What is Hirsutism?

Hirsutism is excessive growth of dark, coarse hair in women in a male-like pattern (face, chest, back, abdomen). It's caused by elevated levels of androgens (male hormones) or increased sensitivity of hair follicles to normal androgen levels.

Common Causes:

• PCOS (Polycystic Ovary Syndrome): Most common cause (70-80% of cases).
• Idiopathic Hirsutism: No identifiable cause; normal hormone levels but increased hair follicle sensitivity.
• Non-Classic CAH (Congenital Adrenal Hyperplasia): Mild enzyme deficiency in adrenal glands.
• Medications: Steroids, danazol, testosterone, some antiseizure drugs.
• Adrenal Tumors: Rare; rapid onset with virilization (deepening voice, clitoral enlargement).
• Ovarian Tumors: Rare androgenic tumors.
• Cushing's Syndrome: Excess cortisol production.

How is it graded?

The Ferriman-Gallwey Score is used to objectively assess hirsutism by evaluating hair growth in 9 body areas (upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, upper arms, thighs). A score ≥8 indicates hirsutism.

Diagnosis:

History: Onset, rate of progression, menstrual history, medications.

Labs:

• Total Testosterone: Elevated in PCOS, CAH, tumors.
• Free Testosterone: More sensitive marker.
• DHEA-S: Adrenal androgen (elevated in adrenal causes).
• 17-Hydroxyprogesterone: Screening for CAH.
• Prolactin: Rule out prolactinoma.
• TSH: Thyroid screening.
• LH/FSH: Helpful in diagnosing PCOS.

Red Flags (Suggest Tumor):

• Rapid onset (< 6 months)
• Virilization: deepening voice, male pattern baldness, increased muscle mass, clitoral enlargement
• Very high testosterone (> 200 ng/dL) or DHEA-S (> 700 µg/dL)

Treatment:

Cosmetic/Mechanical:

• Shaving, waxing, threading, depilatory creams
• Laser hair removal or electrolysis (most effective long-term)

Medical Treatment:

• Birth Control Pills (OCPs): First-line; suppress ovarian androgen production. Takes 6-12 months for effect.
• Spironolactone: Anti-androgen; blocks androgen receptors. Requires contraception (teratogenic).
• Eflornithine Cream (Vaniqa®): Topical treatment to slow facial hair growth.
• Metformin: If insulin resistance/PCOS present (modest effect on hirsutism).
• Finasteride: Rarely used; blocks conversion of testosterone to DHT.

Important Points:

• Medical treatment takes 6-12 months to see results (hair growth cycle is slow).
• Combination therapy (medication + cosmetic removal) is most effective.
• Treatment does NOT remove existing hair; it slows new growth.
• Lifestyle modification (weight loss) can help if PCOS-related.