Hirsutism, virilism, gynaecomastia and impotence

• Common in women ~ 10%, usually benign
• Implies hair growth in women in the male pattern
• Causes;
  • Familial
  • Idiopathic
  • Due to increased androgen secretion which may be due to;
    • Increased androgen secretion from the ovary
      • Polycystic ovary syndrome
      • Ovarian cancer
    • Increased androgen production by the adrenal gland;
      • Late onset congenital adrenal hyperplasia
      • Cushing’s syndrome
      • Adrenal cancer
    • Drugs e.g. steroids

Polycystic ovary syndrome

• Causes secondary oligo- or amenorrhoea, infertility, obesity, acne and hirsutism
• Tests – ultrasound shows polycystic ovaries
• Bloods – increased androgens, decreased sex hormone binding globulin, ­LH:FSH ratio
• Treatment – metformin may restore regular cycles and fertility in some

Management

• Local measures
• Oestrogens may increase sex hormone binding globulin and therefore decrease fee androgens
• An alternative is cyproterone acetate an anti-androgen and progestogen, given with oestrogen (it is teratogenic so make sure you sort out contraception)

Virilism

• Development of male secondary sexual characteristics in the female – amenorrhoea, cliteromegaly, deep voice, temporal hair recession and hirsuitism
• Associated with androgen producing tumours of the adrenal and ovaries so investigate

Gynaecomastia

• Abnormal breast tissue in males – may occur in normal puberty
• There is an increase in the oestrogen:androgen ratio
• Cause;
  • Hypogonadism
  • Liver cirrhosis (increased oestrogen)
  • Hyperthyroidism
  • Drugs – oestrogens, spironolactone, digoxin, testosterone, marijuana
  • Tumours
    • Oestrogen producing – testicular, adrenal
    • hCG producing – testicular, bronchial

Erectile dysfunction

• The inability of an adult male to sustain an adequate erection for penetration to take place
• Does a morning incidental erection still occur? If so more likely to be psychological
• Organic causes;
  • Smoking
  • Alcohol
  • Diabetes
  • Endocrine causes;
    • Hyperthyroidism, hypogonadism, raised prolactin
  • Neurological;
    • Spinal cord lesions, MS, autonomic neuropathy
  • Pelvic surgery ;
    • Bladder neck, prostate surgery, radiotherapy
  • Peripheral vascular disease
  • Renal or hepatic failure
  • Prostatic hypertrophy
  • Penile abnormalities – Peyronie’s and post-priapism
• Drug causes;
  • Antihypertensives – diuretics and ?-blockers
  • Digoxin
  • Major tranquillizers
  • Alcohol
  • Oestrogen
  • Antidepressants
  • Steroids

Tests

• U&E’s, LFTs, glucose, TSH, LH, FSH, cholesterol, testosterone, prolactin

Treatment

• Treat causes
• Counseling
• Oral phosphodiesterase inhibitors (act by increasing cGMP) e.g. sildenafil

Hypogonadism

• Failure of the testes to produce testosterone, spermatozoa or both
• Testes are small
• Reduced libido, impotence and loss of secondary sexual hair
• Causes;
  • Primary hypogonadism
    • Due to testicular failure;
      • Local trauma, torsion, chemotherapy, radiation
      • Post-orchitis e.g. HIV, mumps,
      • Renal failure, liver failure, alcohol excess (toxic to Leydig cells)
      • Chromosomal abnormalities e.g. Klinefelter’s syndrome
  • Secondary hypogonadism
    • Due to reduced gonadotrophins (LH, FSH)
      • Hypopituitarism
      • Kallman’s syndrome – isolated GRH deficiency, often with anosmia and colour blindness
      • Systemic illness