Hirsutism and virilisation — structured oral station (12 minutes)

Opening prompt — "Score this woman's hair. What is the mFG and what threshold defines hirsutism?"

Model response — the mFG verbatim: ^[2][3]

• "The modified Ferriman-Gallwey score grades nine androgen-sensitive body sites — upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, upper arms and thighs — each from 0 to 4, for a maximum of 36. She scores 11, which exceeds the Caucasian threshold of 8 and meets the definition of hirsutism."
• "I would note that the threshold is ethnicity-specific — over 6 for Mediterranean, over 4 to 5 for South Asian and African, over 2 to 3 for East Asian women — because baseline terminal hair varies between populations."^[2][3]

Probe 1 — "What investigations will you order?"

• "The androgen panel: total testosterone, SHBG and the calculated free androgen index — the most sensitive biochemical marker — DHEAS, 17-hydroxyprogesterone, androstenedione, plus prolactin and TSH in every workup. I insist on an LC-MS/MS assay, because direct immunoassays overestimate testosterone in the low female range."^[1]
• "The single most important rule-out is a morning 17-hydroxyprogesterone, drawn day 3 to 5, fasting, to exclude non-classic congenital adrenal hyperplasia. A baseline over 6 nmol/L is confirmed by an ACTH stimulation test with a peak over 30 to 65 nmol/L."^[4]

Probe 2 — "Her 17-OHP is normal, testosterone is mildly elevated, cycles regular. What is your management?"

• "I follow the Endocrine Society 2018 ladder. Cosmetic measures first — shaving, waxing, bleaching — begin immediately. Then a combined oral contraceptive pill, choosing one with an anti-androgenic progestogen like drospirenone or cyproterone. I allow 6 months to judge the response before escalating."^[1]
• "If response is suboptimal at 6 months, I add an anti-androgen — spironolactone 100 to 200 mg a day is first-line. And I add laser or photoepilation for those who want additional cosmetic benefit, plus eflornithine 13.9 percent cream as a topical adjunct."^[5]

Probe 3 — "She is sexually active and uses no contraception. Can you prescribe spironolactone?"

• "No — not without reliable contraception. The Endocrine Society recommends against anti-androgen monotherapy unless adequate contraception is used, because spironolactone, cyproterone and finasteride are teratogenic and feminise a male fetus. I would start the combined oral contraceptive pill first, which both provides contraception and is first-line pharmacotherapy. Spironolactone can be added after 6 months."^[1]

Probe 4 — "Does metformin have a role for her hirsutism?"

• "No. The Endocrine Society 2018 guideline recommends against insulin-lowering drugs for hirsutism alone — they are not effective for this indication. Metformin has a role in PCOS for impaired glucose tolerance or as an adjunct to fertility therapy, but not for hirsutism."^[1]

Probe 5 — "A different patient, 38, has 4 months of progressive hirsutism with clitoromegaly and voice deepening, and a total testosterone of 9 nmol/L. What changes?"

• "Everything changes. This is virilisation with rapid tempo and a testosterone of 9 nmol/L — well above the 5 nmol/L threshold that mandates imaging for an androgen-secreting tumour. The next step is urgent pelvic ultrasound first for an ovarian source, then adrenal CT or MRI, and urgent surgical referral. I do not start a COCP or anti-androgen before excluding the tumour."^[1]

Probe 6 — "She is distressed about her appearance and has stopped socialising. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[1]

• Move to her eye level, use her name, acknowledge the distress: "Excess hair is a real and distressing symptom, and it is not vanity to want it treated. We have a clear evidence-based ladder — the pill, anti-androgens, laser — and most women see a meaningful improvement within 6 months. The hair cycle sets the timeline, so I will not promise overnight results, but I will promise we will work through the options together. You are not coping with this alone."^[1]