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1.  Correlation of biochemical markers and clinical signs of hyperandrogenism in women with polycystic ovary syndrome (PCOS) and women with non-classic congenital adrenal hyperplasia (NCAH) 
Background: Polycystic ovary syndrome (PCOS) is the most common cause of hyperandrogenism in women. Non-classic congenital adrenal hyperplasia (NCAH) is very close to PCOS. The diagnosis of hyperandrogenism is not based on the finding of decreased or increased levels of a single hormone.
Objective: In our paper, we are going to test correlation between clinical signs and biochemical markers of hyperandrogenism.
Materials and Methods: In this prospective study, we calculated free testosterone (cFT), bioavailable testosterone (cBT), free androgen index (FAI), free estrogen index (FEI), total testosterone (TT), sex-hormone binding globulin (SHBG), estradiol (E2), dehydroepiandrosterone-sulfat (DHEA-S), 17α -hydroxyprogesterone (17α -OHP), prolactin (P), C-peptid and homeostasis model assessment for insulin resistance (Homa-IR) were measured in two groups of young untreated women with PCOS and NCAH.
Results: In our research, we did not find any significant differences between PCOS and NCAH groups by age, hormonal and calculated parameters of androgens. Waist to hip ratio (WHP) and body mass index (BMI) values were higher in the group of patients with PCOS than NCAH group. But in all patients we found positive correlation between hirsutism score and FAI, cFT, cBT, as well as we found negative correlation between hirsutism score and SHBG. We also tested hormonal and calculated parameters of androgens between PCOS patients by upper body and lower body obesity, but we did not find any significant differences. There was not any difference by the hirsutism score in these groups either.
Conclusion: In our research we found that the calculated values of cFT, cBT and FAI are helpful for determinate hirsutism score in all hirsute patients, despite of ovarian or adrenal hyperandrogenemia.
PMCID: PMC4165947  PMID: 25246891
Hirsutism; Hyperandrogenemia; Free androgen index (FAI); Polycystic ovary syndrome (PCOS); Non-classic congenital adrenal hyperplasia (NCAH)
2.  REANALYZING THE MODIFIED FERRIMAN-GALLWEY SCORE: IS THERE A SIMPLER METHOD FOR ASSESSING THE EXTENT OF HIRSUTISM? 
Fertility and sterility  2011;96(5):1266-1270.e1.
Objective
To determine whether assessing the extent of terminal hair growth in a subset of the traditional 9 areas included in the modified Ferriman-Gallwey (mFG) score can serve as a simpler predictor of total body hirsutism when compared to the full scoring system, and to determine if this new model can accurately distinguish hirsute from non-hirsute women.
Design
Cross-sectional analysis
Setting
Two tertiary care academic referral centers.
Patients
1951 patients presenting for symptoms of androgen excess.
Interventions
History and physical examination, including mFG score.
Main Outcome Measures
Total body hirsutism.
Results
A regression model using all nine body areas indicated that the combination of upper abdomen, lower abdomen and chin was the best predictor of the total full mFG score. Using this subset of three body areas is accurate in distinguishing true hirsute from non-hirsute women when defining true hirsutism as mFG>7.
Conclusion
Scoring terminal hair growth only on the chin and abdomen can serve as a simple, yet reliable predictor of total body hirsutism when compared to full body scoring using the traditional mFG system.
doi:10.1016/j.fertnstert.2011.08.022
PMCID: PMC3205229  PMID: 21924716
hirsutism; Ferriman-Gallwey; modified Ferriman-Gallwey; androgen excess; polycystic ovary syndrome; PCOS; hair growth
3.  Visually scoring hirsutism 
Human Reproduction Update  2009;16(1):51-64.
BACKGROUND
Hirsutism is the presence of excess body or facial terminal (coarse) hair growth in females in a male-like pattern, affects 5–15% of women, and is an important sign of underlying androgen excess. Different methods are available for the assessment of hair growth in women.
METHODS
We conducted a literature search and analyzed the published studies that reported methods for the assessment of hair growth. We review the basic physiology of hair growth, the development of methods for visually quantifying hair growth, the comparison of these methods with objective measurements of hair growth, how hirsutism may be defined using a visual scoring method, the influence of race and ethnicity on hirsutism, and the impact of hirsutism in diagnosing androgen excess and polycystic ovary syndrome.
RESULTS
Objective methods for the assessment of hair growth including photographic evaluations and microscopic measurements are available but these techniques have limitations for clinical use, including a significant degree of complexity and a high cost. Alternatively, methods for visually scoring or quantifying the amount of terminal body and facial hair growth have been in use since the early 1920s; these methods are semi-quantitative at best and subject to significant inter-observer variability. The most common visual method of scoring the extent of body and facial terminal hair growth in use today is based on a modification of the method originally described by Ferriman and Gallwey in 1961 (i.e. the mFG method).
CONCLUSION
Overall, the mFG scoring method is a useful visual instrument for assessing excess terminal hair growth, and the presence of hirsutism, in women.
doi:10.1093/humupd/dmp024
PMCID: PMC2792145  PMID: 19567450
hirsutism; hair growth; androgen excess; polycystic ovary syndrome
4.  HIRSUTISM IN KASHMIR: AN ETIOLOGICAL STUDY 
Indian Journal of Dermatology  2009;54(1):80-82.
Background:
Hirsutism refers to the presence of terminal hairs at the body sites under androgenic control. Various factors, including genetic makeup and hormonal status, influence the rate and pattern of hair growth at these sites.
Purpose:
To study the pattern of hirsutism in Kashmir.
Materials and Methods:
Thirty five consecutive patients of hirsutism were included in the study. After detailed history taking, physical examination and relevant investigations, scoring of hirsutism was done using the Ferriman Gallwey (FG) scoring system.
Findings:
The FG score ranged from 10-34. Twenty patients had associated menstrual abnormalities. Polycystic ovarian syndrome (PCOS) was diagnosed in four patients, hypothyroidism in two and congenital adrenal hyperplasia (CAH) in one. The rest of the patients had idiopathic hirsutism.
Conclusion:
Idiopathic hirsutism was the most common category, whilst PCOS, hypothyroidism and CAH were also seen.
doi:10.4103/0019-5154.48997
PMCID: PMC2800882  PMID: 20049280
Ferriman-Gallwey scoring; hirsutism; polycystic ovaries
5.  Social support: an important factor for quality of life in women with hirsutism 
Background
Women with hirsutism have reported imparied health and health-related quality of life (HRQoL). Social support is a factor that might increase HRQoL in chronic diseases, but little is known about this association among women with hirsutism.
Aim
The aim of the study was to describe social support and explore its association with HRQoL among women with hirsutism. A further aim was to compare HRQoL in women with hirsutism with a Swedish normal population.
Methods
A questionnaire including socio-demographic questions, Short-Form Health Survey (SF-36), the Multidimensional Scale of Perceived Social Support (MSPSS), and a self-estimation of hairiness using the Ferriman-Gallway scale (F-G scale) was answered by 127 women with hirsutism.
Results
Multiple regression analyses showed significant associations between social support and all health dimensions in the SF-36, also after the model was adjusted for age, hairiness and body mass index. Compared to the normal Swedish population, women with hirsutism reported significantly lower HRQoL in all dimensions of the SF-36 (p < 0.01).
Conclusions
There is a significant positive association between social support and HRQoL, demonstrating its importance for the ability to adapt to problems associated with hirsutism. As women with hirsutism reported poorer HRQoL compared to the normal population, social support may be a factor to consider in clinical practice.
doi:10.1186/s12955-014-0183-3
PMCID: PMC4297415  PMID: 25526751
Association; Health; Hirsutism; Quality of life; Social support
6.  Evaluation of only the chin or lower abdomen for predicting hirsutism 
Background:
Hirsutism is defined as the growth of terminal hair in a male pattern in women; it affects 5-15% of women.
Objective:
The aim of this study is evaluation of only the chin or lower abdomen for predicting hirsutism.
Materials and Methods:
In this cross-sectional diagnostic study, we randomly selected 695 women aged 15-45 years. The examiners scored the subjects on a scale of 0 - 4 for terminal hair growth on nine different body areas according to the Ferriman-Gallwey (FG) scoring system in a form given to the examiners before the examination. An FG score of 8 or more was considered diagnostic of hirsutism. If the sum of the FG scores for the chin or lower abdomen was 2 or more, the test result was assumed to be positive. Statistical analysis was performed using the MacNemar test, and a P value of less than 0.05 was considered to be statistically significant.
Results:
The age group with the highest prevalence rate was 21-25 years. From the 695 subjects examined, 81 subjects (11.7%) had an FG score of 8 or more with a resultant prevalence rate of 11.7% for hirsutism. In our study population, 39% of the patients had an FG score of 2 or more for the chin or lower abdomen, and 61% of the patients had an FG score of less than 2 for the chin or lower abdomen.
Conclusion:
Evaluating terminal hair growth on the chin or lower abdomen for predicting hirsutism seems to be an acceptable screening method.
doi:10.4103/2230-8210.117239
PMCID: PMC3784875  PMID: 24083173
Evaluation; Ferriman-gallwey score; hirsutism
7.  Quality of life of hirsute women. 
Postgraduate Medical Journal  1993;69(809):186-189.
Hirsutism is recognized to cause profound distress in affected women, due to cosmetic and psychosexual implications. It was evaluated in the present study by methods found to be valid and reliable in psychosomatic research. Fifty women with hirsutism belonging to the spectrum of disorders from idiopathic hirsutism to polycystic ovary syndrome, after complete medical work-up, underwent the same psychometric evaluation as 50 healthy non-hirsute women, matched for sociodemographic variables. Hirsute women had a Ferriman and Gallwey score ranging from 8 to 19. Psychometric evaluation for quality of life was carried out by the following methods: (a) Kellner's Brief Problem List, a 12 item self-rating list of psychosocial problems; (b) Kellner's Symptom Rating Test (SRT), a 46 item self-rating scale that yields a total score of distress as well as six subscales (anxiety, depression, somatic symptoms, anger-hostility, cognitive and psychotic symptoms); and (c) Marks' Social Situations Questionnaire (SSQ), a 30 item self-rating scale concerned with social phobia. Patients with hirsutism displayed significantly higher social fears at the SSQ than controls (P < 0.01). They also showed more anxiety (P < 0.01) and psychotic symptoms (P < 0.01) at the SRT, whereas there were no significant differences in depression, somatization, anger-hostility and cognitive symptoms. These results suggest that the complex management of hirsute women, in addition to pharmacological and/or cosmetic measures, may require specific psychotherapy.
PMCID: PMC2399746  PMID: 8497431
8.  PCOS 
Clinical Evidence  2009;2009:1408.
Introduction
Polycystic ovary syndrome (PCOS) is characterised by an accumulation of incompletely developed follicles in the ovaries due to anovulation. It is diagnosed in up to 10% of women attending gynaecology clinics, but the prevalence in the population as a whole is unclear. PCOS has been associated with hirsutism, infertility, acne, weight gain, type 2 diabetes, cardiovascular disease (CVD), and endometrial hyperplasia.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments in women with PCOS? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 24 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: cyproterone acetate–ethinylestradiol (co-cyprindiol), finasteride, flutamide, interventions to achieve weight loss, ketoconazole, mechanical hair removal, metformin, and spironolactone.
Key Points
PCOS is characterised by an accumulation of incompletely developed follicles in the ovaries due to anovulation, and is associated with increased ovarian androgen production. Clinical manifestations of PCOS include infrequent or absent menses, obesity, and signs of androgen excess including acne or seborrhoea. PCOS is diagnosed in up to 10% of women attending gynaecology clinics, but the prevalence in the population as a whole is unclear.PCOS has been associated with hirsutism, infertility, acne, insulin resistance, elevated serum luteinising hormone (LH) levels, weight gain, type 2 diabetes, CVD, and endometrial hyperplasia.
Metformin in selected patients (who have abnormal LH/follicle-stimulating hormone [FSH] ratios) may improve menstrual pattern and oligomenorrhoea. The results of studies comparing metformin with placebo are conflicting for menstrual frequency and hirsutism. Metformin, alone or combined with cyproterone acetate–ethinylestradiol (co-cyprindiol), may be more effective than cyproterone acetate–ethinylestradiol alone at reducing hirsutism. Metformin combined with flutamide reduces hirsutism scores and improves menstrual frequency compared with placebo, but we don't know how the individual drugs compare with each other. Cyproterone acetate–ethinylestradiol may reduce hirsutism, but increases the risk of venous thromboembolism compared with placebo. Finasteride may reduce hirsutism compared with placebo, and seems as effective as spironolactone or cyproterone acetate–ethinylestradiol. Finasteride plus cyproterone acetate–ethinylestradiol may be more effective than cyproterone acetate–ethinylestradiol alone at reducing hirsutism. Flutamide, alone and in combination with metformin, may reduce hirsutism compared with placebo, but has been associated with adverse hepatic effects. Flutamide may reduce hirsutism compared with finasteride, but studies have given conflicting results. Flutamide and spironolactone seem equally effective at reducing hirsutism.Combined treatment with flutamide plus cyproterone acetate–ethinylestradiol may reduce the proportion of women with oligomenorrhoea compared with flutamide alone.
We don't know whether weight loss improves clinical outcomes in women with PCOS. We don't know whether ketoconazole or hair removal treatments are effective at reducing hirsutism compared with other treatments. Mechanical hair removal with certain types of lasers may be effective in the short term (6 months), but longer-term effects are less clear.
PMCID: PMC2907777  PMID: 19445767
9.  Epidemiology of polycystic ovary syndrome: a cross sectional study of university students at An-Najah national university-Palestine 
Background
Polycystic Ovary Syndrome (PCOS) is the most common gynecological endocrinopathy in women of reproductive age. Despite its heavy burden on female reproduction and general health, there is no study regarding PCOS prevalence in Palestine. This study aims to establish prevalence of PCOS among female university students at An-Najah National University-Palestine and to explore its possible risk factors.
Methods
A cross sectional study was conducted on 137 female students using convenience sampling method for age group (18–24) years. PCOS cases were identified according to the National Institute of health (NIH) criteria through clinical interview and assessment for participants at the University clinics. Menstrual irregularities regarding cycle and flow were identified and clinical hyperandrogenism was assessed as the self-reported degree of hirsutism using the modified Ferriman Gallwey (mF-G) scoring method of more than 8 score. Biochemical hyperandrogenism for girls with menstrual irregularities was assessed by measuring free testosterone level. Data were analyzed using SPSS version 17 applying descriptive methods; different risk factor relationships were estimated using bivariate analysis and multivariate logistic regression.
Results
The estimated prevalence of PCOS was 7.3% , acne was the only studied risk factor among others to be statistically significantly related to PCOS patients (OR = 8.430, P-value = 0.015). Clinical Hirsutism was found in 27% of participants, 70% of whom had idiopathic hirsutism.
Conclusions
Prevalence of PCOS in Palestine seems to be relatively high but similar to other Mediterranean statistics. We recommend further studies using wider age group and larger sample for all parts of Palestine in order to generalize results.
doi:10.1186/1477-7827-11-47
PMCID: PMC3661396  PMID: 23688000
Polycystic ovary syndrome; PCOS; Prevalence; Palestine
10.  Anthropometric characteristics and dietary pattern of women with polycystic ovary syndrome 
Objective:
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. PCOS is considered to be not only a reproductive endocrinopathy, but also a metabolic disorder. The objective of the present study was to characterize the anthropometric and dietary profile of women with PCOS and to compare it with that of healthy age-matched women.
Design:
In this case-control study, 65 women with PCOS served as cases. The control group consisted of 65 age-matched healthy women. For each participant, demographic, anthropometric and dietary intake data were gathered and compared between the two groups.
Results:
There was no significant difference between the mean of the body mass index of the two groups, but the mean of waist circumference was significantly higher in the PCOS group, than the control group (P = 0.016). Compared to the normal weight PCOS patients, a significantly higher percentage of overweight patients had hirsutism (P = 0.009). In dietary analysis, women with PCOS consumed more calories and more fat than healthy women (P = 0.001 and P = 0.019, respectively).
Conclusion:
It is concluded that in PCOS patients, android obesity is a common feature and this abdominal adiposity may be related to the syndrome's complications. PCOS symptoms were more severe in overweight patients than the normal weight. Regarding the dietary pattern, it was indicated that patients with PCOS consume more calories and more fat in their diets and this might have been correlated to their disease.
doi:10.4103/2230-8210.113759
PMCID: PMC3743368  PMID: 23961484
Diet; hirsutism; obesity; polycystic ovary syndrome
11.  Altering Hirsutism Through Ovulation Induction in Women With Polycystic Ovary Syndrome 
Obstetrics and Gynecology  2012;119(6):1151-1156.
Objective
Many women with polycystic ovary syndrome (PCOS) experience infertility and hirsutism and often seek treatment for both concurrently. We investigated whether women who ovulate in response to treatment with clomiphene citrate), metformin, or both would have greater improvement in hirsutism compared to those who did not ovulate.
Methods
This is a secondary analysis evaluating the change in Ferriman-Gallwey score for the hirsute women (n = 505, 80.7%) from the Pregnancy in Polycystic Ovary Syndrome 1 study. This was a prospective, randomized, doubled-blind trial of 626 women with PCOS and infertility recruited from 12 university sites. They were treated with clomiphene citrate, metformin, or both (combination) for up to six cycles, and hirsutism evaluators were blinded to group assignment.
Results
There was a significant decrease in the Ferriman-Gallwey score between baseline and completion of the study in each of the three individual groups (clomiphene citrate, p=0.024; metformin, p=0.005; combination, p<0.001). There was no significant difference in the degree to which the hirsutism score changed when comparing the three groups (p=0.44). The change in hirsutism was not associated with the duration of treatment or with the presence or absence of ovulation.
Conclusions
In infertile hirsute women with PCOS, treatment with clomiphene citrate, metformin, or both for up to 6 cycles does not alter hirsutism.
Clinical Trial Registration
ClinicalTrials.gov, www.clinicaltrials.gov, NCT00068861.
doi:10.1097/AOG.0b013e31825618fb
PMCID: PMC3360417  PMID: 22617579
12.  Body image satisfaction and self-esteem status among the patients with polycystic ovary syndrome 
Background: Most previous research has focused on polycystic ovary syndrome (PCOS) characteristics and their association with psychological disorders, such as anxiety and depression.
Objective: In the present study, our aim was to study whether PCOS characteristics are associated with several aspects of psychological well-being namely self-esteem and body satisfaction.
Materials and Methods: This was a cross-sectional study of 300 women with PCOS that was carried out in Kashan, Iran. Main outcome measures were the Body Image Concern Inventory (BICI) and the Rosenberg’s Self-Esteem Scale and clinical information of PCOS. Major clinical PCOS features including obesity (BMI), excessive body hair (hirsutism score), acne, menstrual cycle disturbances and infertility.
Results: The findings of regression analysis indicated that infertile women had lower levels of self-esteem (=-0.11, p=0.049) and poorer body satisfaction (=0.121, p=0.036) compared with PCOS women without infertility. Furthermore, hirsute women experienced poorer self-esteem than women without hirsutism (=-0.124, p=0.032). Women with menstrual irregularities had higher body dissatisfaction (=0.159, p=0.005). Moreover, women with higher body mass index scores had poorer body satisfaction (=0.151, p=0.009) but were not associated with self-esteem.
Conclusion: The emotional well-being of the patients presenting with the syndrome needs to be recognized more fully, particularly in relation to the low self-esteem, poor body image, and struggles with weight, menstrual irregularities, hirsutism and infertility. The results of this study raise implications for clinical practice and suggest that a multidisciplinary approach to the management of women with PCOS.
This article extracted from Ph.D. thesis. (Fatemeh Bazarganipour)
PMCID: PMC3941334  PMID: 24639704
Polycysticovarysyndrome; Self-esteem; Bodyimage.
13.  Hirsutism: A Clinico-investigative Study 
Background:
Hirsutism is a common clinical condition characterized by presence of terminal hair at body sites under androgenic influence. Inspite of the significant worldwide prevalence of hirsutism, studies on hirsutism from India are not many.
Objective:
To assess the etiology of hirsutism and correlate its severity with underlying causes and various hormone levels.
Materials and Methods:
In this prospective study, 40 patients of hirsutism enrolled on first come basis were included. All patients underwent detailed clinical assessment and transabdominal ultrasonography. Free and total testosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, luteinizing hormone, follicle stimulating hormone, prolactin, free tri-iodothyronine, free tetra-iodothyronine, and thyroid stimulating hormone, and sex hormone binding globulin were estimated. Forty age-matched controls without features of hyperandrogenemia were included for the comparison.
Results:
Thirteen (32.5%) patients had mild, 52.5% had moderate whereas 15% had severe hirsutism. Positive family history was documented in 42.5% patients. The clinical features found to be associated with hirsutism included acne (55%), menstrual irregularities (40%), acanthosis nigricans (37.5%), obesity (37.5%), and androgenetic alopecia in 27.5% of patients. Polycystic ovarian syndrome (PCOS) was the underlying cause in 70%, non-classical congenital adrenal hyperplasia and hypothyroidism in 7.5% each whereas idiopathic hirsutism was found in 15% patients.
Conclusion:
PCOS was the most common cause of hirsutism found in the instant study. Further, there was positive correlation between severity of hirsutism and free testosterone levels.
doi:10.4103/0974-7753.111204
PMCID: PMC3681104  PMID: 23766607
Etiology; hirsutism; polycystic ovarian syndrome
14.  Diagnostic value of prostate-specific antigen in women with polycystic ovary syndrome* 
BACKGROUND:
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women. Its presentation is that of irregular menstruation associated with ovulation defects. Because of adverse outcomes such as metabolic and cardiovascular disorders, its diagnosis and treatment is very important. Therefore, the diagnostic value of prostatespecific antigen (PSA) in women with polycystic ovary syndrome was evaluated.
METHODS:
A total of 32 women with PCOS and 32 aged matched healthy females were recruited in this case-control study. The subjects were compared by means of metabolic measures and serum PSA level. The correlations between these markers were evaluated. Sensitivity and specificity values and cut off levels of PSA were established for diagnosis of PCOS.
RESULTS:
Mean PSA, Ferriman Gallwey score (FGS), luteinizing hormone/follicle stimulating hormone ratio (LH/FSH), testosterone, dehydroepiandrosterone sulfate (DHEAS), 17α hydroxyprogesterone (17α HP) levels were significantly higher in PCOS (P<0.001, respectively). PSA levels greater than 0.07 ng/ml yielded a sensitivity of 91% and specificity of 82%, and was helpful as a diagnostic tool for women with PCOS. Circulating androgens and hirsutism were associated with higher levels of PSA in PCOS women.
CONCLUSIONS:
Our results showed direct correlation between PSA, hirsutism and hyperandrogemsm state. Therefore, it seems logical to use PSA level for detection of hyperandrogemsm state in women.
PMCID: PMC3263095  PMID: 22279474
Hirsutism; Prostate-Specific Antigen (PSA); Polycystic Ovary Syndrome (PCOS)
15.  Idiopathic Hirsutism and Insulin Resistance 
Background and Objectives. Polycystic ovary syndrome (PCOS) and idiopathic hirsutism (HI) are the two most common causes of hirsutism. Insulin resistance plays a key role in PCOS, but there are not enough data showing that patients with HI also have insulin resistance. This study was designed to evaluate the presence of insulin resistance in women with HI. Methods. Based on a cross-sectional study, two groups of age-BMI matched, hirsute women were compared to age-BMI matched, nonhirsute women. Sixty nonobese women with PCOS, thirty nonobese women with HI, and sixty nonobese control women were included in the study. Samples of hormones including androgens were measured. Insulin resistance based on homeostasis model assessment of insulin resistance (HOMA-IR) was compared between three groups by the Kruskal-Wallis test. Results. Patients with PCOS had significantly higher basal insulin level (16.04 ± 1.4 versus 7.32 ± 6.85 μIu/mL) and HOMA-IR score (3.7 ± 3.36 versus 1.75 ± 1.67) than patients with HI (P  0.001). Patients with HI also had significantly higher basal insulin level and HOMA-IR score than control group (P  0.001). Conclusion. Our data suggest that both PCOS and HI are associated with insulin resistance and these patients are more insulin resistant than healthy control people.
doi:10.1155/2013/593197
PMCID: PMC3817738  PMID: 24228029
16.  The effect of fennel (Foeniculum vulgare) gel 3% in decreasing hair thickness in idiopathic mild to moderate hirsutism, A randomized placebo controlled clinical trial 
Background: Hirsutism is a common symptom presenting to primary care endocrinologists, gynecologists, and dermatologists. Management is usually a long and troublesome process. This study was designed to evaluate the effect of fennel topical gel on mild to moderate idiopathic hirsutism.
Methods: The randomized, double-blind, placebo-controlled clinical trial was carried out from 2009 to 2011, in Sari, Iran. Forty four women with mild to moderate idiopathic hirsutism were randomly divided to case and control groups, each group included 22 cases. The case group received fennel gel 3% and the control group received placebo. The effect of fennel gel 3% was defined as reduction of thickness of facial hair in micrometer by microscope in comparison with placebo. Measurements were performed at zero time and 24 weeks after treatment. This study was registered in the Iranian Registry of Clinical Trial (www.irct.ir) with registration number 138901213672N1.
Results: The mean age of patients was 26.9±6.7 and 25.6±4.3 years in case and control groups, respectively. Hair thickness was similar between the two groups before intervention. The hair thickness reduced from 97.9±31.5 to 75.6±26.7 micron in patients receiving fennel gel after 24 weeks (P<0.001). Four patients complained of itching (3 in case group) and 4 patients complained of irritation and itching (3 in case group). However, this difference was not statistically significant.
Conclusion: The study indicated that fennel gel 3% is effective in decreasing hair thickness in women with idiopathic mild to moderate hirsutism.
PMCID: PMC3894467  PMID: 24490010
Idiopathic Hirsutism; Gel; Foeniculum vulgare (fennel); Hair thickness.
17.  Mixed Form of Hirsutism in an Adolescent Female and Laser Therapy 
Introduction:
Hirsutism is a common disorder of excess growth of terminal hair in an androgen-dependent male distribution in women, including the chin, upper lip, breasts, back, and abdomen. It is very important to identify the etiology of hirsutism and adequate treat is prior to any cosmetic therapy.
Case Presentation:
The case was a 17-year-old female with severe hirsutism, oligomenorrhea, and obesity. She was evaluated to identify the etiology and diagnosed as a case of polycystic ovarian syndrome (PCOS), nonclassic congenital adrenal hyperplasia (NC-CAH), and hyperandrogenic insulin-resistant acanthosis nigricans (HAIR-AN) syndrome, which is a rare combination of hirsutism etiology. She was successfully treated according to the underlying pathology, and laser photoepilation was used as the preferred hair removal method.
Discussion:
Establishing the etiology, using the evidence–based strategies to improve hirsutism, and treating the underlying disorder, are essential for proper management of women with hirsutism.
doi:10.5812/ircmj.9410
PMCID: PMC4103002  PMID: 25068069
Hirsutism; PCOS; NC-CAH; Lasers
18.  Genetic Alterations within the DENND1A Gene in Patients with Polycystic Ovary Syndrome (PCOS) 
PLoS ONE  2013;8(9):e77186.
Polycystic ovary syndrome (PCOS), the most common endocrine disease among premenopausal women, is caused by both genes and environment. We and others previously reported association between single nucleotide polymorphisms (SNPs) in the DENND1A gene and PCOS. We therefore sequenced the DENND1A gene in white patients with PCOS to identify possible alterations that may be implicated in the PCOS pathogenesis. Patients were referred with PCOS and/or hirsutism between 1998 and 2011 (n = 261). PCOS was diagnosed according to the Rotterdam criteria (n = 165). Sequence analysis was performed in 10 patients with PCOS. Additional patients (n = 251) and healthy female controls (n = 248) were included for SNP genotyping. Patients underwent clinical examination including Ferriman-Gallwey score (FG-score), biochemical analyses and transvaginal ultrasound. Mutation analysis was carried out by bidirectional sequencing. SNP genotyping was tested by allelic discrimination in real-time PCR in the additional patients and controls. Sequencing of the DENND1A gene identified eight SNPs; seven were not known to be associated with any diseases. One missense SNP was detected (rs189947178, A/C), potentially altering the structural conformation of the DENND1A protein. SNP genotyping of rs189947178 showed significantly more carriers among patients with PCOS and moderate hirsutism compared to controls. However, due to small sample size and lack of multiple regression analysis supporting an association between rs189947178 and FG-score or PCOS diagnosis, this could be a false positive finding. In conclusion, sequence analysis of the DENND1A gene of patients with PCOS did not identify alterations that alone could be responsible for the PCOS pathogenesis, but a missense SNP (rs189947178) was identified in one patient and significantly more carriers of rs189947178 were found among patients with PCOS and moderate hirsutism vs. controls. Additional studies with independent cohort are needed to confirm this due to the small sample size of this study.
doi:10.1371/journal.pone.0077186
PMCID: PMC3785455  PMID: 24086769
19.  Serum Adiponectin Level and Clinical, Metabolic, and Hormonal Markers in Patients with Polycystic Ovary Syndrome  
Background:
To investigate the relationship between adiponectin, metabolic and hor- monal parameters, and insulin resistance in patients with non-treated polycystic ovary syndrome.
Materials and Methods:
In this cross-sectional observational study, 81 patients admitted to out-patient clinic with complaints of menstrual irregularity, hirsutism and obesity were enrolled. Serum adiponectin, biochemical and hormonal parameters, and 75 gram oral glu- cose tolerance test (OGTT) were measured. Spearman’s correlation coefficient was used for statistical analysis.
Results:
We observed inverse correlations between serum adiponectin level and body mass index, homeostasis model assessment insulin-resistance score, insulin level, fast- ing glucose level, and prolactin level (p=0.001, p=0.02, p=0.04, p=0.02, and p=0.005, respectively). No significant correlations were found between serum adiponectin level and age, height, weight, Ferriman-Gallwey score, 2 hours OGTT test value and free tes- tosterone level (p=0.3, p=0.6, p=0.2, p=0.8, p=0.9, and p=0.01, respectively).
Conclusion:
The present study demonstrated that in polycystic ovary syndrome patients, when serum adiponectin level decreased, degree of insulin resistance increased. Our find- ings indicate that serum adiponectin level is likely to be an adequate marker for deter- mination of the degree of insulin resistance, and may be a predictor of diseases, such as type 2 diabetes mellitus (T2DM) and metabolic syndrome, which develop on the basis of insulin resistance.
PMCID: PMC3901186  PMID: 24520503
Adiponectin; Insulin Resistance; Polycystic Ovary Syndrome
20.  The effect of calcium and vitamin D supplementation on menstrual cycle, body mass index and hyperandrogenism state of women with poly cystic ovarian syndrome 
Background:
Poly cystic ovary syndrome (PCOS) is considered one of the most common endocrine disorders of women in reproductive age. The aim of this study was evaluating the efficacy of calcium and Vitamin D supplementation on the regularity of menstrual cycles, body mass index (BMI) and hyper androgenism state of women with PCOS.
Materials and Methods:
In this clinical trial, 80 women with PCOS were evaluated. They randomly located in four groups receiving metformin (group 1), metformin plus calcium and Vitamin D (group 2), calcium and Vitamin D (group 3) and placebo (group 4) for 4 months. BMI, regularity of menstrual cycles, hyperandrogenism (hirsutism and acne) and serum calcium and Vitamin D levels were compared in four studying groups at baseline and 4 months after the trial.
Results:
All studied subjects were similar at baseline (P > 0.05). After trial, the frequency of hirsutism and acne were not different among groups. Frequency regular menstrual cycle and dominant follicle were significantly higher in group 1 and 2 than others (P < 0.05). After trial, there was no significant difference with respect to BMI among groups.
Conclusion:
Vitamin D and calcium supplementation in addition to metformin therapy in women with PCOS could result in a better outcome in a variety of PCOS symptoms including menstrual regularity, and ovulation.
PMCID: PMC4268197  PMID: 25535503
Calcium; metformin; poly cystic ovary syndrome; vitamin D
21.  Insulin resistance in women with hirsutism 
Introduction
There are still not enough data showing whether patients with idiopathic hirsutism (IH) also have insulin resistance. The association between polycystic ovary syndrome (PCOS) and insulin resistance is well documented in the literature, but the Rotterdam Consensus has concluded that principally obese women with PCOS should be screened for the metabolic syndrome. We intended to investigate the presence/absence of insulin resistance in non-obese women with hirsutism.
Material and methods
Twenty-eight women with PCOS (14 non-obese and 14 obese), 12 non-obese with IH, and 16 non-obese healthy women were included in the study. The presence of insulin resistance was investigated by using basal insulin levels and the homeostasis model assessment (HOMA) score in the study group.
Results
Patients with obese and nonobese PCOS had significantly (p < 0.05) higher basal insulin levels and HOMA scores than IH and control subjects. Insulin levels and HOMA scores did not differ between obese and non-obese PCOS patients. Patients with IH did not show any difference from the control group.
Conclusions
Insulin resistance exists in non-obese women with PCOS as well as obese women with PCOS. The PCOS is associated with insulin resistance independent of obesity. Insulin resistance should be assessed in all hirsute women with PCOS regardless of their body mass index. More studies in larger numbers of patients should be performed to investigate the role of insulin resistance in women with IH.
doi:10.5114/aoms.2012.28563
PMCID: PMC3361048  PMID: 22662009
insulin resistance; idiopathic hirsutism; non-obese women
22.  The Effect of Flaxseed Supplementation on Hormonal Levels Associated with Polycystic Ovarian Syndrome: A Case Study 
Flaxseed is a rich source of lignan and has been shown to reduce androgen levels in men with prostate cancer. Polycystic ovarian syndrome (PCOS), a common endocrine disorder among women in their reproductive years, also is associated with high levels of androgens and is frequently accompanied by hirsutism, amenorrhea and obesity. This clinical case study describes the impact of flaxseed supplementation (30 g/day) on hormonal levels in a 31-year old woman with PCOS. During a four month period, the patient consumed 83% of the flaxseed dose. Heights, weights, and fasting blood samples taken at baseline and 4-month follow-up indicated the following values: BMI (36.0 vs. 35.7m/kg2); insulin (5.1 vs. 7.0 uIU/ml); total serum testosterone (150 ng/dl vs. 45 ng/dl); free serum testosterone (4.7 ng/dl vs. 0.5 ng/dl); and % free testosterone (3.1% vs. 1.1%). The patient also reported a decrease in hirsutism at the completion of the study period. The clinically-significant decrease in androgen levels with a concomitant reduction in hirsutism reported in this case study demonstrates a need for further research of flaxseed supplementation on hormonal levels and clinical symptoms of PCOS.
PMCID: PMC2752973  PMID: 19789727
Androgens; Flaxseed; Polycystic Ovarian Syndrome; Diet; Intervention Studies
23.  Current Approaches to the Diagnosis and Treatment of Polycystic Ovarian Syndrome in Youth 
Hormone research  2007;68(5):209-217.
Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in reproductive-age women. It often presents during late adolescence but in some cases certain features are evident even before menarche. PCOS is a spectrum of disorders with any combination of oligo/anovulation, clinical and/or biochemical evidence of androgen excess, obesity, insulin resistance and polycystic ovaries on ultrasound. The pathogenesis is unknown; however, it is a complex multigenetic disorder where disordered gonadotropin release, dysregulation of steroidogenesis, hyperinsulinism and insulin resistance play a role. The diagnosis is based on a typical physical exam (acne, hirsutism, obesity, and acanthosis nigricans) and laboratory evidence of hyperandrogenism, such as elevated free testosterone, androstenedione and dehydroepiandrosterone sulfate (DHEAS), decreased sex hormone-binding globulin (SHBG) and increased luteinizing hormone (LH). An ovarian ultrasound may detect the multiple cysts. Secondary causes of PCOS need to be excluded. There are several classes of medications correcting different parameters of PCOS that can be used alone or in combination. Oral contraceptive therapy is used to reduce androgen and LH levels with resultant improvement in acne and hirsutism, and the induction of regular menses. Antiandrogens are usually required for a substantial improvement in hirsutism score. Insulin sensitizers such as metformin are a new class of drugs utilized in treatment of PCOS. By improving insulin sensitivity and decreasing insulin levels, they improve the unfavorable metabolic profile of patients with PCOS. Metformin also helps to increase SHBG, decrease androgen levels and induce ovulation. Despite all the available medications, life-style changes are the mainstay of therapy as weight loss and exercise improve all parameters of PCOS without the potential side effects of medication.
doi:10.1159/000101538
PMCID: PMC4287252  PMID: 17426408
Polycystic ovary syndrome; Ovarian ultrasound; Life-style changes
24.  Degree of hyperinsulinemia, independent of androgen levels, is an important determinant of the severity of hirsutism in PCOS 
Fertility and sterility  2008;92(2):643-647.
Objective
To determine whether the severity in hyperandrogenemia determines, to a significant degree, the severity of hirsutism in patients with polycystic ovary syndrome (PCOS).
Design
Cross-sectional study.
Setting
Tertiary care academic referral center.
Patient(s)
A total of 749 patients with PCOS.
Intervention(s)
History and physical examination, blood sampling.
Main Outcome Measure(s)
Hirsutism defined by a value of ≥6 using the modified Ferriman-Gallwey (mFG) score, age, body mass index (BMI), calculated homeostatic assessment for insulin resistance (HOMA-IR) value, and levels of total (TT) and free (FT) testosterone, dehydroepiandrosterone sulfate (DHEAS) 17-hydroxyprogesterone (17OH-P), and fasting insulin (INS) and glucose (GLC).
Result(s)
Univariate correlations revealed associations between the mFG score and INS, 17OH-P, HOMA-IR, and BMI. Multivariate classification and regression tree analysis indicated that INS had the most significant association with mFG score and that at higher INS levels T played an additional role whereas at lower INS levels 17OH-P had an effect; however, this model accounted for only 8.2% of total variation in mFG score.
Conclusion(s)
Insulin appears to have a direct effect on the severity of hirsutism in PCOS and appears to have a synergistic interaction with TT. Notably, over 90% of the variation in the mFG score was not related to the factors studied and likely reflects intrinsic factors related to pilosebaceous unit function or sensitivity and to other factors not yet assessed.
doi:10.1016/j.fertnstert.2008.06.021
PMCID: PMC3714600  PMID: 18722607
Polycystic ovary syndrome; testosterone; DHEAS; 17-hydroxyprogesterone; hirsutism; hair
25.  Assessment of C-reactive Protein and C3 as Inflammatory Markers of Insulin Resistance in Women with Polycystic Ovary Syndrome: A Case-Control Study 
Background
Polycystic ovary syndrome (PCOS), a common endocrine disorder, is associated with infertility, menstrual dysfunction, hirsutism and frequent miscarriages. Insulin resistance, as a major cause of PCOS, represents a disorder with increase in inflammatory markers and risk of type 2 diabetes. We aimed to investigate whether inflammatory markers, including C-reactive protein and C3 (Complement), are related and altered in polycystic ovary syndrome.
Methods
A case-control study including forty-two women diagnosed with PCOS, according to Rotterdam criteria, and forty-two healthy controls, matched for body mass index (BMI) and age, was conducted in 2012. C-Reactive protein (CRP) and C3 were assessed as possible determinants of the homeostasis model assessment (HOMA) index. Independent-sample t-test was used to compare the means of the groups in age, BMI, C3, FBS and BS 2hpp (2 hr postprandial glucose) and for CRP, Fasting Insulin and 2 hr Plasma Insulin and HOMA index. Mann-Whitney test and Pearson correlation were used for analyzing the data. The p<0.05 was considered as statistically significant.
Results
Levels of plasma CRP (p=0.039), 2 hr pp (p=0.045), Fasting Insulin (p=0.002), 2 hr Plasma Insulin (p=0.002) and HOMA index (p=0.002) were significantly higher in PCOS patients. But C3 was not significantly higher in cases (p=0.885). There was no significant correlation between C3 and CRP with HOMA index.
Conclusion
CRP increased significantly in patients with PCOS and was associated with insulin resistance, the most probable cause of PCOS. However, such an association was not found in C3.
PMCID: PMC3911815  PMID: 24551574
C3; C-reactive Protein; Insulin Resistance; Polycystic Ovary Syndrome

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