Hirsutism - Hyperandrogenism - Causes - Treatment

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.

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

Recommended Books:

Hirsutism - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References

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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

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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.

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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.

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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.

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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.  

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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 (Q8.15)

increase sensitivity to insulin.

Metformin: There has been accumulating evidence that the clinical manifestations, including hirsutism, associated with PCOS can be related to insulin resistance (PCOS cause). 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.

Cyproterone acetate is an anti-androgen; it competes at the receptor sites (hormones) with androgens and reduces their effects. 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-se Quential dose regimen' when there is an inade Quate 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 request 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.^2007-01

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.

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What surgical procedures are available for my hirsutism?

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 (laparoscopy) by cautery, diathermy or laser vaporisation has become possible. Ovarian drilling has had a definite part to play in infertility associated with PCOS usually when medical treatment has been unsuccessful.

We must always consider the risks and benefits of treatment (surgery risks). There are risks associated with laparoscopic ovarian drilling and essentially we are treating a cosmetic problem. So far surgical treatment for hirsutism associated with PCOS does not seem to have been fully evaluated. It will be a while before the recently introduced metformin treatment will have been compared to ovarian drilling.

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

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Support Groups

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,

• relating personal experiences,
• listening to others' experiences,
• providing sympathetic understanding and
• establishing social networks.

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.

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:-

This page was last updated 19th April 2008