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Hirsutism – Causes, Symptoms and Treatment

Hirsutism refers to excessive growth of coarse, dark body and facial hair in women following a male pattern. It is most commonly caused by elevated androgen levels.

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Things worth knowing about "Hirsutism"

Hirsutism refers to excessive growth of coarse, dark body and facial hair in women following a male pattern. It is most commonly caused by elevated androgen levels.

What is Hirsutism?

Hirsutism is a medical condition characterised by excessive growth of thick, dark hair in women and girls in areas where such hair growth is typically seen only in men – including the face (upper lip, chin), chest, abdomen, back, and inner thighs. The condition results from increased exposure of hair follicles to male sex hormones, known as androgens.

Hirsutism should be distinguished from hypertrichosis, which describes generalised excess hair growth that is not related to androgen levels.

Causes

The most common cause of hirsutism is Polycystic Ovary Syndrome (PCOS), accounting for up to 75% of cases. Other causes include:

Androgen-secreting tumours of the ovaries or adrenal glands (rare but important to exclude)
Congenital adrenal hyperplasia (CAH): an inherited disorder affecting adrenal hormone production
Cushing syndrome: excess cortisol due to adrenal overproduction or a tumour
Hyperprolactinaemia: elevated prolactin levels, e.g. caused by a prolactinoma
Medications such as anabolic steroids, certain antiepileptics, glucocorticoids, or minoxidil
Idiopathic hirsutism: increased sensitivity of hair follicles to androgens without measurably elevated hormone levels

Symptoms and Associated Complaints

The primary symptom is unwanted hair growth in androgen-dependent body areas. Additional signs of androgen excess frequently occur alongside:

Acne and oily skin
Irregular or absent menstrual periods
Scalp hair thinning (androgenetic alopecia)
Weight gain and insulin resistance (especially in PCOS)
Deepening of the voice or clitoral enlargement (in cases of severe virilisation)

The severity of hirsutism is commonly assessed using the Ferriman-Gallwey score, which evaluates hair growth in nine body areas on a scale of 0 to 4.

Diagnosis

Diagnosis is based on clinical assessment and laboratory testing. The following hormonal values are typically measured:

Total and free testosterone
DHEA-S (dehydroepiandrosterone sulphate)
17-OH-progesterone (to exclude CAH)
LH and FSH (LH/FSH ratio often elevated in PCOS)
Prolactin and TSH

If a hormone-secreting tumour is suspected, imaging studies such as ultrasound or MRI may be performed.

Treatment

Medical Therapy

Treatment is directed at the underlying cause. Commonly used medications include:

Combined oral contraceptives (the pill): suppress androgen synthesis and reduce free androgen levels
Antiandrogens such as spironolactone, cyproterone acetate, or flutamide: block androgen action at the hair follicle
Metformin: used in PCOS-associated hirsutism with insulin resistance
Glucocorticoids: indicated in congenital adrenal hyperplasia

Cosmetic and Non-Medical Approaches

To reduce the visible appearance of hair, the following approaches are commonly used alongside medical treatment:

Shaving, waxing, depilatory creams
Laser hair removal: effective long-term solution for dark hair
Electrolysis: provides permanent hair removal
Eflornithine cream (Vaniqa): slows facial hair growth

Lifestyle Modifications

In PCOS-related hirsutism, weight loss can lower androgen levels and improve symptoms. Regular physical activity and a balanced diet are strongly recommended.

References

Martin K.A. et al. - Evaluation and treatment of hirsutism in premenopausal women: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism, 2018.
Rosenfield R.L. - Hirsutism. New England Journal of Medicine, 2005;353(24):2578-2588.
World Health Organization (WHO) - Polycystic ovary syndrome. WHO Fact Sheet, 2023. Available at: https://www.who.int/news-room/fact-sheets/detail/polycystic-ovary-syndrome

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