What is hirsutism?
Hirsutism is a symptom and a sign of a health condition, likely benign, it is a clinical diagnosis, and not a disease (1).
To understand more of it, we must know the difference between terminal hair and vellus hair; the former is coarse, curly and has the same color as the hairs in the head, while vellus hair is fine, soft, less pigmented and doesn’t depend on androgens (2),(3).
Now we can better understand the definition of hirsutism in women: the excessive growth of terminal hair in areas that depend on androgens (hormones), such as the face, upper arms, thighs, chest or the abdomen (1).
How is hirsutism diagnosed?
The diagnosis can be made using the Ferriman-Gallwey scoring system, which assesses terminal hair in nine androgen-dependent body areas.
A score from 0 (absence of terminal hairs) to 4 (extensive terminal hairs) is given to each of the nine body areas as shown in the figure, all scores are summed to a total score (3).
Race/Ethnicity | total Score (classifies as hirsutism) |
Black British and Us women White British and US women | ≥8 |
Diagnosis | |
Absence of terminal hair | 0 |
Normal | 1-8 |
Mild hirsutism | 8-15 |
moderate | 16-24 |
severe hirsutism | ≥25 |
The cutoff total score to give the diagnosis of hirsutism varies according to the race and ethnicity of the woman.
Race/Ethnicity | total Score (classifies as hirsutism) |
Mediterranean Hispanic Middle eastern | ≥9 |
South american | ≥6 |
Asian | ≥2 |
What causes hirsutism?
Since hirsutism might be the first manifestation of an important underlying condition, its cause must be studied.
There are three main categories of disorders that can cause hirsutism (3):
1. Conditions associated with an excess of androgenic hormones, such as:
· Polycystic ovary syndrome (the most common cause of hirsutism)
· Androgen-secreting tumors
· Idiopathic hyperandrogenism
· Non-classic adrenal congenital hyperplasia
2. Iatrogenic hirsutism
· Valproic acid
· Topical testosterone used by a partner
· History of anabolic steroids use
3. Idiopathic (unknown cause)
Other conditions that may present with hirsutism are: Cushing syndrome, hyperprolactinemia thyroid disorders and acromegaly.
What percentage of women is affected by hirsutism?
About 5-15% of reproductive-aged women are affected by hirsutism.
Women with a family history of polycystic ovary syndrome and congenital adrenal hyperplasia are propense to develop hirsutism; obesity is another condition associated with it (1).
Does hirsutism affect mental health?
Yes, hirsutism can affect women’s mental health since it has a negative impact on their body image and causes emotional distress and even embarrassment on certain cultures given the associated virilization signs of hirsutism.
Some studies have reported a correlation between hirsutism and lower quality of life, anxiety and depression (4).
What is virilization and how is it related to hirsutism?
Virilization includes a high degree of hirsutism along with a male-pattern balding, a clitoris diameter greater than 4 mm, libido affectation and the characteristics of masculinization.
Masculinization is when a female develops secondary sexual characteristics of males, such as the growth of facial hair, a deep voice, increased chest muscles and a male distribution of body fat.
Virilization indicates a high and fast androgen production. There are tumors that produce androgens, so it is important to study the cause of virilization signs and any high-degree hirsutism (1).
Are there any tests to evaluate and diagnose de cause of hirsutism?
The assessment of hirsutism includes questions about the medical history of the affected woman and her family, a physical examination, lab tests and diagnostic images (1).
How can hirsutism be treated?
Medications
The prescription of medications, when possible, considers the woman’s conception desires and the risks associated with the therapy.
Some medications aim at decreasing the production of androgens, others have the objective of inhibiting the effects of androgens on the skin.
Oral contraceptives pills are the first line of treatment for women with low risk of developing venous clots (venous thromboembolism) (5).
Since the growth cycles of hair have determined durations, it may take approximately six months to perceive a change in hirsutism; the maximal effects can be seen after nine months (3).
Hair removal
Not every woman needs medication, mild cases can be managed with hair removal.
These are some physical methods to remove or at least reduce unwanted hair (1):
Shaving
Chemical depilation with creams
Plucking
Waxing
Threading
Laser
IPL (intense pulse lights)
Electrolysis
Laser, IPL and electrolysis achieve the most permanent results. Alexandrite laser, at high energy levels, is very effective and has demonstrated to improve psychological symptoms associated with hirsutism (6).
A highly effective treatment is the combination of medication and hair removal (2), (6).
What specialists study and treat hirsutism?
The specialists involved in the study and treatment of hirsutism are endocrinologists, dermatologists and gynecologists.
References
1. Elliott J, Liu K, Motan T. Guideline No. 444: Hirsutism: Evaluation and Treatment. J Obstet Gynaecol Canada [Internet]. 2023;45(12):102272. Available from: https://doi.org/10.1016/j.jogc.2023.102272
2. Griffing G. Hirsutism Treatment & Management. Medscape [Internet]. 2012;1–12. Available from: https://emedicine.medscape.com/article/121038-treatment
3. Matheson E BJ. Hirsutism in Women. Am Fam Physician. 2019;100(3):168–75.
4. Ekbäck MP, Lindberg M, Benzein E, Årestedt K. Health-Related Quality of Life, Depression and Anxiety Correlate with the Degree of Hirsutism. Dermatology [Internet]. 2013 Oct 4;227(3):278–84. Available from: https://doi.org/10.1159/000355356
5. Barrionuevo P, Nabhan M, Altayar O, Wang Z, Erwin PJ, Asi N, et al. Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis. J Clin Endocrinol Metab [Internet]. 2018 Apr 1;103(4):1258–64. Available from: https://doi.org/10.1210/jc.2017-02052
6. Tan K, Coster T, Mousa A, Mar A, Piltonen T, Boyle JA, et al. Laser and Light-Based Therapies for Hirsutism Management in Women With Polycystic Ovarian Syndrome: A Systematic Review. JAMA Dermatology [Internet]. 2024 Apr 17; Available from: https://doi.org/10.1001/jamadermatol.2024.0623 Assessed and Endorsed by the MedReport Medical Review Board