Family medicine
Hirsutism In Women
Hirsutism in women is the excessive growth of coarse, dark (terminal) hair in a male-pattern distribution, most commonly caused by androgen excess or increased skin sensitivity to androgens.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Polycystic ovary syndrome (PCOS) | Hirsutism + oligomenorrhoea + obesity/acne; LH:FSH > 2.5 | 「月經係咪成日遲？面有冇暗瘡？有冇肥咗？」 |
| Idiopathic hirsutism | Normal menses, normal androgens, +ve FHx | 「月經正常，屋企人有冇類似情況？」 | |
| Serious Not To Miss | Androgen-secreting tumour (ovarian / adrenal) | Rapid onset, severe virilisation, testosterone > 150 ng/dL or DHEAS > 800 μg/dL [1] | 「毛係咪突然間好多？把聲粗咗？頭頂甩髮？」 |
| Cushing's syndrome | Central obesity, striae, proximal myopathy, moon face, easy bruising [2][3] | 「有冇紫色肚紋？蹲低起身有冇腳軟？」 | |
| Late-onset (non-classic) congenital adrenal hyperplasia (CAH) | Young onset, prominent androgen excess, raised 17-OH progesterone [4] | 「幾歲開始有？細個有冇發育太早？」 | |
| Pitfalls | Hyperprolactinaemia | Galactorrhoea, amenorrhoea, headache | 「乳頭有冇出奶？」 |
| Hypothyroidism | Cold intolerance, weight gain, constipation, dry skin | 「怕唔怕凍？有冇便秘？皮膚乾唔乾？」 | |
| Masquerades | Drug-induced hirsutism | Temporal relationship with drug; valproate, cyclosporine, minoxidil, phenytoin, steroids | 「有冇食緊或者搽緊任何藥物？」 |
| Depression / stress | Low mood, sleep disturbance → may worsen PCOS via weight gain & cortisol | 「心情點？瞓得好唔好？」 | |
| Trying to Tell Me Something? | Body image distress / relationship concern / fertility anxiety | Hidden agenda — fear of being "unfeminine", partner rejection, infertility | 「呢個問題對你自信心或者同伴侶嘅關係有冇影響？你最擔心嘅係咩？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好，我係X醫生。今日想同你傾吓你嚟睇嘅原因，我會問你幾條問題，之後同你傾吓下一步點做，好唔好？」(Hi, I'm Dr X. Today I'd like to chat about why you came. I'll ask some questions then discuss next steps, OK?) | Rapport, permission, signposting — high interpersonal marks |
| 0:30–1:30 | Chief complaint & HPI — onset, duration, distribution, severity, progression; menstrual history | 「你可唔可以同我講吓，邊度嘅毛多咗？幾時開始㗎？」「有冇越來越嚴重？」「月經正唔正常？」 | Defines HPI; anchors the case report chief complaint and HPI section |
| 1:30–2:30 | Systems review / red flags — virilisation signs, weight change, Cushingoid symptoms, galactorrhoea, visual changes, drug history | 「有冇覺得把聲變粗？頭頂甩頭髮？」「有冇食緊咩藥，例如類固醇？」「有冇頭痛或者眼矇？」 | Screens for serious causes (tumour, Cushing's, CAH, prolactinoma) |
| 2:30–3:30 | PMHx, FHx, O&G Hx, Social Hx — PCOS/DM/thyroid; family hirsutism/PCOS/CAH; fertility desire; occupation, stress, mood | 「屋企人有冇類似情況？」「你有冇想生BB？」「工作壓力大唔大？心情點？」 | Completes biopsychosocial picture for Q5b; screens hidden agenda |
| 3:30–4:30 | ICE — Ideas, Concerns, Expectations | 「你自己覺得點解會咁？」(Ideas) 「你最擔心嘅係咩？」(Concerns) 「你今日嚟最希望我幫到你啲咩？」(Expectations) | Directly tested in Q3 of Case Report Form — must ask all three |
| 4:30–5:15 | Summarise back, check understanding | 「等我歸納吓：你大約X個月前開始面、下巴同身多咗毛，月經疏咗，你擔心可能係荷爾蒙問題，想check吓，啱唔啱？」 | Demonstrates active listening; scores summarisation marks |
| 5:15–6:00 | Explain plan, safety-net, close | 「我建議幫你抽血check吓荷爾蒙，同埋照吓超聲波。如果有咩不舒服，例如月經完全冇咗或者突然好多毛，要盡快覆診。」「你仲有冇問題想問？多謝你今日嚟。」 | Safe closure, safety-net, invitation to ask questions — finishes professionally |
Uncovering the hidden agenda: The simulated patient with hirsutism may actually be most worried about infertility, self-image/relationship impact, or fear of cancer. Always ask 「你最擔心嘅係咩？」 and 「今日特別嚟睇嘅原因係咩？」 — "Why today?" often reveals the real RFC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & Duration | When did you first notice the excess hair? Gradual or sudden? | 「幾時開始發覺毛多咗？係慢慢多定突然間好多？」 | Rapid onset → tumour; gradual → PCOS/idiopathic | Sudden + severe → androgen-secreting tumour |
| Distribution | Where exactly? Face, chest, abdomen, back, thighs? | 「邊度最明顯？面、下巴、胸口、肚、背、大髀？」 | Terminal hair in androgen-dependent areas = true hirsutism vs hypertrichosis | Modified Ferriman-Gallwey score ≥ 5 in Chinese women [1] |
| Severity / Progression | Is it getting worse? How do you manage it? | 「有冇越嚟越嚴重？你平時點處理？剃、漂、蠟？」 | Progressive worsening → active androgen source | Tumour, late-onset CAH |
| Virilisation signs | Voice deepening, scalp hair loss, increased muscle, clitoromegaly? | 「把聲有冇粗咗？頭頂有冇甩頭髮？」 | Virilisation = red flag for androgen-secreting tumour [1] | Ovarian/adrenal tumour |
| Menstrual Hx | Regular periods? How often? Last period? | 「月經幾耐嚟一次？上次幾時嚟？」 | Oligomenorrhoea → PCOS, CAH; amenorrhoea → tumour, Cushing's | PCOS most common |
| Weight change | Any recent weight gain? Distribution? | 「體重有冇增加？肚腩特別大？」 | Central obesity → PCOS / Cushing's | Cushing's if + striae, moon face |
| Cushing's features | Easy bruising? Purple stretch marks? Weakness standing from squat? | 「容唔容易瘀？有冇紫色紋？蹲低起身辛唔辛苦？」 | Proximal myopathy + striae = more specific for Cushing's [2][3] | Cushing's syndrome |
| Galactorrhoea | Any milk from nipples? | 「乳頭有冇出奶？」 | Galactorrhoea → hyperprolactinaemia | Prolactinoma |
| Headache / Vision | Headaches? Bumping into things on the side? | 「有冇頭痛？有冇撞到旁邊嘅嘢？」 | Bitemporal hemianopia → pituitary macroadenoma | Pituitary tumour |
| Drug Hx | Any steroids, valproate, cyclosporin, minoxidil, phenytoin? | 「有冇食緊類固醇、薄血藥、抗癲癇藥、或者搽開咩藥？」 | Drug-induced hirsutism is a masquerade [2] | Iatrogenic |
| Thyroid symptoms | Heat/cold intolerance? Weight change? Fatigue? | 「怕唔怕熱？怕唔怕凍？易唔易攰？」 | Hypothyroidism can cause hirsutism [1] | Hypothyroidism |
| Acne | Acne on face/back? | 「面同背有冇暗瘡？」 | Acne + hirsutism + oligomenorrhoea → PCOS triad | PCOS |
| Fertility | Are you trying to have a baby? | 「你有冇想生BB？」 | Key concern and expectation; affects Mx choice | PCOS-related subfertility |
| FHx | Anyone in family with similar hair growth, PCOS, diabetes? | 「屋企人有冇多毛、糖尿、或者經期唔準？」 | FHx of PCOS, CAH, DM | PCOS, late-onset CAH |
| Social / Psychosocial | How does this affect your daily life, mood, relationships? | 「呢個問題對你日常生活、心情、同伴侶關係有冇影響？」 | Psychosocial impact is tested in Q5b | Body image distress, depression, relationship strain |
| Sexual Hx | Sexually active? Contraception? | 「有冇性生活？有冇避孕？」 | R/O pregnancy before Ix/Tx; COCP is a Mx option | — |
Case Report Form Answer Builder
- CC: "Excessive facial / body hair growth for X months/years"
- HPI high-yield points: onset (gradual vs rapid), duration, distribution (face/chest/abdomen/back), progression, associated menstrual irregularity (oligomenorrhoea/amenorrhoea), weight gain, acne, any virilisation signs (voice change, temporal balding, clitoromegaly), cosmetic measures tried, drug history, family history of hirsutism/PCOS
Examples (choose based on history):
- "Patient concerned about increasing facial hair affecting self-confidence"
- "Patient worried excess hair may indicate a hormonal problem"
- "Patient wants to know if hirsutism is related to difficulty conceiving"
- Phrase it as the patient's perspective, not a medical diagnosis.
| Likely Example | How to Write | |
|---|---|---|
| Ideas | "I think it might be hormonal" / "Maybe it's PCOS — I Googled it" | Patient thinks her excess hair is due to a hormonal imbalance |
| Concerns | "I'm worried it could be something serious like a tumour" / "I'm worried I can't have children" / "I feel unfeminine and my boyfriend noticed" | Patient is concerned about the possibility of a serious cause / concerned about fertility / concerned about appearance and self-esteem |
| Expectations | "I want a blood test" / "I want treatment to reduce the hair" / "I want a referral to a specialist" | Patient expects investigation to identify the cause and treatment to reduce hair growth |
Polycystic ovary syndrome (PCOS) — the most common cause of hirsutism in reproductive-age women [1][5]
Minimum supporting evidence: hirsutism (modified Ferriman-Gallwey score ≥ 5 in Chinese [1]) + oligomenorrhoea + acne ± obesity. Confirm with LH:FSH ratio > 2.5, raised testosterone, pelvic USS showing polycystic ovaries.
| DDx | Key Discriminator |
|---|---|
| 1. Idiopathic hirsutism | Hirsutism with regular menses, normal androgens, often +ve FHx |
| 2. Late-onset (non-classic) CAH | Young onset, raised 17-OH progesterone, family history, sometimes primary amenorrhoea [4] |
| 3. Cushing's syndrome | Central obesity, purple striae, proximal myopathy, moon face, easy bruising, hypertension, DM [2][3] |
| Domain | Problem |
|---|---|
| Biological | Androgen excess causing hirsutism and oligomenorrhoea; associated metabolic risk (insulin resistance, obesity, dyslipidaemia) |
| Psychological | Body image distress, low self-esteem, possible depressive symptoms related to altered appearance |
| Social | Impact on intimate relationships, social embarrassment, potential subfertility affecting family planning |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| PCOS (most likely) | Hirsutism scored by modified Ferriman-Gallwey scale (≥ 5 in Chinese women) [1] + acanthosis nigricans (insulin resistance marker) | Inspect 9 body areas for terminal hair (lip, chin, chest, upper/lower abdomen, upper/lower back, upper arm, thigh); inspect axillae/neck for velvety dark patches | Terminal hair in androgen-dependent areas confirms clinical hyperandrogenism; acanthosis nigricans supports insulin resistance seen in PCOS |
| Cushing's syndrome | Proximal myopathy — unable to stand from squatting without using hands [2][3] | Ask patient to squat and stand up unaided; also look for purple striae > 1 cm wide, thin skin, easy bruising | Proximal myopathy is a more specific sign for Cushing's; purple striae and spontaneous bruising also highly suggestive |
| Late-onset CAH | No reliable single physical sign in brief FM station | Check for signs of virilisation (clitoromegaly on pelvic exam — unlikely in OSCE); best exam clue is severe hirsutism + acne disproportionate to other features; confirm by serum 17-OH progesterone [4] | Elevated early morning 17-OH progesterone is diagnostic; physical signs overlap with PCOS |
| Androgen-secreting tumour | Signs of virilisation: temporal balding, deepened voice, clitoromegaly, increased muscle mass [1] | Inspect hairline (temporal recession), listen to voice pitch, examine for clitoromegaly | Virilisation is rare in PCOS; its presence should trigger urgent investigation (testosterone, DHEAS, imaging) |
| Idiopathic hirsutism | No distinguishing physical sign | Normal BMI, no acne, no virilisation, no acanthosis nigricans; diagnosis of exclusion | Absence of other signs + normal androgens supports idiopathic aetiology |
Top Traps That Lose Marks
- Confusing hirsutism with hypertrichosis — Hirsutism = androgen-dependent terminal hair in male-pattern distribution. Hypertrichosis = generalised vellus hair growth (non-androgen dependent, e.g. hypothyroidism, drugs like minoxidil, cyclosporine).
- Forgetting to ask about medications — Valproate, cyclosporine, danazol, phenytoin, anabolic steroids, and topical/systemic corticosteroids are common culprits.
- Missing virilisation signs — Voice change, temporal balding, clitoromegaly, increased muscle mass → red flag for androgen-secreting tumour; requires urgent referral.
- Not asking about fertility — This is often the hidden agenda. PCOS is the #1 cause of anovulatory infertility.
- Forgetting to ask ICE — Q3 is directly marked. If you don't ask all three, you lose easy marks.
- Writing "hormonal imbalance" as the RFC — The RFC should be the patient's reason, not a medical term. E.g., "Worried about increasing facial hair and inability to conceive."
Must-Not-Miss Red Flags → Urgent Referral:
- Rapid-onset severe hirsutism + virilisation → suspect androgen-secreting tumour → urgent gynaecology/endocrine referral + imaging
- Total testosterone > 150 ng/dL or DHEAS > 800 μg/dL → tumour workup [1]
- Features of Cushing's syndrome → 1mg overnight DST → refer endocrinology [2][3]
Shortest Safe Management / Safety-Net Line:
「我會幫你安排驗血（荷爾蒙、血糖）同超聲波。如果你發覺毛突然多好多、把聲變粗、或者月經完全停咗，要盡快返嚟覆診。」 (I'll arrange blood tests — hormones, glucose — and an ultrasound. If the hair suddenly gets much worse, your voice deepens, or your periods stop completely, please come back urgently.)
High Yield Summary
What to ASK: Onset/progression, distribution (Ferriman-Gallwey areas), menstrual history, virilisation signs, weight change, Cushingoid symptoms, galactorrhoea, drug history, FHx, fertility desire, psychosocial impact, and ICE.
What to WRITE:
- CC: Excessive hair growth in androgen-dependent areas for [duration]
- Most likely Dx: PCOS (hirsutism + oligomenorrhoea ± acne ± obesity)
- DDx: Idiopathic hirsutism, late-onset CAH, Cushing's syndrome
- Biopsychosocial: metabolic risk / body image distress-depression / relationship-fertility-social impact
- Physical sign: Modified Ferriman-Gallwey score ≥ 5 in Chinese women [1] + acanthosis nigricans
What NOT to MISS:
Active Recall - Family Medicine Clinical Test
[1] Adrian Lui Gynecology Notes.pdf (p41 — hirsutism, Ferriman-Gallwey score ≥ 5 in Chinese women, androgen-secreting tumour testosterone > 150 ng/dL, DHEAS > 800 μg/dL) [2] Ryan Ho Endocrine.pdf (p61 — Cushing's syndrome clinical features: hirsutism, proximal myopathy, striae, thin skin) [3] Ryan Ho Fundamentals.pdf (p435–436 — Cushing's syndrome: clinical features, approach, diagnostic tests) [4] Ryan Ho Endocrine.pdf (p73 — late-onset CAH: hirsutism, oligomenorrhoea, raised 17-OH progesterone) [5] Maksim Medicine Notes.pdf (p103 — hirsutism investigations: DHEAS, testosterone, LH/FSH, 17-OH progesterone)
Hip And Buttock Pain
Hip and buttock pain is a clinical presentation arising from musculoskeletal, neurological, or referred sources—including osteoarthritis, bursitis, sacroiliac dysfunction, lumbar radiculopathy, or piriformis syndrome—causing discomfort in the hip joint, gluteal, or surrounding regions.
Hoarseness
Hoarseness is an abnormal change in voice quality, typically characterized by a rough, breathy, or strained sound, resulting from disorders affecting the vocal folds or laryngeal function.