Hirsutism , Virilism, Gynaecomastia, Impotence

1. Hirsutism , Virilism, Hirsutism , Virilism,
gynaecomastia, gynaecomastia,
impotenceimpotence

2. HirsutismHirsutism is common (10% of women)and is common (10% of women)and
usually benign . usually benign .
It implies increased hair growth in women , in It implies increased hair growth in women , in
the male pattern . the male pattern .
If menstruation is normal there is almost If menstruation is normal there is almost
certainly no increased testosterone certainly no increased testosterone
production. production.
If menstruation is abdominal the cause is usually If menstruation is abdominal the cause is usually
polycystic ovary syndrome. polycystic ovary syndrome.
(stein – Levelthl syndrome): bilateral polycystic (stein – Levelthl syndrome): bilateral polycystic
ovaries; secondary oligomenorrhoea; ovaries; secondary oligomenorrhoea;
infertility ; obesity, Hirsutism . infertility ; obesity, Hirsutism .
The cause is androgen hypersecretion.The cause is androgen hypersecretion.

3. TestsTests: :
Ultrasound Ultrasound ↑plasma LH:FSH ratio, ↑plasma LH:FSH ratio,
and less consistently,and less consistently,
↑ ↑ testosterone and ↑ oestradiol.testosterone and ↑ oestradiol.
Another cause of Hirsutism with irregular Another cause of Hirsutism with irregular
menses is late-onset congenital adrenal menses is late-onset congenital adrenal
hyperplasia – deficiency of 21-hyperplasia – deficiency of 21-
hydroxylase enzyme in the adrenal hydroxylase enzyme in the adrenal
gland. Ovarian tumours are a rare gland. Ovarian tumours are a rare
cause.cause.

4. ManagementManagement: :
operative . Explain that she is not turning into a man operative . Explain that she is not turning into a man
Depilation with wax or creams, or electrolysis (which is Depilation with wax or creams, or electrolysis (which is
expensive , and time-consuming, but does work).expensive , and time-consuming, but does work).
1:10 hydrogens help by increasing serum sex 1:10 hydrogens help by increasing serum sex
hormone-binding globulin – but always combine with hormone-binding globulin – but always combine with
a progesterone (= the Pill) to prevent excess risk of a progesterone (= the Pill) to prevent excess risk of
uterine neoplasia or cyproterone acetate ( an anti-uterine neoplasia or cyproterone acetate ( an anti-
androgen and progestogen ), eg up to 00 mg on days androgen and progestogen ), eg up to 00 mg on days
1–11, with oestrogen on days 1–21.1–11, with oestrogen on days 1–21.
Clomifene (= clomiphene) or infertility.Clomifene (= clomiphene) or infertility.

5. Virilism Virilism isis rarerare. .
It is characterized by amenorrhoea: It is characterized by amenorrhoea:
climoromegaly; climoromegaly;
deep voice;deep voice;
temporal hair recession; Hirsutism. temporal hair recession; Hirsutism.
This condition needs further This condition needs further
investigations for androgen investigations for androgen
secreating adrenal and ovarian secreating adrenal and ovarian
tumours.tumours.

6. GynaecomastiaGynaecomastia: :
implies an abnormal amount of breast tissue in implies an abnormal amount of breast tissue in
males (it may occur in normal puberty). males (it may occur in normal puberty).
It is due to an increase in the It is due to an increase in the
oesterogen/androgen ration. oesterogen/androgen ration.
It is seen in syndromes of androgen deficiency It is seen in syndromes of androgen deficiency
(eg Klinefleter’s, Kallman’s). (eg Klinefleter’s, Kallman’s).
It may result from liver disease or testicular It may result from liver disease or testicular
tumours (oestrogenstumours (oestrogens ↑), ↑),
or accompany hyperthyroidism . or accompany hyperthyroidism .

7. The commonest causes are drugs: The commonest causes are drugs:
oestrogens, especially stiboestrol oestrogens, especially stiboestrol
(= diethylistible-strol); (= diethylistible-strol);
spironolactone; spironolactone;
cimetidine ; cimetidine ;
digoxin; digoxin;
testosterone; testosterone;
marijuanamarijuana

8. Impotence: Impotence:
Failure in adult male to sustain adequate erection for Failure in adult male to sustain adequate erection for
viginal penetration . viginal penetration .
It is common in old age. It is common in old age.
Psychological causes are common and are more Psychological causes are common and are more
likely if impotence occurs only in some situations; likely if impotence occurs only in some situations;
if there is a clear stress to account for the onset of if there is a clear stress to account for the onset of
the impotence, and if early morning erections the impotence, and if early morning erections
occur (although these may persist at the onset of occur (although these may persist at the onset of
organic disease) . organic disease) .
Psychological causes may exacerbate organic Psychological causes may exacerbate organic
causes. causes.
The major organic cause is diabetes. The major organic cause is diabetes.

9. Other organic causes are:Other organic causes are:
Drug causes:
Antihypertensives including diuretics and B –Antihypertensives including diuretics and B –
blockers), blockers),
major transquillizers, major transquillizers,
alcohol , alcohol ,
Oestrogens , Oestrogens ,
antidepressants, antidepressants,
cimetidine. cimetidine.

10. Pathological causes: Pathological causes:
Hyperthyroidism, Hyperthyroidism,
hypepgonadism,hypepgonadism,
MS, MS,
autonomic neuropahy, autonomic neuropahy,
atheoma, atheoma,
bladder-neck surgery, bladder-neck surgery,
prolactin ↑, prolactin ↑,
cirrhosis, cirrhosis,
cancer.cancer.

11. Tests:Tests:
UCEs, UCEs,
LFT, LFT,
Glucose, Glucose,
TFT; TFT;
LH; LH;
FSH; FSH;
cholestrol; cholestrol;

12. testosterone (eg if libido ↓) Nocturnal testosterone (eg if libido ↓) Nocturnal
tumescence studies are not usually tumescence studies are not usually
needed if alprostadial does not needed if alprostadial does not
induced erection, the cause is induced erection, the cause is
probably vasscular. probably vasscular.
Doppler may show ↓ blood flow, Doppler may show ↓ blood flow,
but is rarely needed as vascular but is rarely needed as vascular
reconstruction is difficult.reconstruction is difficult.

13. Treatment:Treatment:
Mange underlying causes. Mange underlying causes.
Offer counseling Offer counseling ++ vacuum aids; vacuum aids;
implants; implants;
alprostadil, ie prostaglandin E1 (Injection or via urethra); alprostadil, ie prostaglandin E1 (Injection or via urethra);
or sildenafil (Viagra), a phosphodiesterase inhibitor – or sildenafil (Viagra), a phosphodiesterase inhibitor –
increases GMP levels. increases GMP levels.
It is effective and administrated orally, SE; headache (16%); It is effective and administrated orally, SE; headache (16%);
flushing (10%); flushing (10%);
dyspepsia (7%); dyspepsia (7%);
nasal congestion (40%); nasal congestion (40%);
mild, transient. mild, transient.
Predominantly blue/green tingeing of vision (due to inhibition Predominantly blue/green tingeing of vision (due to inhibition
of isoenzyme of PDE6 in the retina or increased pulsatile of isoenzyme of PDE6 in the retina or increased pulsatile
choroidal flow)choroidal flow)

14. Contraindications to sildenafil (Viagra)Contraindications to sildenafil (Viagra)
Concurrent use of nitrates Concurrent use of nitrates
Hepatic impairmentHepatic impairment
BP > 90/50 mmHG BP > 90/50 mmHG
Recent strokeRecent stroke
Recent myocardial infraction Recent myocardial infraction
Bleeding disordersBleeding disorders
Degenerative retinal disorders Degenerative retinal disorders
Active peptic ulcerationActive peptic ulceration

15. Other causations:Other causations:
Peyronie’s disease Peyronie’s disease
Risk of priapmism (sickle cell anaemia, myeloma , Risk of priapmism (sickle cell anaemia, myeloma ,
leukemia)leukemia)
Concurrent complex antihypertensive régimentsConcurrent complex antihypertensive régiments
Dyspnoea on minimal effort (sexual activity may be Dyspnoea on minimal effort (sexual activity may be
unsupportable)unsupportable)
There is a theoretical risk of interactions with There is a theoretical risk of interactions with
inhibitors of cytochrome, inhibitors of cytochrome,
such as cimetidine. such as cimetidine.
Use in men with severe coronary disease has been a Use in men with severe coronary disease has been a
question, but in one careful study, question, but in one careful study,
no adverse cardiovascular effects of were detected in no adverse cardiovascular effects of were detected in
men with severe coronary artery disease.men with severe coronary artery disease.