Hirsutism and virilisation — structured SAQ (15 marks)

(a) The modified Ferriman-Gallwey score (3 marks)

One mark per element. ^[2][3]

• Nine androgen-sensitive sites (verbatim): (1) upper lip, (2) chin, (3) chest, (4) upper back, (5) lower back, (6) upper abdomen, (7) lower abdomen, (8) upper arms, (9) thighs.
• Grading scale: each site 0 to 4 (0 = no terminal hair; 1 = a few; 2 = more than a few; 3 = approaching a male pattern; 4 = frankly male pattern). Maximum total 36.
• Caucasian threshold: an mFG score over 8 defines hirsutism in a Caucasian/Northern European woman (over 6 Mediterranean, over 4–5 South Asian/African, over 2–3 East Asian).^[2][3]

(b) The investigation panel (4 marks)

One mark per element. ^[1][4]

• The androgen panel: total testosterone, SHBG, calculated free androgen index (total testosterone ÷ SHBG × 100), DHEAS, 17-hydroxyprogesterone, androstenedione; plus prolactin and TSH in every workup.
• Assay-quality requirement: use liquid chromatography–mass spectrometry (LC-MS/MS) — direct immunoassays overestimate testosterone in the low female range and mislead.
• 17-Hydroxyprogesterone is the single test that rules out non-classic congenital adrenal hyperplasia: drawn morning, day 3–5, fasting; a baseline over 6 nmol/L (200 ng/dL) is confirmed by an ACTH (Synacthen) stimulation test with a stimulated peak over 30–65 nmol/L.
• Timing caveat: 17-OHP is falsely elevated in the luteal phase and in pregnancy — draw it in the follicular phase. DHEAS over 700 µg/dL suggests an adrenal tumour.^[1][4]

(c) The Endocrine Society 2018 management ladder (5 marks)

One mark per element, maximum five. ^[1][5]

• Cosmetic measures first (shaving, waxing, bleaching) — begin immediately; they do not wait for the workup.
• Combined oral contraceptive pill first-line — raises SHBG, lowers free testosterone, suppresses ovarian androgen production; choose an anti-androgenic progestogen (drospirenone, cyproterone). Allow 6 months to judge the response.
• Add an anti-androgen after 6 months if response is suboptimal — spironolactone 100–200 mg/day (first-line), cyproterone, or finasteride 5 mg/day (third-line). Eflornithine 13.9% cream topically and laser/photoepilation for those wanting additional cosmetic benefit.
• The contraceptive rule: the Endocrine Society recommends against anti-androgen monotherapy unless adequate contraception is used — anti-androgens (spironolactone, cyproterone, finasteride) feminise a male fetus. The COCP is the contraceptive of choice.
• Recommend against insulin-lowering drugs (metformin) for hirsutism alone; they are not effective for this indication. Flutamide is hepatotoxic and should not be used.^[1][5]

(d) The tumour-threshold red flag (3 marks)

One mark per point. ^[1]

• Diagnosis to exclude: an androgen-secreting tumour (ovarian: Sertoli-Leydig, hilus, granulosa-theca; or adrenal carcinoma). The combination of rapid tempo (4 months), virilisation (clitoromegaly, voice deepening) and a total testosterone of 9 nmol/L is the classical red-flag profile.
• The threshold: total testosterone over 5 nmol/L (around 150–200 ng/dL) or DHEAS over 700 µg/dL (around 18.5 µmol/L) mandates imaging.
• The next step: urgent pelvic ultrasound first (for an ovarian source), then adrenal CT or MRI, and urgent surgical referral. Do not start a COCP or anti-androgen before excluding the tumour.^[1]