Hirsutism

Hirsutism or excessive hair growth is a common clinical condition that can be seen in women of all ages. This condition is caused by hormonal imbalance where increased levels of androgens (male sex hormones like testosterone) are produced in women.

Other names #

Also known as Excessive hair, Pilosity and Hairiness

Causes #

Increased levels of androgens (male sex hormones such as testosterone) or oversensitivity of the hair follicles to androgens can cause hirsutism.The conditions that can cause hirsutism include:

Polycystic ovarian disorder (PCOS) #

It is a common hormonal condition that causes excessive production of androgens. Some women with this disorder do not have cysts, while some women without the disorder can develop cysts. Other than Hirsutism, PCOS can also cause:

• Thinning hair on the head

• Infertility

• Acne

• Mood changes

• Pelvic pain

• Headaches

• Sleep problem

• Weight gain/ obesity

• Genetic disorder A group of genetic disorders that affect the adrenal glands (a pair of walnut-sized organs above the kidneys) like congenital adrenal hyperplasia can cause hirsutism.

Adrenal and ovarian tumor #

Tumors of the adrenal glands, pituitary glands, and ovaries can sometimes lead to hirsutism. In the rare group of ovarian and adrenal tumors female sex hormone levels are often suppressed to or below the lower limit of normal, while the levels of androgen in the circulation is twice the upper limit of normal or higher.

Idiopathic hirsutism #

Hirsutism with normal androgen levels is called idiopathic hirsutism. Idiopathic Hirsutism may be due to increased sensitivity to androgens. A typical example is familial Hirsutism, a typical symptom of this is a gradually increased growth of rough facial hair.

Cushing’s syndrome #

Cushing syndrome is a sign of very long exposure of cortisol. Cortisol is a steroid hormone and its level is increased in case of high levels of stress and low blood glucose concentration. Along with excessive hair growth, some visible signs are having a big stomach but thin arms and legs. It can also lead to abnormal weak muscles, weak bones, breakouts, and sensitive skin.

Increased sensitivity to Androgens #

Under a quarter of premenopausal women who have hirsutism have normal androgen levels. This happens due to increased sensitivity to androgens.

Certain medications #

The following medications can lead to excessive hair growth or hirsutism:

• Anabolic steroids

• Testosterone

• Glucocorticoids

• Minoxidil

• Cyclosporine

• Phenytoin

• Diazoxide

• Progestin-containing medications

Symptoms #

• Decreased breast size

• Enlarged ovaries

• Enlarged shoulder muscles

• Acne

• Oily skin

• Enlarged clitoris

• Irregular periods

• Deepening of voice

Diagnosis #

Medical history #

• A physician will look at the detailed medical history with a special focus on the menstrual cycle.

• Detailed history includes the age of onset of hirusitsm (puberty, middle age, menopause), rate of onset of symptoms (gradual or sudden), and any other signs or symptoms (acne, deepening of voice, infrequent menstruation, loss of breast tissue, increased muscle mass as in shoulder girdle, malodorous perspiration, etc).

• The doctor will also inquire about the history of weight gain or diabetes and whether a drug history prior to onset should be taken.

Physical examination #

• Complete general physical examination is done including the palpation of the abdomen for any ovarian mass.

• To evaluate hirsutism in females, the Ferriman-Gallwey score is used to measure the amount and location of the hair.

• The score is used to determine whether a patient’s hirsutism is considered mild, moderate, or severe.

• Ferriman–Gallwey Scoring System for Hirsutism evaluates the extent of hair growth (score 0-4) in 9 areas of the body.

• A score of 8-15 is mild, score >15 is moderate/severe. This score can be helpful in determining response to treatment.

Lab tests #

Testosterone: Serum testosterone may be normal or elevated in case of PCOS (polycystic ovarian syndrome) and CAH (Congenital adrenal hyperplasia) but is significantly raised (>200 ng/ml) in case of malignant tumor of the adrenal or ovary.

Dehydroepiandrosterone sulfate (DHEAS): DHEA stands for dehydroepiandrosterone. This is a hormone produced by the adrenal glands which are located above the kidneys. A raised DHEAS (>700 μg/dl) always indicates an adrenal cause, benign or malignant.

17 Hydroxy progesterone: This serum marker is unique for congenital adrenal hyperplasia.

Cortisol: Cortisol is measured for those having signs and symptoms of Cushing’s syndrome. Cushing syndrome occurs when the body makes too much of the hormone cortisol.

Serum Thyroid-stimulating hormone (TSH): Serum TSH is usually regarded as a marker of thyroid function. TSH is responsible for the synthesis and secretion of thyroxine (T4) and triiodothyronine (T3) by the thyroid gland. Hypophyseal hypothyroidism (a condition resulting from decreased production of thyroid hormones) can act as a cofactor in hirsutism causing raised TSH levels.

Prolactin: A prolactin (PRL) test measures the level of prolactin in the blood. Prolactin is a hormone made by the pituitary gland, a small gland at the base of the brain. High levels of prolactin may induce hirsutism via several mechanisms.

LH/FSH (Luteinising hormone to follicular stimulating hormone): Luteinising hormone and follicular stimulating hormones play an important role in sexual development and functioning. The change in the LH to FSH ratio can disrupt ovulation. This ratio can be a useful indicator in diagnosing PCOS.

Treatments #

Cosmetic therapies (temporary solution) #

Most women adapt to the removal of hair by different epilation methods, such as plucking, shaving, and waxing before presenting to the clinic. Though these methods are simple and inexpensive, these methods are temporary and have side effects like physical discomfort, scarring, irritant dermatitis, and discoloration.

Electrolysis (50% efficacy) #

Hair follicles are damaged by inserting a needle that emits a pulse of electrical current into each hair follicle. With repeated treatments, the efficacy ranges from 15 to 50% permanent hair loss. However, it is difficult to treat large areas like hairs on the chest or upper back with electrolysis and it can be time-consuming.

Laser hair treatment (80% reduction) #

• Lasers have gained wide popularity in the past two decades and can achieve permanent reduction of hair (not removal).

• Laser therapy works on the principle of selective photothermolysis where the laser energy acts specifically to destroy the target (melanin) and it acts specifically on anagen hair follicles. Therefore, multiple treatments are required to get a significant (i.e. 80%) reduction.

• An ideal candidate for laser hair removal is a patient with light skin color and dark-colored hair.

• The possible side effects like skin irritation, swelling, and redness can be explained by the dermatologist.

• Mostly used lasers are the 755-nm alexandrite laser, 800-nm diode laser, and 1064-nm Nd: YAG laser and pulsed light sources

Medications #

Before starting any medications, the right diet and exercise are advised for all women with PCOS. For all obese women, weight loss as a therapy should be advised. The drugs usually used in the treatment of hirsutism are:

Oral contraceptive pills (OCP) #

• OCP is the first-line treatment for hirsutism, particularly in women desiring contraception. These estrogen/progesterone combinations act by

• Reduction of gonadotropin secretion and thereby reducing ovarian androgen production.

• Inhibiting adrenal androgen production.

• Increasing levels of SHBG (Sex hormone-binding globulin, which is a protein that binds to the sex hormones testosterone and estrogen) resulting in lower levels of free testosterone.

5-alpha-reductase inhibitors (5-RA inhibitors) #

Finasteride, a 5-alpha reductase inhibitor, is effective in the treatment of Idiopathic hirsutism (IH).

Gonadotropin-releasing hormone (GnRH agonists) #

This therapy is reserved for women with severe hirsutism who don’t respond to oral contraceptives (OC) and antiandrogens. GnRH analogs reduce ovarian stimulation, estrogen production, and hence testosterone.

Corticosteroids #

Glucocorticoids: The main use of corticosteroids (dexamethasone and prednisone) has been to treat hirsutism associated with congenital adrenal hyperplasia.