Diagnostic evaluation of hirsutism in women.

Many of the androgenic steroids are precursor hormones that undergo metabolic conversion to other prehormones in peripheral tissue before they reach the target organs. The most studied of the circulating androgens are dehydroepiandrosterone (DHEA) DHEA-sulphate delta-4-androstenedione testosterone and dihydrotestosterone. The concentration of DHEA-sulphate in peripheral blood is the highest of all circulating androgens. Over 90% of this steroid is secreted by the adrenal glands and less than 10% by the ovaries. In the hirsute patient the production rates of testosterone delta-4-androstenedione and dihydrotestosterone are almost always significantly elevated. In the hirsute woman only 24% of plasma testosterone is derived from glandular secretion. Urinary androgen determinations particularly for 17-ketosteroids have been made but are not considered accurate in determining androgen secretion biologic potency of individual androgens or the glands of origin. Testosterone glucuronide determinations do not identify the glandular source nor does blood production of testosterone. Plasma androgen determinations do not direct the clinician to the proper pharmacologic or surgical therapy. A change in urinary or plasma androgens following dexamethasone administration does not implicate the adrenal glands as the source of androgen. Measurement of plasma testosterone following estrogen suppression may lead to erroneous conclusions. Percutaneous ovarian and adrenal venous catheterization studies via the femoral vein with analyses of the effluent blood for androgens is considered accurate and clinically applicable for the etiologic diagnosis of hirsutism. Combined with the other assays the major glands of origin for the androgens have been demonstrated in individual patients. The suppressibility of peripheral plasma androgens following dexamethasone administration has been used to further conduct therapy.