Referral Guidelines are peer reviewed guidelines developed to assist referring providers in their approach to a patient presenting with common signs or symptoms suggestive of an endocrine condition, and when to refer to Pediatric Endocrinology.
Symptoms/signs:
• Excessive terminal hair growth in locations typically seen in adult males (face, sternum, lower abdomen, back, and thighs)
• Can be associated with other signs associated with androgen excess, such as acne and irregular periods
• History of premature adrenarche may be present
Family history:
• Family history of hirsutism and/or polycystic ovarian syndrome (PCOS) may be present
Refer to Differential Diagnosis section
Blood tests:
• Total and free testosterone (assay for women and children)
• DHEAS
• Androstenedione
• 17 OH progesterone
• TSH
Radiologic studies:
• Pelvic ultrasound for very elevated testosterone levels
Other tests to consider after consultation with Pediatric Endocrinologist:
• Prolactin
• ACTH stimulation test for androgens
Urgent:
Concern for tumor:
• Total testosterone >200 ng/dl
• DHEAS >700 mcg/dl
Concern for non classic CAH:
• Elevated 17 OH progesterone
Routine:
• Laboratory findings at or just above the normal ranges
- Previous growth data/growth charts
- Pertinent medical records
- Recent laboratory studies
Physiologic hyperandrogenism of puberty
- Idiopathic hyperandrogenism
- PCOS Less commonly:
- Congenital Adrenal Hyperplasia (CAH): late onset CAH, mild CAH, non classic/virilizing CAH
- Androgen secreting tumors of the adrenal glands or ovaries
- Hypothyroidism
- Cushing’s disease
- Severe hyperprolactinemia
- Hypertrichosis
- Exposure to androgenic drugs
- Hirsutism affects 5–10% of reproductive-aged females
- Diagnosis of hyperandrogenism can be based on clinical symptoms or measurement of serum androgens. In females, androgens originate from three primary sources:
(1) the ovarian theca,
(2) the adrenal cortex, and
(3) within end organs by peripheral conversion.
The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:
- Pelvic ultrasonography is not routinely indicated unless serum androgen levels or the degree of virilization is concerning for an ovarian tumor.
- Multimodal therapy is the most effective approach to the treatment of hirsutism; this includes lifestyle changes, physical hair removal, and androgen suppression or blockade with medication that slows or prevents new hair growth.
- If hormonal therapy is initiated, patients should be counseled that it may take >6 months before they see the benefits of treatment.
- Patients should be assessed at routine intervals (every 3–6 months) for adverse effects and response to treatment until their condition is stable; they then should be monitored annually.
- Monitoring serum androgens is not recommended.
Paola Palma Sisto
June 23, 2021