What is hirsutism?
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.
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Figure 8.1 Hirsutism - Excess Hair Distribution
What is virilism?
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
Related Medical Abstracts - Click on the paper title:-
Development of a hair.
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 hormones Q 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).
How Common is Hirsutism?
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
Related Medical Abstracts - Click on the paper title:-
- Hirsutism (2006-01)information?
- The evaluation of clinical signs and hormonal changes in women who complained of excessive body hair growth. (2005-01)information?
- The evaluation and management of hirsutism. (2003-01)
How can the severity of hirsutism be assessed?
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.
Related Medical Abstracts - Click on the paper title:-
- Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. (2006-01)
- Facial and abdominal hair growth in hirsutism: a computerized evaluation. (2001-01)
- Semiquantitative assessment of hirsutism in Dutch women. (1993-01)
- Body hair growth in women: normal or hirsute. (1984-01)
What are the effects of increased androgens in women?
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
- eventually there may be male pattern balding.
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.
What are the sources of excess androgens?
The increased androgen can originate from the
- ovaries
- adrenal glands, or from
- medication.
The commonest cause of hirsutism is polycystic ovary syndrome.
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.
Related Medical Abstracts - Click on the paper title:-
- A Prospective Study of the Prevalence of Nonclassical Congenital Adrenal Hyperplasia among Women Presenting with Hyperandrogenic Symptoms and Signs.(2008-01)
- Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism (2006-01).
- Androgen excess in women: experience with over 1000 consecutive patients. (2004-01)
- The etiology of hyperandrogenism in women (1995)
How can the cause of my hirsutism be determined?
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.
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.
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.
Figure 8.2 Flowchart for the investigation of hirsutism.
Related Medical Abstracts - Click on the paper title:-
What cosmetic treatments are available for my 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.
If I lose weight will my hirsutism
improve?
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.
Related Medical Abstracts - Click on the paper title:-
- Clinical, hormonal and biochemical changes after treatment with metformin and weight reduction in women with polycystic ovary syndrome (2006-01)
- Clinical and hormonal
characteristics of obese amenorrheic hyperandrogenic women before and after
weight loss. (1989-01)
What medical treatments are available for my hirsutism?
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. The new pill - Yasmin- is particularly helpful.
- 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.
- block androgen receptor sites.
Cyproterone acetate (15)
- increase sensitivity to insulin.
Metformin: There had been accumulating evidence that the clinical manifestations, including hirsutism, associated with PCOS can be related to insulin resistance (PCOS cause). Recent controlled research studies have shown disappointing results. Metformin is a drug that increases insulin sensitivity and it has been used from the 1950s in the management of diabetes. Recent studies have demonstrated that metformin may be of value in the treatment of hirsutism associated with PCOS.
Patients often present with a combination of hirsutism and infertility. Investigation to establish the cause is required. Several medical treatments for hirsutism, such as the combined oral contraceptive, would clearly be inappropriate when pregnancy is being contemplated. Metformin may have a place in the treatment of PCOS associated hirsutism and anovulatory infertility. Currently we recommend that the drug should be discontinued as soon as pregnancy is confirmed.
A meta-analysis found a significant reduction in hirsutism for flutamide,
spironolactone, cyproterone acetate combined with an oral contraceptive,
thiazolidinediones, oral contraceptive pills (OCPs), finasteride and
metformin.0801
Eflornithine HCl (Vaniqa - Vaniqa is pronounced 'Vanika') 13.9% cream is the
first topical prescription treatment to be approved by the US FDA for the
reduction of unwanted facial hair in women. It irreversibly inhibits ornithine
decarboxylase (ODC), an enzyme that catalyzes the rate-limiting step for
follicular polyamine synthesis, which is necessary for hair growth. In clinical
trials eflornithine cream slowed the growth of unwanted facial hair in up to 60%
of women. Improvement occurs gradually over a period of 4-8 weeks or longer.
Most reported adverse reactions consisted of minor skin irritation.
Vaniqa is an enzyme inhibitor used topically to slow the growth of
unwanted facial hair in women. It does not remove hair. Re-growth of unwanted
hair can be dramatically slowed by the use of Vaniqa and in some cases, hair
becomes so weak, it barely grows at all. The hairs that do grow after continued
use of Vaniqa become considerably weakened which makes them finer and far less
noticeable than coarse thick or dark hair often associated with unwanted facial
hair in women. Vaniqa is a cream that helps women to manage unwanted facial hair. It is the
first cream that is clinically proven to slow the growth of unwanted facial hair
in women. Vaniqa does not remove hair . Applying this fragrance-free cream
twice a day, every day, does not replace your current method of removal.
Instead, Vaniqa complements it, by slowing hair growth. You should continue
to use your current method of hair removal or treatment. Vaniqa is a
prescription drug for external use only. Some medicines or medical conditions may interact with this medicine. Inform
your doctor or pharmacist of all prescription and over-the-counter medicine you
are taking including any facial or skin creams. Also, any other medical
conditions such as broken skin, sores on the face, allergies, or if you are
pregnant or breast-feeding should be indicated. Vaniqa is not a depilatory agent. You will need to continue your routine
method of hair removal whilst using Vaniqa. You may not see improvement for the
first month of use. Side effects of Vaniqa which may go away during treatment include: stinging,
burning, redness, tingling, rash of the skin or hair follicle infection (folliculitis).
Vaniqa cream does not have contact sensitising, photocontact allergic or
phototoxic properties. It can cause irritation under exaggerated conditions of
use. Eflornithine HCl 13.9% cream, therefore, has a favourable dermal safety
profile appropriate for a topical treatment to be applied routinely.0102
Related
Medical Abstracts - Click on the paper title:- The oestrogen in the combined oral contraceptive pill: Hormone replacement therapy involves administration of oestrogen and there is
some evidence that it may have a part to play in the management of hirsutism
when the pill is not acceptable. Related Medical Abstracts - Click on the paper title:- Cyproterone acetate is an anti-androgen; it competes at the receptor sites (hormones)
with androgens and reduces their effects. This medication is further discussed on
cyproterone acetate. Dianette (Schering) is a special combined oral contraceptive pill that
contains 2mg cyproterone acetate. Higher dose cyproterone acetate may be considered. It is prescribed in a
'reverse-sequential dose regimen' when there is an inadequate response to
previous medication. Usually, progestogens are taken in the latter half of
cyclical oestrogen therapy, in HRT for example (HRT
and progestogen). Cyproterone acetate is stored in the fat tissues and when
it is administered late in the cycle there is a tendency for the period to be
delayed. Cyproterone acetate 50mg or 100mg is, therefore, given on the first 10
days of each course of the pill. When cyproterone acetate is given in
combination with the pill, it is likely to reduce hair growth, lighten the hair
colour, and decrease the hair thickness in hirsute areas. Your doctor may re
quest blood tests from time to time to check hormone levels and to ensure that
your chemistry is not being affected adversely.
Until recently, it was believed that cyproterone pills (Dianette) carried a
greater risk of being associated with thromboembolism. This no longer appears
valid.2007-011 Medical treatments for hirsutism are not rapidly effective, overnight
remedies. New hair follicles are developing all the time and each lasts for
about three years. In one study of hirsute patients, 10-20% of patients were
improving after six months and 90% were happy after 36 months. These treatments
only work whilst they are being taken. They do not cure the underlying
abnormality so that when treatment is discontinued the hirsutism may recur. Related Medical Abstracts - Click on the paper title:- The commonest cause of hirsutism is polycystic ovary syndrome (PCOS). It has
been known for sixty years that removing part of these ovaries surgically (wedge
resection) can restore normal ovarian function. More recently, ovarian drilling puncturing small holes are in the surface of
the ovaries at laparoscopy ( Hormone secreting tumours of the ovaries and adrenal glands are rare. If such
a tumour is detected, surgical removal is required. Laser therapy directly to the hair follicles was initially thought likely to
provide long-term results9701
but it has not lived up to its early expectations.0601 Related Medical Abstracts - Click on the paper title:- Members of a support group, provide each other with various types of help and
information for a particular shared difficulty. The support may take the form of providing relevant information, A support group may also provide ancillary support, such as serving as a
voice for the public or engaging in advocacy. Support groups maintain interpersonal contact among their members in a
variety of ways. Support groups also maintain contact through printed information rich
newsletters, telephone chains, internet forums, and mailing lists.
This page was last updated 19th April 2008
This is the personal website of
David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at
, Londonn. The aim of this web site is to provide a general
guide and it is not intended as a substitute for a consultation
with an appropriate specialist in respect of individual care and
treatment.Vaniqa and unwanted facial hair
Vaniqa comes with a patient information leaflet. Apply a thin layer of Vaniqa
to the affected areas of the face and under the chin, at least 5 minutes after
hair removal (e.g., plucking, shaving). Rub in thoroughly. Do not wash the
treated area for at least 4 hours. Wait at least 8 hours between applications of
this medicine. Cosmetics or sunscreens may be applied after the Vaniqua has
dried. Store Vaniqa at room temperature (77 degrees F or 25 degrees C) in a
tightly-closed container, away from heat and light. Brief storage between 59 and
86 degrees F (15 and 30 degrees C) is permitted. Do not freeze. If you miss a
dose of this medicine, skip the missed dose and return to your regular dosing
schedule.
How could the combined pill help my hirsutism?
What is cyproterone acetate?
What surgical procedures are available for
my hirsutism??
Support Groups
Support groups offer companionship and information for people coping
with diseases or disabilities. Support groups may not be appropriate for
everyone, and some find that a support group actually adds to their stress
rather than relieving it.
Evaluation of the quality of Web sites is discussed in
(Q4.27).
You may find that several general women's health sites may help you (internet
information). The following are more specialised relevant Web sites:-
SEO training courses
My Google Profile
