4.2.3 Hirsutism

Hirsutes, excessive hair, endocrine hypertrichosis; endocrine and para-endocrine hypertrichosis (whereas hirsutism defines an excessive form of hypertrichosis probably due to underlying disease).

Excessive, disease-associated, terminal hair in women with a male pattern distribution or ethnic hypertrichosis pattern without endocrinological changes.

There are many different causes and an early and late onset of hirsutism.

Genetically determined in both genders with early onset in a hirsute pattern. This is not ethnic or genetic hypertrichosis. While 80-90 % of women with hirsutism have measurable hyperandrogenemia, the severity of hirsutism and the level of androgen metabolism and excess are not well-correlated. Most probably a peripheral metabolic disorder affects the distribution of hair and within the follicle.

Endocrine hirsutism with late onset around puberty or even later: about 50% of women with hirsutism have endocrine abnormalities: polycystic ovary syndrome; androgen-producing ovarian tumours; congenital adrenal hyperplasia (adrenogenital syndrome); adrenal tumours; ACTH-cell hyperplasia; pituitary adenomas (Cushing’s disease); hyperprolactinemia; acromegaly.

Other causes: postmenopausal hirsutism; idiopathic hirsutism; medication-induced hirsutism (e.g. anabolic steroids).

In most women with hirsutism, the hormone status (FSH/LH ratio, DHEAS, androstendione, free testosterone, 17-hydroxyprogesterone, SHBG, anti-Müllerian hormone, prolactin, TSH) should be assessed and investigations such as a transvaginal ultrasound evaluation of ovaries considered.

Psychosocial problems are common. Females suffer very strongly and spend a lot of time and money for hair removal. There is also a tendency towards folliculitis due to shaving and dewaxing. Type 2 diabetes mellitus may be more common if polycystic ovarian syndrome is present.

The diagnosis is usually clinical, with typical hair pattern. Endocrine screening is usually performed with more detailed evaluation if hyperandrogenism is present. Duplex sonography should be considered to exclude superficial thrombophlebitis.

Examine and treat the causes of hyperandrogenism and metabolic changes if present.

Mechanical removal of hair includes shaving, waxing, epilation, electroepilation, laser or light-assisted hair removal. Hair growth may be slowed or stopped by chemical means (e.g. eflornithine topically). Consider spironolactone, finasteride, low dose cyproterone acetate or oral contraceptives. Clinical effects may be seen after six to twelve months. Psychosocial support should be offered.