Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe the clinical work-up of an adolescent girl with hirsutism or acne
2. Discuss the various treatment modalities for adolescents presenting with idiopathic hirsutism or acne

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/15/2020 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

ACOG provides guidance on the diagnosis and management of adolescents with hirsutism and acne, the most common manifestation of hyperandrogenism. While PCOS is the most common cause, making the diagnosis in this age group can be challenging. Furthermore, there are other diagnoses to consider and, while less frequent, may have significant clinical implications.

Diagnosis of Hyperandrogenism

Role of Lab Testing

Hirsutism Treatment – Multimodal Approach

Acne Treatment – Multimodal Approach

Additional Notes

CLINICAL ACTIONS:

Diagnosis of Hyperandrogenism

History

• Ask about the following
  • Menses: Regular vs irregular
  • Age of thelarche, adrenarche, and menarche
  • Hirsutism: Hair removal and/or shaving
  • Acne: Use of treatments
  • Medications, including possible use of anabolic steroids or testosterone
  • Family history of acne, hirsutism and possible PCOS

Physical exam

• Key elements include the following
  • BP
  • BMI
  • Derm exam
    • Hyperandrogenism: Acne | Hirsutism
    • Hyperinsulinism: Acanthosis | Skin tags
  • Pelvic exam
    • External examination “may be helpful” to assess presence or absence of clitoromegaly
    • Clitoromegaly definition: Glans >8 mm | Hood length >27.4 mm
    • “Internal vaginal examination is rarely indicated”
• Hirsutism grading system: Modified Ferriman–Gallwey score (see ‘Learn More – Primary Sources’ for the chart)
  • 9 body areas
  • Scored from 0 to 4 based on extent of hair growth and location
  • Hirsutism: Score >8
• Acne grading system: No universally agreed upon scoring system or scale
  • Overall severity (related to lesion quality, quantity and location)
    • Mild (only a few lesions)
    • Moderate (higher number of inflammatory papules and pustules on face and trunk)
    • Severe (may include nodules with extensive involvement of face and trunk)
  • Location: Face and/or trunk
  • Quality: Comedonal | Inflammatory (e.g, erythematous papules/nodules) | Mixed
• Need for Pelvic exam
  • External examination “may be helpful” to assess presence or absence of clitoromegaly
    • Clitoromegaly: Glans >8 mm | Length of the hood >27.4 mm
    • If clitoromegaly present, additional androgen studies warranted
  • “Internal vaginal examination is rarely indicated”
• Need for pelvic ultrasound
  • Usually not indicated on a routine basis but consider androgen producing tumor if the following are present
    • High laboratory androgen levels | Significant virilization
    • Adrenal ultrasound and CT scan may be used as well, especially if DHEAS is suggestive of adrenal tumor
  • Polycystic ovarian morphology
    • Present in up to 40% of adolescent girls
    • Does not generate a diagnosis of PCOS nor predict future risk

KEY POINTS:

Role of Lab Testing

Regular Menses

• Free/Total testosterone
  • >200 ng/dL: Consider ovarian tumor
• DHEAS
  • >700 micrograms/dL: Consider adrenal tumor
• 17OHP (first thing in the morning)
  • >200 ng/dL: Consider nonclassical congenital adrenal hyperplasia (CAH)

Note: If labwork is normal, consider idiopathic hirsutism and/or acne

Irregular Menses

• Testosterone, DHEAS and 17OHP (as above) plus
• LH/FSH
• Prolactin
• TSH

Note: If patient meets diagnostic criteria for PCOS (see ‘Related ObG Topics’ below), screen for diabetes and elevated lipids

Hirsutism Treatment – Multimodal Approach

Lifestyle modifications

• Weight loss for obese patients is effective with multiple other long term benefits aside from addressing hyperandrogenism

Medication

• Combined hormonal contraceptives (not currently FDA approved for this indication)
  • Effective regardless of route
  • Third-generation progestins (desogestrel, gestodene, and norgestimate): Less androgenic activity vs levonorgestrel
  • Drospirenone (spironolactone derivative): Antiandrogen activity
• Antiandrogens
  • Spironolactone (approved indication): 50 to 200 mg/day
    • May be used to enhance hormonal contraceptive
  • Less data available on other antiandrogens
• Other medications
  • Metformin: Used in adolescents with PCOS and insulin resistance

Hair removal

• Temporary removal
  • Bleaching | Shaving | Waxing Chemical depilatories | Eflornithine cream (approved for facial hirsutism)
• Permanent removal affecting follicle
  • Electrolysis | Laser

Acne Treatment – Multimodal Approach

• Consider working with dermatologist for moderate to severe acne and referral for more severe/complex cases (see American Academy of Dermatology guidelines in ‘Learn More – Primary Sources, below)
• Multiple topical agents are available
  • Benzoyl Peroxide (BP) | Salicylic acid | Antibiotics | Combination antibiotics with BP | Retinoids | Retinoid with BP | Retinoid with antibiotic | Azelaic acid | Sulfone agent
• Hormonal therapy
  • ACOG considers hormonal therapy (e.g., OCP) “acceptable first-line” therapy in postmenarchal adolescents
  • Additional benefits: Cycle control and contraception
  • May be especially effective for adolescents with flares prior to menses
  • Any OCP with estrogen component should be effective
  • Consider higher generation progestin (see above) if patient not responding to current OCP
• Spironolactone
  • Start at 25 mg/day and can go up to 100 to 200 mg/day
• Oral antibiotics
  • Used for moderate to severe with inflammatory lesions following failure of topical therapy
  • Tetracycline | Doxycycline | Minocycline |TMP/SMX | Trimethoprim | Erythromycin| Azithromycin | Amoxicillin | Cephalexin
  • Doxycycline and minocycline are more effective than tetracycline
  • Erythromycin and azithromycin can be effective in treating acne, its use should be limited to those who cannot use the tetracyclines (e.g., pregnancy)
  • Use limited to shortest duration possible
• Isotretinoin
  • For severe acne
  • Teratogenic in pregnancy
  • Requires compliance with iPLEDGE program (FDA mandated program) to mitigate pregnancy risk (see ‘Primary Sources – Learn More’ below) and use of dual contraception to avoid pregnancy

Additional Notes

• Hormonal therapy slows growth but does not remove hair | Due to lifespan of terminal hair, counsel patient that it may take 6 months to see an effect
• Elicit whether the adolescent is troubled by symptoms and address psychosocial issues
• ACOG suggests that in the setting of severe acne, a discussion regarding risk of scarring if acne left untreated should be considered
• Insufficient evidence currently to advise regarding diet and acne

Learn More – Primary Sources:

ACOG Committee Opinion 789: Screening and Management of the Hyperandrogenic Adolescent

Modified Ferriman–Gallwey scoring chart  

Visually scoring hirsutism

Guidelines of care for the management of acne vulgaris – Journal of the American Academy of Dermatology

iPLEDGE PROGRAM

Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls

Related ObG Topics:

Polycystic Ovary Syndrome: Making the Diagnosis

PCOS: Targeting Treatments to Improve Reproductive Outcomes and Reduce CVD

Hormonal Contraception Benefits – Beyond Pregnancy Prevention

Just how Common is Nonclassic Congenital Adrenal Hyperplasia?