Hirsutism is characterised by excess body hair in a typically male distribution. The hair is pigmented and thick. It may be particularly obvious when it is on the moustache or beard areas. The other common sites are the chest, abdomen, thighs and back. Pubic hair growth may extend upward from the usual bikini-line to the middle of the abdomen (umbilicus) (Figure 8.1). For a woman to be hirsute is understandably embarassing.

Figure 8.1 Hirsutism - Excess Hair Distribution

Virilism is more extensive than hirsutism, with additional evidence of masculinisation. There may be acne, oily skin, temporal scalp baldness, enlargement of the clitoris, voice deepening, breast size reduction, and irregular or absent periods. Occasionally, there may be increased libido and aggression.

Virilization is a relatively uncommon feature of hyperandrogenism, and its presence often suggests an androgen-producing tumor.⁰⁶⁰¹

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Each hair is formed from a hair follicle in the skin and each follicle lives for about three years. A hair consists of a column of dead cells derived from the living hair follicle. There is a central medulla, which contains the coloured melanin, and a hard external cuticle. Sebaceous glands are connected to the follicle. The sebaceous glands and the hair follicles are sensitive to the circulating androgens (masculinising sex hormonesQ 2. 9). Acne and excess body hair may be associated with increased levels of androgens.

Our skin is covered by hair follicles but those in the typical male distribution are sensitive to androgens which increase the hair production, and oestrogens (female sex hormones) which decrease it. These sex hormones are carried in the blood on a protein called sex hormone binding globulin (SHBG). Androgens decrease the amount of circulating SHBG and oestrogens increase the SHBG. If there is less SHBG, more of the androgen is free (unbound to protein) and available to act on the hair follicles. (SHBG).

In one survey 15% of women thought they had excess body hair although doctors found objective evidence of hirsutism in only 7%. There is a variation in normal hair production between ethnic groups. One study suggests that the incidence of hirsutism in the USA and Europe is about 10%^(2006-01) A study in Lithuania found that only 60% of patients complaining of hirsutism were clinically hirsute. ^2005-01

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A scoring system for assessing hirsutism was first described in North London by Ferriman and Galway nearly forty years ago. The hair production at eleven sites is scored from 1 representing a few hairs to 4 representing heavy hair growth. The sites evaluated are the upper lip, chin, chest, upper and lower back, upper and lower abdomen, arms, forearms, thighs and legs. The scoring system allows an initial assessment and facilitates comparison whilst on treatment.

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The first signs of increased androgen levels (hyperandrogenism) are hirsutism and acne. The sensitivities of individuals to hormone levels vary considerably. When there are high androgen levels, other signs of virilisation may be found including muscle enlargement, deepening of the voice, reduction or absence of periods, reduced breast size and enlargement of the clitoris. About 50% of women with hirsutism have normal hormone levels although there is likely to be increased activity of the skin enzyme '5 alpha- reductase', which raises local androgen levels. Eventually there may be male pattern balding.

The increased androgen can originate from the ovaries, or the adrenal glands, or from medication. The commonest cause of hirsutism is polycystic ovary syndrome (Q7.2).

Hormone secreting tumours of an ovary or an adrenal gland causing hirsutism are extremely uncommon.^2006-01

The adrenogenital syndrome (congenital adrenal hyperplasia) usually presents in early life. The adrenal glands produce a variety of hormones. When they are unable to produce cortisol, the pituitary gland produces increased amounts of the hormone ACTH and this results in an increased production of androgens. If the cortisol synthesis is only partly deficient the adrenogenital syndrome may not be apparent during childhood but presents later in life with hirsutism or virilism. Some medicines can cause hirsutism and virilism and there are some rare diseases, such as porphyria, which are associated with hirsutism.

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The story and examination findings may suggest the cause. Investigations including blood tests to determine hormone levels, and ultrasound are usually required. A simple flowchart (Figure 8.2) indicates the basic investigations and how they lead to a diagnosis.

Ultrasound examination and blood tests help to determine the cause. If you have polycystic ovaries, ultrasound examination will usually demonstrate the typical picture (Q7. 1). Tumours of an ovary or adrenal gland are uncommon but could be shown by the ultrasound examination. An elevated LH in the blood during the first eight days of the menstrual cycle suggests polycystic ovary syndrome unless the FSH is also high suggesting the menopause. Testosterone may be slightly elevated in polycystic ovary syndrome or higher if there is a hormone secreting tumour. An elevated 17 alpha hydroxyprogesterone level suggests the adrenogenital syndrome. Sometimes the tests demonstrate no obvious abnormality and we assume that the skin is particularly sensitive to androgens; this may be a familial problem.

Many patients presenting with hirsutism are understandably anxious to exclude a major medical problem. Reassurance that investigations are normal or show just a minor imbalance may be all that they are seeking.  

Figure 8.2 Flowchart for the investigation of hirsutism.

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Usually clinical assessment and investigation will identify a cause but this is not always the case. This idiopathic hirsutism occurs in about 5% of patients with hirsutism.

There are a variety of cosmetic treatments, which may be all that you require, although each may be associated with occasional problems.

Shaving is the simplest and most effective in the short term but some find this psychologically unacceptable.

Bleaching is not usually suitable for severe hirsutism.

Plucking, waxing, sugaring, depilatory creams are effective but on occasion they can result in skin irritation or infection.

Electrolysis is effective but expensive, time-consuming, and painful.

There is no evidence that any of these treatments aggravate hirsutism.

Fat tissue is involved in altering some sex steroids to androgens. If you are overweight, this will tend to increase body hair production. Going on a diet and increasing your exercise should help you lose some of the unwanted hair and also help your general health.

Insulin resistance is common in polycystic ovary syndrome and this may be associated with weight gain, which in turn increases hirsutism. A diet designed to reduce weight may reverse this trend.  

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There are medical treatments that:-

inhibit gonadotrophins (sex hormones).

Combined oral contraceptive pills, and in particular one containing the anti-androgen cyproterone acetate (Dianette - Schering) are the most popular treatments for hirsutism (Q8.14):

inhibit overproduction of androgens.

Steroids such as dexamethasone may be used if there is evidence of congenital adrenal hyperplasia. There is some evidence that a small dose of steroids can be an effective treatment when no obvious cause can be found. Suppression of ovarian hormone production with GnRH analogues (gonadotrophins) is expensive and they can only be used by themselves for short spells. Combinations of GnRH and add-back hormone replacement therapy (HRT-Add-Back) may have an occasional place.

increase SHBG (SHBG).

Combined oral contraceptive pill.