What is the cause of hirsutism in a 70-year-old female?

From the Guidelines

Hirsutism in a 70-year-old woman requires prompt evaluation for underlying malignancy, particularly adrenal or ovarian tumors. The sudden onset of excessive hair growth in postmenopausal women is concerning and warrants comprehensive workup including serum testosterone, DHEAS, androstenedione, 17-hydroxyprogesterone, and pelvic/adrenal imaging, as other causes of androgen excess such as Cushing's syndrome, androgen-secreting tumors of the ovary or adrenal gland, and nonclassic (late-onset) congenital adrenal hyperplasia need to be excluded 1. Initial management should include referral to endocrinology and possibly gynecology. While awaiting diagnosis, cosmetic treatments like topical eflornithine (Vaniqa) cream applied twice daily to affected areas can slow hair growth. Some key points to consider in the evaluation and management of hirsutism in a 70-year-old woman include:

• Physical hair removal methods such as shaving, waxing, or laser therapy may provide temporary relief
• Pharmacologic treatments might include spironolactone 25-100mg daily (monitoring potassium levels) or finasteride 2.5-5mg daily, though these address symptoms rather than the underlying cause
• The pathophysiology typically involves androgen excess, which in older women often stems from androgen-secreting tumors rather than conditions like PCOS that affect younger women
• Age-related changes in hormone metabolism and receptor sensitivity may also contribute Given the patient's age, new-onset hirsutism should never be dismissed as a benign condition, and thorough investigation is essential to rule out malignancy.

From the Research

Hirsutism in a 70-year-old Lady

• Hirsutism is defined as excessive terminal hair growth in androgen-dependent areas of the body in women, which grows in a typical male distribution pattern 2.
• The condition is often associated with a loss of self-esteem and can be a sign of excessive androgen levels 3.
• Polycystic ovary syndrome and idiopathic hirsutism are the most common causes of the condition, accounting for more than 85% of cases 3.
• Less common causes of hirsutism include idiopathic hirsutism, nonclassic congenital adrenal hyperplasia, androgen-secreting tumors, medications, hyperprolactinemia, thyroid disorders, and Cushing syndrome 3.

Diagnosis of Hirsutism

• A woman's history and physical examination are particularly important in evaluating excess hair growth 2.
• The Ferriman-Gallwey scoring system can be used to evaluate hirsutism, and women with an abnormal score should be evaluated for elevated androgen levels 3.
• Laboratory tests such as serum testosterone level, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, prolactin, and thyrotropin levels can help diagnose the cause of hirsutism 4.
• A serum testosterone level >200 ng/dL is highly suggestive of adrenal or ovarian tumor 2, while a level > 150 ng/dl (5.2 nmol/l) should prompt further investigations to exclude an underlying androgen-secreting tumour 5.

Treatment of Hirsutism

• Treatment of hirsutism should be based on the degree of excess hair growth presented by the patient and in the pathophysiology of the disorder 2.
• Recommended pharmacologic therapies include combined oral contraceptives, finasteride, spironolactone, and topical eflornithine 3.
• Lifestyle therapies, androgen suppression, peripheral androgen blockage, and cosmetic treatments can also be effective in treating hirsutism 2, 5.
• Combination therapy is often the most effective approach, and women should be warned not to expect improvement for at least 3-6 months after therapy is begun 5.