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Hirsutism
Laura Novak, MD
Imola K. Osapay, MD
image BASICS
DESCRIPTION
  • Presence of excessive terminal (coarse, pigmented) hair of body and face, in a male pattern, in women of reproductive age
  • May be present in normal adults as an ethnic characteristic or may develop as a result of androgen excess
  • Often seen in polycystic ovarian syndrome (PCOS) which is characterized by hirsutism, acne, menstrual irregularities, and obesity
  • System(s) affected: dermatologic, endocrine/metabolic, reproductive
Pregnancy Considerations
  • May have related infertility. Offer intervention, if desired.
  • As hormone balance improves, fertility may increase; provide contraception, as needed.
  • Several medications used for treatment are contraindicated in pregnancy.
EPIDEMIOLOGY
Prevalence
5-10% of adult women
ETIOLOGY AND PATHOPHYSIOLOGY
  • Hirsutism is due to increased androgenic (male) hormones, either from increased peripheral binding (idiopathic) or increased production from the ovaries, adrenals, or fat.
  • Exogenous medications can also cause hirsutism.
Genetics
Multifactorial
RISK FACTORS
  • Family history
  • Ethnicity—increased in Ashkenazi Jews and Mediterranean backgrounds
  • Anovulation
GENERAL PREVENTION
  • Women with late-onset congenital adrenal hyperplasia (CAH) should be counseled that they may be carriers for the severe early-onset childhood disease.
  • Avoid quackery.
COMMONLY ASSOCIATED CONDITIONS
  • PCOS: most common cause of hirsutism. Variable presentation but commonly presents with a combination of excess androgen, abnormal menses, and insulin resistance. It is estimated that 75% of hirsute women have PCOS (1).
  • Associated insulin resistance or PCOS can increase the risk of heart disease.
  • Prolonged amenorrhea and anovulation:
    • Prolonged amenorrhea may, over time, put the patient at risk for endometrial hyperplasia or carcinoma.
  • Hypothyroidism or hyperprolactinemia
  • Late-onset CAH (21-hydroxylase deficiency): a genetic enzyme deficiency associated with more severe and earlier onset hirsutism; present in <2% of hirsute, amenorrheic patients
  • Tumor: rare (<0.2%); ovarian or adrenal; especially if associated with virilization (rapid onset, clitoromegaly, balding, deepening voice) (2)
  • Cushing syndrome: rare; characterized by central obesity, moon facies, striae, hypertension
image DIAGNOSIS
PHYSICAL EXAM
  • Increased hair growth on face, chest, and groin
  • Check skin for acne, striae, acanthosis nigricans (velvety black skin in the axilla or neck).
  • Virilization: Deep voice, male pattern balding, and clitoromegaly indicate risk of tumor.
  • The Ferriman-Gallwey scale (an instrument that rates hair growth in nine areas on a scale of 0 to 4, with >8 being positive) may be used for diagnosis but underrates patient's perception of hirsutism and altered by previous cosmetic treatment (1).
DIFFERENTIAL DIAGNOSIS
  • Idiopathic hirsutism—hirsutism with normal androgen levels
  • PCOS—irregular menses, elevated androgens, polycystic ovaries on US, infertility, insulin resistance
  • Late-onset CAH presents in adolescence with severe hirsutism and irregular menses.
  • Androgen-secreting tumor—rapid onset, virilization, resistance to treatment
  • Thyroid dysfunction
  • Hyperprolactinemia if accompanied by galactorrhea or amenorrhea
  • Rare endocrine disorders—Cushing (central obesity, stria, and hypertension), acromegaly (enlarging extremities and facial deformity)
DIAGNOSTIC TESTS & INTERPRETATION
  • Diagnosis is clinical. Empiric treatment without lab workup is an acceptable option in mild-moderate hirsutism (2)[C].
  • PCOS is diagnosed by having two out of three signs: menstrual dysfunction, clinical or biochemical hyperandrogenemia, polycystic ovaries on US (2)[C].
  • Lab testing is performed to rule out underlying tumor and pituitary diseases, which are rare.
Initial Tests (lab, imaging)
  • Basic workup of mild-moderate hirsutism is a total testosterone level +/- a thyroid screen (1,2,3)[C]. Testosterone: random total testosterone level is usually sufficient. A morning free testosterone is slightly more sensitive, but the difference is not clinically relevant (1,4).
  • If testosterone is >150 (some use 200) ng/dL, consider ovarian or adrenal tumor (2,3).
  • Testosterone is made by both the ovaries and adrenals, so both areas should be imaged. US is best for the ovaries, and CT is best for the adrenals.
  • If testosterone is not in the tumor range, treat clinicallyTSH-elevation indicates hypothyroidism.
  • The workup of PCOS recommended by ACOG (the American Congress of Obstetricians and Gynecologists) includes the above plus:
    • Screening for metabolic syndrome with a fasting and 2-hour glucose after 75-g glucose load, lipid panel, waist circumference, and blood pressure (3)[C]
  • Ovarian US
  • If the patient is amenorrheic, check prolactin, FSH, LH, and a pregnancy test.
Follow-Up Tests & Special Considerations
  • 17-hydroxyprogesterone (17-OHP)
    • Elevations of 17-OHP (>300) can indicate lateonset CAH; rare (<2%)
    • Consider in patients with onset in early adolescence or high-risk group (Ashkenazi Jews) (2)[C].
    • If elevated, do corticotropin stimulation test.
  • If prolactin level is high, MRI the pituitary
  • If PCOS is diagnosed, ACOG recommends screening for dyslipidemia and DM type 2 (3)[C].
  • Dehydroepiandrosterone sulfate (DHEA-S) is no longer recommended routinely but should be checked in virilization (4)[C].
    • Levels >700 may indicate adrenal tumor.
image TREATMENT
GENERAL MEASURES
  • Treatment in mild hirsutism depends on patient preference and psychosocial effect.
  • If patient desires pregnancy, induction of ovulation may be necessary.
  • Provide contraception, as needed.
  • Encourage patient to maintain ideal weight with lifestyle modification.
  • Treat accompanying acne.
P.487

MEDICATION
First Line
  • Treatment goal is to decrease new hair growth and improve metabolic disorders.
  • Oral contraceptives are first line to manage menstrual abnormalities and hirsutism/acne (5)[B]; it will decrease androgens, improve metabolic syndrome, and slow but not reverse hair growth. It take 6 months to show effect and are continued for years; any preparation is effective; however, those containing the progestins, norgestimate, desogestrel, or drospirenone may have more androgen-blocking effects, but also are associated with more DVTs (3)[C].
  • Progesterone (depot or intermittent oral) can be used if estrogens are contraindicated (3)[C].
  • Eflornithine (Vaniqa) HCl cream: apply BID at least 8 hours apart; reduces facial hair in 40% of women (must be used indefinitely to prevent regrowth). Only FDA-approved hirsutism treatment.
Second Line
  • Antiandrogenic drugs will further reduce hirsutism to 15-25%. Usually begun 6 months after first-line therapy if results are suboptimal. Must be used in combination with oral contraceptives to prevent menorrhagia and potential fetal toxicity. All should be avoided in pregnancy (2,4)[C].
    • Spironolactone, 50 to 200 mg/day: onset of action is slow; use with oral contraceptives to prevent menorrhagia. Watch for hyperkalemia, especially with drospirenone-containing OCP (Yasmin); avoid use in pregnancy.
    • Finasteride: 5 mg/day decreases androgen binding; not approved by FDA. Use with contraception (pregnancy Category X).
    • Cyproterone, not available in the United States: 12.5 to 100 mg/day for days 5 to 15 of cycle combined with ethinyl estradiol 20 to 50 &mgr;g days 5 to 25 of cycle
    • Flutamide is not recommended (2).
  • Insulin sensitizers (metformin, thioglitazones): mildly effective but less so than oral contraceptives. May be used in diabetes or if oral contraceptives are contraindicated. Metformin is more effective than thioglitazones (2)[A].
  • Steroids: used in late-onset CAH
    • Dexamethasone: 2 mg/day
  • Cosmetic treatment: includes many methods of hair removal
    • Temporary: shaving, chemical depilation, plucking, waxing
    • Permanent: Laser epilation and photoepilation are preferred to electrolysis (3)[C].
COMPLEMENTARY & ALTERNATIVE MEDICINE
Several herbals including spearmint tea, saw palmetto, licorice, fennel, and soy have been shown in small (<50 people) and short (<12 weeks) studies to decrease hair size or lower androgen levels (5)[C].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
No special activity
Patient Monitoring
Monitor for known side effects of medications.
DIET
No special diet
PATIENT EDUCATION
  • Hormonal treatment stops further hair growth and will improve but not reverse present hair.
    • Treatment takes 6 months to effect and may need to be lifelong.
  • Cosmetic measures may be needed for the present hair (see above).
PROGNOSIS
  • Good (with long-term therapy) for halting further hair growth
  • Moderate to poor for reversing current hair growth
REFERENCES
1. Azziz R, Carmina E, Dewailly D, et al. The androgen excess and PCOS society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009;91(2):456-488.
2. Martin KA, Chang RJ, Ehrmann DA, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008;93(4): 1105-1120.
3. ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin no. 108: polycystic ovary syndrome. Obstet Gynecol. 2009;114(4):936-949. Reaffirmed 2013.
4. Rosenfeld RL. Clinical practice. Hirsutism. N Eng J Med. 2005;353(24):2578-2588.
5. Anjum F, Mubeen U, Tabasum H, et al. Physiological perspectives of hirsutism in Unani medicine: An overview and update. IJHM. 2013;1(3):79-85.
Additional Reading
&NA;
  • Bode D, Seehusen DA, Baird D. Hirsutism in women. Am Fam Physician. 2012;85(4):373-380.
  • Brown J, Farquhar C, Lee O, et al. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev. 2009;(2):CD000194.
  • Harborne L, Fleming R, Lyall H, et al. Metformin or antiandrogen in the treatment of hirsutism in polycystic ovary syndrome. J Clin Endocrinol Metab. 2003;88(9):4116-4123.
  • National Institute of Health. Evidence-based methodology workshop on PCOS. https://prevention.nih.gov/docs/programs/pcos/FinalReport.pdf.
  • Somani N, Harrison S, Bergfeld WF. The clinical evaluation of hirsutism. Dermatol Ther. 2008;21(5): 376-391.
  • Swiglo BA, Cosma M, Flynn DN, et al. Clinical review: antiandrogens for the treatment of hirsutism: a systematic review and metaanalyses of randomized controlled trials. J Clin Endocrinol Metab. 2008;93(4):1153-1160.
See Also
&NA;
Acne Vulgaris; Infertility; Polycystic Ovarian Syndrome (PCOS)
Codes
&NA;
ICD10
  • L68.0 Hirsutism
  • E28.2 Polycystic ovarian syndrome
Clinical Pearls
&NA;
  • PCOS is the most common cause of hirsutism (two out of three: menstrual dysfunction, clinical or biochemical hyperandrogenemia, polycystic ovaries on US)
  • Treatment is long term and often lifelong.
  • Associated insulin resistance and DM is common and need to be treated.