While lab tests are important in determining hirsutism, there are limitations because they do not always determine the diagnosis. In today's technology driven world, we believe that lab tests make a condition "real." This is not always the case. Lab tests do not tell us what is wrong with someone, but simply aid in doing so. Symptoms may be present and lab tests may be ordered if a disease is suspected. Diseases like tumors or cancer on the ovaries or adrenal glands or Cushing's syndrome can be determined or eliminated as the cause of the hirsute condition through testing. A negative result does not mean that there is no problem, just that a particular disease is not present.
Hirsutism is always due to androgens. Androgens are commonly known as male hormones; but both men and women actually have effective levels of androgens in their blood just as men have estrogen in theirs. Prior to puberty, androgen levels are almost impossible to measure in both girls and boys. After puberty, males have approximately 10 times more androgen in their blood than females.
Testosterone is the most active androgen, but there are several others such as androstenedione and DHEA. Androstenedione and DHEA do not directly affect hair growth, but they do when they are converted to testosterone. Both the ovary and the adrenal gland release testosterone. If the blood level of testosterone is elevated, it is important to find out whether it is coming from the ovary, the adrenal or both. Tests are required to determine the source.
A common test for determining these elevated testosterone levels uses a drug similar to cortisone to suppress the adrenal for about a week. Any testosterone still left in the blood is generated by the ovaries. The levels after the test determine whether the main source is the adrenal or the ovary. If the testosterone levels were 100 prior to the test and 20 after the test, the test shows that the adrenals are the main source of the testosterone production. If the value was 85, then it shows that the ovaries are the main source.
Poly-cystic ovary syndrome (PCOS) is usually the blanket diagnosis for these increased levels of testosterone in women; however, this is not an accurate description of the condition. PCOS is a collection of conditions that may include: infrequent periods, failure of the ovary to release an egg cell, obesity and hirsutism. In classic PCOS obesity, the added weight tends to be on the upper body with the hips and legs usually being thin.
When high testosterone levels seem to begin at or after menopause, the cause is often a condition called "thecal cell hyperplasia." The theca cells are in the ovary and make testosterone. In females, androstenedione is released into the blood by theca cells. The function of this is to provide androstenedione base for estrogen production in granulosa cells, since these cells lack a particular enzyme required for androstenedione. Theca cells lack an enzyme required to make estrogens themselves. Thus, theca cells and granulosa cells work together to form estrogen. This condition may be the result of late onset PCOS, but the actual cause is unknown.
Sometimes ovarian androgen excess is measured, but the woman lacks most of the features of PCOS – this diagnosis has no term. This is also true when the testosterone comes from the adrenal. A hereditary form of this adrenal condition is called "late onset adrenal hyperplasia." Severe cases of the hereditary adrenal condition may be confirmed by a lab test, but mild cases usually are not. This means that a small number of adult women with hirsutism have this condition known as late onset adrenal hyperplasia. But for the common, milder forms, this term is not really appropriate and to label the woman with PCOS when she does not display all of the characteristics can be emotionally upsetting.
The reason why tests may come back with normal levels of androgens is because hirsutism is not always caused by high levels of androgen in women, but by their actions. It is possible, although not usually the case, to have high levels of androgens and not have increased hair growth. Women who have normal levels of androgen, but still display signs of hirsutism like increased hair growth around nipples, abdomen, underarm, facial hair and genital hair, may actually have very sensitive skin that acutely responds to the actions of the androgens.
Testosterone levels in women are their highest in their late teens or early twenties. These levels will continue to decline until menopause when they are traditionally very low. Active hair follicles are stimulated by testosterone and will produce hair. A woman with hirsutism might have had excessive testosterone levels in her early twenties but by her midforties, when tested, the testosterone levels may actually test normal or low. The stimulation was started in the twenties and because testosterone levels fluctuate, any physical or emotional stress may have caused a flood of testosterone and trigger sensitive follicles to produce excessive hair growth. Due to these fluctuations, small increases in testosterone that could trigger hair growth may be too small to be detected in tests. Also, the fluctuations at the time of testing the levels of testosterone may be determined to be normal.
Increased testosterone levels in the adrenals and ovaries are just one explanation for hirsutism. If tests prove that the client's ovaries and adrenals are working fine but they still have too much hair, this can often be confusing to the client and their physician. Some people have follicles that are so sensitive to testosterone that even normal levels stimulate them. In fact, this is by far the most common reason for increased hair growth in women. Women with sensitive follicles do not have a hormonal disorder at all.
Tests should be carried out to eliminate diseases such as tumors and cancer or serious hormone imbalances. If tests prove that either the adrenals or ovaries are producing too much testosterone, there are medications that will control this imbalance. Birth control pills or other hormonal contraceptives, which contain the hormones estrogen and progestin, treat hirsutism by inhibiting androgen production by ovaries. Anti-androgen drugs block androgens from attaching to their receptors in the body. The most commonly used anti-androgen for treating hirsutism is spironolactone (Aldactone). These anti-androgens protect the hair follicles against testosterone. A topical cream such as Eflornithine, commonly known as Vaniqa, is a prescription cream specifically for excessive facial hair in women. It is applied directly to the affected area of the face and helps slow new hair growth, but does not get rid of existing hair. Eflornithine may take up to two months to work, and hair growth returns to pre-treatment levels within eight weeks of discontinuing the medication. After beginning a medication for hirsutism, it usually takes a month before the client notices a significant difference in hair growth. It is recommended that the client continues taking the medication for six months before changing or adding medications or changing doses. Of course, electrolysis and laser hair removal are the long proven methods of getting rid excess hair growth.
The frustration your client feels may come from the fact that physicians might dismiss the excessive hair growth because the test results show no overproduction of testosterone. Your client should be relieved that their test results were normal but should continue to search for the underlying cause of the condition. As technicians, we should continue to work with the client to find solutions to control the hair growth and offer information that will assist them in their search.