) and free T is poor and must be measured by rela tively costly and time-consuming methods for improved accuracy.

• Multiple androgens are present; the greater the number of androgens measured, the higher the fraction of patients identified as androgen excess

• Androgens are suppressed rapidly by hormonal suppression and may remain suppressed even after dis continuation of hormonal treatment

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