What is Hirsutism?
Hirsutism refers to the growth of excessive hair in areas typically seen in men, but occurring in women after puberty. These areas include the upper lip and chin (like a moustache or beard), pubic area, buttocks, and thighs. Hirsutism is a common reason for women to seek advice from skin specialists. It’s also the most common hormonal disorder, affecting roughly 10% of women in the United States.
Regardless of what’s causing it, hirsutism can lead to a significant amount of emotional distress and psychological discomfort. Dealing with this issue involves identifying the cause and addressing the cosmetic aspects of the hair growth.
What Causes Hirsutism?
Hirsutism, or excessive hair growth, can be caused by various conditions. These conditions may involve the ovaries or adrenal glands, and may or may not involve tumors. Here are some examples:
Hyperandrogenic Hirsutism is often due to excess production of androgens (male hormones), either from the ovaries or adrenal glands. Androgens produced by tumors are usually more severe, while those not related to tumors are usually mild or moderate.
Polycystic Ovary Syndrome (PCOS) is the most common cause of hirsutism, making up about 75% of all cases. It affects 5% to 10% of women during their reproductive years and 20% to 25% of teenage girls. It’s a complex condition that causes the ovaries to develop lots of small follicles and leads to an excess of small cyst-like sacs under the skin of the ovaries. Symptoms typically begin at puberty and may include irregular periods, weight gain, acne, and dark patches of skin. There might also be symptoms such as less heavy menstruation and problems getting pregnant. Sometimes, there might be an issue with the thyroid or liver.
Androgen-Secreting Tumors, which overproduce androgens, are an uncommon cause of hirsutism. These tumors operate independently of the brain’s hormone regulation system. Around 50% of these tumors are malignant (cancerous), leading to very high levels of androgens. Symptoms often include a rapid onset of masculine features, excessive hair growth, and a mass in the abdomen or pelvis.
Non-classical Congenital Adrenal Hyperplasia (NCAH) is a common disorder caused by partial deficiency of an enzyme called 21-hydroxylase. This is the most common adrenal cause of excess androgens. It varies in prevalence depending on ethnicity – it is more common in Ashkenazi Jews (3.7%) and Central Europeans (2%) and rare in Caucasians (0.1%). Similar to PCOS, symptoms after puberty include hirsutism, acne, hair loss, irregular menstruation and problems getting pregnant.
Non-Hyperandrogenic Hirsutism can also be caused by certain medications, including androgens, glucocorticosteroids, progestins, estrogen antagonists, minoxidil, among others. Some other medicines, like cyclosporine, can cause a more widespread growth of hair, a condition called hypertrichosis.
Endocrinopathies, which are hormonal imbalances, are a rare cause of hirsutism and often have other more noticeable symptoms. An example is Cushing syndrome, which can cause hirsutism due to excessive secretion of androgens. Factors such as higher or lower thyroid hormone levels (hyperthyroidism or hypothyroidism) or excessive levels of prolactin hormone (hyperprolactinemia) can also cause hirsutism but these cases are rare.
Some other causes of hirsutism include pregnancy (due to the body naturally producing more prolactin) and menopause (due to the drop in the production of estrogen by the ovaries).
Lastly, Idiopathic Hirsutism is hirsutism with normal menstruation and hormone levels, and it makes up about 10% of hirsutism cases and 50% of mild cases. This type might be due to hair and skin cells being overly sensitive to androgens. Frequently reported in women of East Indian and Mediterranean origin, it may be influenced by genetics.
Risk Factors and Frequency for Hirsutism
Hirsutism, a condition characterized by excessive hair growth, varies significantly in its prevalence. It’s said to affect anywhere from 10% to over 50% of people. This whole range can vary based on different aspects like ethnics and cultural norms. In some societies, where less body hair is seen as beautiful for women, even slight hirsutism can be viewed as a serious problem. On the other hand, in other societies, even heavy hirsutism may be accepted.
- Darker-skinned individuals more commonly experience hirsutism.
- While men can also have hirsutism, it’s harder to spot.
- In kids, hirsutism might indicate early onset of puberty.
- Hirsutism can also occur in women who stop using birth control pills and gain weight.
Signs and Symptoms of Hirsutism
Hirsutism, or excessive hair growth in women, can be a symptom of several conditions. When it develops slowly during puberty, it’s often due to primary hirsutism or non-cancerous conditions. However, if it begins later in life or progresses rapidly, there may be a tumour present, often in the adrenal glands, ovaries, or pituitary gland. The existence of menstrual disorders can also suggest hirsutism connected to these conditions.
The key characteristic of hirsutism is the change in density and nature of hair on the body, specifically in areas traditionally associated with male hair growth. Commonly affected areas include the face, chest, around the nipples, belly button, lower back, inner thighs, and genitals. The Ferriman and Gallwey system is used to measure the severity by assigning points to nine areas of the body based on hair density. A total score exceeding 7 (out of a possible 36) is considered abnormal. Other symptoms might include acne, irregular periods, a receding hairline at the temples, and baldness at the frontal part of the scalp.
Testing for Hirsutism
When doctors need to perform a basic assessment of your hormones, they typically do this during the early days of your menstrual cycle (between day 3 and day 6). You will likely need to go in the early morning and without having eaten anything. It’s also advised that you stop taking any oral contraceptives for two or three months beforehand unless the doctor suspects a tumor.
The hormones they’re looking to measure include testosterone, dehydroepiandrosterone sulfate (which your adrenal gland produces), delta4-androstenedione (another type of hormone), luteinizing hormone (which helps control the menstrual cycle), follicle-stimulating hormone (which helps manage the production of eggs in the ovaries), 17-hydroxyprogesterone (involved in the production of other hormones) and steroid hormone-binding globulin (a protein made by your liver).
If you have irregular periods, doctors may also order tests to measure the levels of your thyroid-stimulating hormone (which tells your thyroid gland to make and release thyroid hormones into your blood) and prolactin (a hormone that helps women produce milk after childbirth).
Depending on your symptoms, doctors might also need to do more tests. These can include a short dexamethasone suppression test (to look for Cushing syndrome, a condition that involves prolonged exposure to cortisol), an ACTH stimulation test and a prolonged dexamethasone suppression test (to look for late adrenogenital syndrome, a condition characterized by early onset of puberty and unusually fast growth), a carbohydrate tolerance test or HOMA index (to test for insulin resistance syndrome, a condition that makes your body less effective at using insulin).
Doctors will normally only diagnose you with idiopathic hirsutism if they can’t find any other clear cause for your symptoms. Idiopathic hirsutism is one type of hirsutism where women have excessive, coarse body hair, and it affects between 15% and 50% of women with hirsutism. It follows similar patterns as primary androgenetic alopecia, which is also known as male or female pattern hair loss.
Treatment Options for Hirsutism
Non-tumoral hirsutism, a condition where women experience excessive hair growth, is usually treated with oral contraceptives. How do these work? Well, they slow down the release of hormones that trigger the production of male hormones (androgens) in the ovaries. Also, oral contraceptives increase the production of a protein called sex hormone-binding globulin (SHBG), which reduces the amount of active male hormones in your body. Alongside this, a medication is often prescribed that reduces the effects of male hormones, and commonly used medications include flutamide, spironolactone, cyproterone acetate, and finasteride.
While oral contraceptives are a preferred starting point for hirsutism treatment, they don’t always work. Also, if you’re planning to become pregnant, oral contraceptives may not be the best option for you.
Spironolactone, which blocks male hormone receptors, is the second most common treatment for hirsutism. This medicine can even be combined with an oral contraceptive. However, it takes a long time to see results from spironolactone – often several months – which means that many people stop taking it.
Finasteride is another medication used to treat hirsutism and is often preferred because it doesn’t contain any estrogen or progesterone – hormones that can cause unwanted side effects. However, finasteride can potentially harm a developing fetus, so it is not recommended in women who could become pregnant. Flutamide, another medication used to treat hirsutism, can work well but is expensive and there’s a risk it can cause liver damage.
If hirsutism is caused by increased male hormone production from adrenal glands (adrenal hyperandrogenism), doctors often prescribe low dose corticosteroids to slow this down. These may be combined with the other treatments mentioned earlier.
Another option is twice-daily applications of a topical cream called eflornithine, which can slow down the growth of fine hair.
With medication treatment often taking 1 to 2 years to show results, doctors also recommend cosmetic approaches for immediate relief. This could include shaving, hair removal creams, lightening the hair with hydrogen peroxide, or chemical hair removers. Using eflornithine cream, which inhibits hair growth, can be particularly helpful for managing the growth of fine hair. Electrolysis, a method of hair removal, isn’t used as often as before, but can be effective for removing coarse white hairs. It has largely been replaced by long-term hair removal techniques such as depilatory lasers and various intense pulsed light devices.
In certain cases, surgical treatment may be necessary. This is typically in situations where there is a tumor causing excessive hair growth. In such cases, the tumor might need to be removed. In severe cases of hirsutism in women who are nearing or past menopause, ovariectomy (removal of ovaries) may need to be considered.
What else can Hirsutism be?
Hypertrichosis is a condition where too much hair grows over large areas of the body, typically in places that aren’t usually affected by hormones known as androgens. These areas are often the cheeks and arms. This condition could be caused by too many glucocorticoids (a type of hormone), certain medications (like phenytoin, penicillamine, ciclosporin, minoxidil, diazoxide), or certain body-wide disorders like anorexia nervosa, hypothyroidism, porphyria, and dermatomyositis. Sometimes, hypertrichosis can just be a result of family traits or ethnic background and usually starts before puberty.
Lanugo is very fine, soft, and colorless hair that can be found anywhere on the body. Hypertrichosis, in particular, is marked by excessive hair growth that impacts areas that are usually hairier in women.
What to expect with Hirsutism
Hirsutism, or excessive hair growth in women, can lead to serious health conditions, and in some cases, when caused by a malignant disease, can have a very grim outcome. A link has also been observed between postmenopausal hirsutism, which occurs after the menstruation cycle ends, and an increased risk of osteoporosis (a condition that weakens bones) and fractures.
