Title: The hirsutism scoring system should be population specific
Abstract: The aim of our study was to evaluate severity of hirsutism, assessed via the Ferriman-Gallwey scoring system in 12 different androgen-sensitive skin areas among 65 consecutive hirsute patients with functional androgen excess (polycystic ovary syndrome and idiopathic hirsutism) from the Central Anatolian region of Turkey. Results of this descriptive study showed that the buttocks/perineum, sideburn, and neck areas greatly contributed to the total hirsutism score, rather than the upper arm, upper back, and upper abdomen. The aim of our study was to evaluate severity of hirsutism, assessed via the Ferriman-Gallwey scoring system in 12 different androgen-sensitive skin areas among 65 consecutive hirsute patients with functional androgen excess (polycystic ovary syndrome and idiopathic hirsutism) from the Central Anatolian region of Turkey. Results of this descriptive study showed that the buttocks/perineum, sideburn, and neck areas greatly contributed to the total hirsutism score, rather than the upper arm, upper back, and upper abdomen. Hirsutism is characterized by excessive growth of terminal hair in the androgen-sensitive skin regions. It may be the result of androgen excess or the increased sensitivity of the pilosebaceous unit to normal levels of androgens (1Ehrmann D.A. Rosenfield R.L. An endocrinologic approach to the patient with hirsutism.J Clin Endocrinol Metab. 1990; 71: 1-4Crossref PubMed Scopus (66) Google Scholar, 2Sahin Y. Kelestimur F. Medical treatment regimens of hirsutism.Reprod BioMed Online. 2004; 8: 538-546Abstract Full Text PDF PubMed Scopus (8) Google Scholar). Although more than 95% of the women with hirsutism have functional androgen excess (FAE), disorders including idiopathic hirsutism or polycystic ovary syndrome (PCOS), specific identifiable disorders such as congenital adrenal hyperplasia, Cushing's syndrome, and benign and malignant androgen-secreting adrenal or ovarian tumors or some drugs may lead to this clinical presentation (2Sahin Y. Kelestimur F. Medical treatment regimens of hirsutism.Reprod BioMed Online. 2004; 8: 538-546Abstract Full Text PDF PubMed Scopus (8) Google Scholar). Clinical diagnosis of hirsutism is relatively subjective, based on visual scale on which the degree of excess terminal hair growth is scored. Visual methods of determining the severity of hirsutism usually follow those originally described by Ferriman and Gallwey (3Ferriman D. Gallwey J.D. Clinical assessment of body hair growth in women.J Clin Endocrinol Metab. 1961; 21: 1440-1447Crossref PubMed Scopus (2035) Google Scholar). Although the Ferriman-Gallwey scale is a useful clinical scoring system, there are a number of potential limitations, one of which is the fact that the existing scoring system does not take into account the fact that abnormal amounts of hair growth may be confined to only a few areas without exceeding the cutoff value in total hirsutism score. Also it does not include areas such as the neck, sideburns, and buttocks/perineum where increased hair growth may be a concern in some women. Moreover, it is also less prominent in adolescents and older women and regresses as women age (4Azziz R. PCOS a diagnostic challenge.Reprod BioMed Online. 2004; 8: 644-648Abstract Full Text PDF PubMed Scopus (98) Google Scholar). In an aim to elucidate these issues, we conducted this descriptive study to assess the distribution of terminal hair in 12 different androgen-sensitive skin areas. After the approval of the institutional review board, 65 consecutive hirsute patients were enrolled into the study from January 2002 to March 2003 in a university hospital setting. None of the patients had taken any medication for treatment of hirsutism or had been previously treated cosmetically. Twelve androgen-sensitive skin areas, including upper lip, chin, neck, sideburn, upper arm, chest, upper and lower abdomen, upper and lower back, thigh, and buttocks/perineum, were assessed and separately graded as 0 (absence of terminal hairs) through 4 (extensive terminal hair growth). All patients had a score of ≥8 according to the modified Ferriman-Gallwey scoring system (3Ferriman D. Gallwey J.D. Clinical assessment of body hair growth in women.J Clin Endocrinol Metab. 1961; 21: 1440-1447Crossref PubMed Scopus (2035) Google Scholar). Day 3 serum FSH, LH, E2, total and free T, DHEA-S, PRL, 17-OHP, free T3, T4, TSH, cortisol, and luteal-phase P levels and BMI (kg/m2) were measured. Transvaginal or transabdominal pelvic ultrasound scan was routinely performed to evaluate ovaries. Polycystic ovary was defined by the presence of >10 cysts measuring 2–8 mm in diameter arranged peripherally around a dense core of stroma. In cases with 17-OHP level >200 ng/mL, ACTH stimulation test was conducted to exclude late-onset congenital adrenal hyperplasia (5Hatch R. Rosenfield R.L. Kim M.H. Tredway D. Hirsutism implications, etiology and management.Am J Obstet Gynecol. 1981; 140: 815-830Abstract Full Text PDF PubMed Scopus (824) Google Scholar). Having excluded the other identifiable etiologies of hyperandrogenism, as a phenotype of FAE, normoandrogenemic normo-ovulatory (day 22–24 P level >4 ng/mL on at least two consecutive menstrual cycles) hirsute patients were diagnosed to have idiopathic hirsutism (IH) (6Azziz R. Zacur H.A. 21-Hydroxylase deficiency in female hyperandrogenism screening and diagnosis.J Clin Endocrinol Metab. 1989; 69: 577-584Crossref PubMed Scopus (153) Google Scholar, 7Azziz R. Waggoner W.T. Ochoa T. Knochenhauer E.S. Boots L.R. Idiopathic hirsutism an uncommon cause of hirsutism in Alabama.Fertil Steril. 1998; 70: 274-278Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar). The diagnostic criteria for PCOS was based on 1990 National Institute of Child Development and Health (NICHD) criteria, as the cardinal presence of hyperandrogenism associated with chronic oligoanovulation, with the exclusion of other causes of hyperandrogenism such as adult-onset congenital adrenal hyperplasia, hyperprolactinemia, or androgen-secreting neoplasms (8Zadawski J.K. Dunaif A. Diagnostic criteria for polycystic ovary syndrome. Towards a rational approach.in: Dunaif A. Haseltine F. Merriam G.E. Polycystic ovary syndrome. Blackwell, Boston1992: 377-384Google Scholar). Recent criteria for PCOS suggested by the expert meeting held in May 2003 in Rotterdam was not applied in this study (9Rotterdam ESHRE/ASRM sponsored PCOS Consensus Workshop GroupRevised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome.Hum Reprod. 2004; 19: 41-47Crossref PubMed Scopus (4412) Google Scholar). Continuous and categorical data were analyzed by using Statistical Package Program for Social Sciences (SPSS, Chicago, IL). Statistical analyses included unpaired Student's t-test and chi-squared test with Yates' correction where necessary. Data were expressed as mean ± standard error of mean (SEM). P value of <.05 was considered statistically significant. After the clinical evaluation and laboratory workup, 31 patients had IH and 34 patients were diagnosed with PCOS. In PCOS cases, 28 (82.3%) were found to have polycystic ovaries on ultrasound, and 4 (12.9%) were found among the IH group. Mean age, duration of hirsutism, presence of the family history of hirsutism, age of menarche, parity, and BMI were not different statistically between PCOS and IH groups. Mean total hirsutism scores of all 12 skin areas were comparable in both IH and PCOS patients. Circulating androgen levels (total and free T, DHEA-S) were higher in the PCOS group, compared to IH women (P<.001 in all comparisons). Among the PCOS group, about one-third (10/31) had an abnormal concentration of gonadotropins, namely LH:FSH ratio ≥2:1. As shown in Figure 1, with regard to comparison of the mean hirsutism values of each skin area, highest mean score and the main contributor to the total hirsutism score was found to be the thigh area. Furthermore, areas that are not included in the Ferriman-Gallwey score, such as buttocks/perineum, sideburn, and neck also had higher scores—the second, third, and seventh highest scores, respectively. However, the upper arm, upper back, and upper abdomen had mean scores less than 1, as depicted in Figure 1. Hair follicles of different body sites respond with a variable sensitivity to circulating androgens. The most sensitive areas on the face are the chin and under the jaw, followed by the upper lip and the cheeks (10Redmond G.P. Androgenic disorders of women diagnostic and therapeutic decision making.Am J Med. 1995; 98: 120S-129SAbstract Full Text PDF PubMed Scopus (4) Google Scholar). Sensitive areas on the body are the lateral aspects of the pubic region and upper thighs, the linea alba, and the midline of the chest. In general, the more intense the terminal hair density lateral to the midline, the greater is the androgen effect (10Redmond G.P. Androgenic disorders of women diagnostic and therapeutic decision making.Am J Med. 1995; 98: 120S-129SAbstract Full Text PDF PubMed Scopus (4) Google Scholar). Whether the hirsutism originated from increased serum androgens or from increased sensitivity of hair follicles to androgens, the clinical presentation of FAE did not differ in our study. The degree of hirsutism can be graded by the method of Ferriman and Gallwey, enabling the physician to evaluate the case on uniform criteria, albeit subjectively based, for the density of terminal hairs at 11 different body sites (i.e., upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, arm, forearm, thigh, and lower leg) (3Ferriman D. Gallwey J.D. Clinical assessment of body hair growth in women.J Clin Endocrinol Metab. 1961; 21: 1440-1447Crossref PubMed Scopus (2035) Google Scholar). However, the presence of terminal hair on the forearm and lower leg was noted to be less sensitive or indifferent to androgens, and subsequent modifications of the Ferriman-Gallwey method were made (5Hatch R. Rosenfield R.L. Kim M.H. Tredway D. Hirsutism implications, etiology and management.Am J Obstet Gynecol. 1981; 140: 815-830Abstract Full Text PDF PubMed Scopus (824) Google Scholar). However, among our population, the thigh area had the highest mean score and thus was the greatest contributor to the total hirsutism score. Another result of this study was the low impact of upper arm, upper back, and upper abdomen regions on the total hirsutism score. Had these regions been excluded from the scoring system, none of the patients would have been assigned a Ferriman-Gallwey score of <8. Although based on a small series of cases, it can be concluded that these regions should be disregarded in the scoring. However, buttocks/perineum, neck, and sideburns, areas which are not being assessed via the Ferriman-Gallwey scoring system, have an important impact on total score. The available scoring system does not allow the grading of sideburn or neck areas, which is usually considered a cosmetic concern by most women. In the same way, it does not include evaluation of hair on the perineal and buttock area, which can be troublesome for some hirsute women. Prior to scoring the case, it is important to keep in mind the racial/ethnic differences in terminal hair quantity and distributions (11Carmina E. Koyama T. Chang L. Stanczyk F.Z. Lobo R.A. Does ethnicity influence the prevalence of adrenal hyperandrogenism and insulin resistance in polycystic ovary syndrome?.Am J Obstet Gynecol. 1992; 167: 1807-1812Abstract Full Text PDF PubMed Scopus (371) Google Scholar). In addition to the aforementioned concerns, the score has no definite cutoff value. Furthermore, the terminal hair excess in a woman is the first concern to be eliminated and treated prior to clinical examination. Thus, the existing scoring is open to intra- and interobserver variations. The number of women evaluated in this study is too small, however, to recommend a change in the way hirsutism is scored. Despite a need for a large data set to yield more robust results, buttocks/perineum, sideburns, and neck should be included in the scoring system of hirsutism for clinical diagnosis and follow-up in our indigenous population7Azziz R. Waggoner W.T. Ochoa T. Knochenhauer E.S. Boots L.R. Idiopathic hirsutism an uncommon cause of hirsutism in Alabama.Fertil Steril. 1998; 70: 274-278Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar.