Hirsutism
SpecialtyDermatology, endocrinology
TreatmentBirth control pills, antiandrogens, insulin sensitizers[1]
Hirsutism depicted in a female patient with PCOS and nonclassic congenital adrenal hyperplasia

Hirsutism is excessive body hair on parts of the body where hair is normally absent or minimal. The word is from early 17th century: from Latin hirsutus meaning "hairy".[2] It usually refers to a male pattern of hair growth in a female that may be a sign of a more serious medical condition,[3] especially if it develops well after puberty.[4] Cultural stigma against hirsutism can cause much psychological distress and social difficulty.[5] Discrimination based on facial hirsutism often leads to the avoidance of social situations and to symptoms of anxiety and depression.[6]

Hirsutism is usually the result of an underlying endocrine imbalance, which may be adrenal, ovarian, or central.[7] It can be caused by increased levels of androgen hormones. The amount and location of the hair is measured by a Ferriman-Gallwey score. It is different from hypertrichosis, which is excessive hair growth anywhere on the body.[3]

Treatments may include certain birth control pills, antiandrogens, or insulin sensitizers.[1]

Hirsutism affects between 5 and 15% of women across all ethnic backgrounds.[8] Depending on the definition and the underlying data, approximately 40% of women have some degree of facial hair.[9] About 10 to 15% of cases of hirsutism are idiopathic with no known cause.[10]

Causes

The causes of hirsutism can be divided into endocrine imbalances and non-endocrine etiologies. It is important to begin by first determining the distribution of body hair growth. If hair growth follows a male distribution, it could indicate the presence of increased androgens or hyperandrogenism. However, there are other hormones not related to androgens that can lead to hirsutism. A detailed history is taken by a provider in search of possible causes for hyperandrogenism or other non-endocrine-related causes. If the distribution of hair growth occurs throughout the body, this is referred to as hypertrichosis, not hirsutism.[11]

Endocrine causes

Endocrine causes of hirsutism include:

Non-endocrine causes

Causes of hirsutism not related to hyperandrogenism include:

Hormonal causes:[14] Description: Clinical cues:
Polycystic ovary syndrome PCOS is a condition characterized by excess androgens that can lead to hirsutism, irregular periods, and even infertility. The excess androgens can lead to disruptions in normal body hormones in the hypothalamic-pituitary-gonadal axis leading to these symptoms.[20] Characterized by having two of three Rotterdam criteria:
  • Oligomenorrhea (fewer than eight menses in a year)
  • Clinical or biochemical evidence of hyperandrogenism
  • Polycystic ovaries on ultrasound

[21]

Cushing's syndrome Cushing syndrome occurs when there is an endogenous or exogenous elevated levels of cortisol. One cause of endogenous Cushing syndrome is an adrenocorticotrophic hormone-secreting pituitary adenoma that is responsible for high secretion of not just cortisol but also androgens from the pituitary gland.[22] Cushing syndrome has an apparent symptoms including: Hirsutism weight gain, extra fat build up around the face, abdominal striae, and irregular menstruation.[22]
Congenital adrenal hyperplasia CAH can be attributed to several enzymatic deficiencies but the most common is 21-beta-hydroxylase. In CAH, a missing enzyme responsible for normal cortisol synthesis creates a build-up of androgen precursors. This precursor gets shunted to the androgen synthesis pathway leading to increased levels of androgen. Classical CAH is discovered at birth due to increased androgens during development causing ambitious genitalia. Meanwhile, non-classical CAH is found in puberty presenting as anovulation.[19] Can present similar to PCOS in non-classical CAH. Increase levels of 17-hydroxyprogesterone.[14][19]
Androgen-secreting tumors Tumors in the adrenal glands or in the ovaries leading to increase levels of androgens.[19] Rapid progression and virilization symptoms.[14]
Other less common hormonal causes: Acromegaly: Elevated levels of insulin-like growth factor-1.[18] Hyperthyroidism or hypothyroidism: Elevated or decreased levels of thyroid hormones.[18] Hyperprolactinemia: Elevated levels of prolactin.[18] Each of these have their own distinct presentation.[19]

Diagnosis

Hirsutism is a clinical diagnosis of excessive androgenic, terminal hair growth.[23] A complete physical evaluation should be done prior to initiating more extensive studies, the examiner should differentiate between widespread body hair increase and male pattern virilization.[15] One method of evaluating hirsutism is the Ferriman-Gallwey Score which gives a score based on the amount and location of hair growth.[24] The Ferriman-Gallwey Score has various cutoffs due to variable expressivity of hair growth based on ethnic background.[25][26]

Diagnosis of patients with even mild hirsutism should include assessment of ovulation and ovarian ultrasound, due to the high prevalence of polycystic ovary syndrome (PCOS), as well as 17α-hydroxyprogesterone (because of the possibility of finding non-classic 21-hydroxylase deficiency[27]). People with hirsutism may present with an elevated serum dehydroepiandrosterone sulfate (DHEA-S) level, however, additional imaging is required to discriminate between malignant and benign etiologies of adrenal hyperandrogenism.[28] Levels greater than 700 μg/dL are indicative of adrenal gland dysfunction, particularly congenital adrenal hyperplasia due to 21-hydroxylase deficiency. However, PCOS and idiopathic hirsutism make up 90% of cases.[15]

Treatment

Treatment of hirsutism is indicated when hair growth causes patient distress. The two main approaches to treatment are pharmacologic therapies targeting androgen production/action, and direct hair removal methods including electrolysis and photo-epilation. These may be used independently or in combination.[29]

Pharmacologic therapies

Common medications consist of antiandrogens, insulin sensitizers, and oral contraceptive pills. All three types of therapy have demonstrated efficacy on their own, however insulin sensitizers are shown to be less effective than antiandrogens and oral contraceptive pills.[30] The therapies may be combined, as directed by a physician, in line with the patient's medical goals. Antiandrogens are drugs that block the effects of androgens like testosterone and dihydrotestosterone (DHT) in the body.[13] They are the most effective pharmacologic treatment for patient-important hirsutism, however they have teratogenic potential, and are therefore not recommended in people who are pregnant or desire pregnancy. Current data does not favor any one type of oral contraceptive over another.[30]

List of medications:

Other methods

See also

References

  1. 1 2 3 Barrionuevo, P; Nabhan, M; Altayar, O; Wang, Z; Erwin, PJ; Asi, N; Martin, KA; Murad, MH (1 April 2018). "Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis". The Journal of Clinical Endocrinology and Metabolism. 103 (4): 1258–1264. doi:10.1210/jc.2017-02052. PMID 29522176.
  2. ↑ "hirsute adjective - Definition, pictures, pronunciation and usage notes | Oxford Advanced Learner's Dictionary". www.oxfordlearnersdictionaries.com. Retrieved 2021-07-22.
  3. 1 2 "Merck Manuals online medical Library". Merck & Co. Retrieved 2011-03-04.
  4. ↑ Sachdeva S (2010). "Hirsutism: Evaluation and Treatment". Indian J Dermatol. 55 (1): 3–7. doi:10.4103/0019-5154.60342. PMC 2856356. PMID 20418968.
  5. ↑ Barth JH, Catalan J, Cherry CA, Day A (September 1993). "Psychological morbidity in women referred for treatment of hirsutism". J Psychosom Res. 37 (6): 615–9. doi:10.1016/0022-3999(93)90056-L. PMID 8410747.
  6. ↑ Jackson J, Caro JJ; Caro G, Garfield F; Huber F, Zhou W; Lin CS, Shander D & Schrode K (2007). the Eflornithine HCl Study Group. "The effect of eflornithine 13.9% cream on the bother and discomfort due to hirsutism". International Journal of Dermatology. 46 (9): 976–981. doi:10.1111/j.1365-4632.2007.03270.x. PMID 17822506. S2CID 25986442.
  7. ↑ Blume-Peytavi U, Hahn S. "Medical treatment of hirsutism. Dermatol Ther. 2008 Sep-Oct; 21(5): 329-39. Review". {{cite journal}}: Cite journal requires |journal= (help)
  8. ↑ Azziz R. (May 2003). "The evaluation and management of hirsutism". Obstet Gynecol. 101 (5 pt 1): 995–1007. doi:10.1016/s0029-7844(02)02725-4. PMID 12738163.
  9. ↑ Blume-Peytavi U, Gieler U, Hoffmann R, Shapiro J (2007). "Unwanted Facial Hair: Affects, Effects and Solutions". Dermatology (Basel). 215 (2): 139–146. doi:10.1159/000104266. PMID 17684377. S2CID 9589835.
  10. 1 2 3 4 de Kroon RW, den Heijer M, Heijboer AC (June 2022). "Is idiopathic hirsutism idiopathic?". Clin Chim Acta. 531: 17–24. doi:10.1016/j.cca.2022.03.011. PMID 35292252. S2CID 247419684.
  11. ↑ Sachdeva, Silonie (2010). "Hirsutism: Evaluation and treatment". Indian Journal of Dermatology. 55 (1): 3–7. doi:10.4103/0019-5154.60342. ISSN 0019-5154. PMC 2856356. PMID 20418968.
  12. ↑ Somani N, Harrison S, Bergfeld WF (2008). "The clinical evaluation of hirsutism". Dermatol Ther. 21 (5): 376–91. doi:10.1111/j.1529-8019.2008.00219.x. PMID 18844715. S2CID 34029116.
  13. 1 2 3 4 Unluhizarci K, Kaltsas G, Kelestimur F (2012). "Non polycystic ovary syndrome-related endocrine disorders associated with hirsutism". Eur J Clin Invest. 42 (1): 86–94. doi:10.1111/j.1365-2362.2011.02550.x. PMID 21623779. S2CID 23701817.
  14. 1 2 3 4 5 6 Radi, Suhaib; Tamilia, Michael (2019-12-30). "Adrenocortical carcinoma: an ominous cause of hirsutism". BMJ Case Reports. 12 (12): e232547. doi:10.1136/bcr-2019-232547. ISSN 1757-790X. PMC 6954802. PMID 31892624.
  15. 1 2 3 4 5 6 Sachdeva, Silonie (2010). "Hirsutism: Evaluation and treatment". Indian Journal of Dermatology. 55 (1): 3–7. doi:10.4103/0019-5154.60342. PMC 2856356. PMID 20418968.
  16. ↑ Chellini PR, Pirmez R, Raso P, Sodré CT (2015). "Generalized Hypertrichosis Induced by Topical Minoxidil in an Adult Woman". Int J Trichology. 7 (4): 182–3. doi:10.4103/0974-7753.171587. PMC 4738488. PMID 26903750.
  17. ↑ Dawber RP, Rundegren J (2003). "Hypertrichosis in females applying minoxidil topical solution and in normal controls". J Eur Acad Dermatol Venereol. 17 (3): 271–5. doi:10.1046/j.1468-3083.2003.00621.x. PMID 12702063. S2CID 23329383.
  18. 1 2 3 4 Hafsi, Wissem; Badri, Talel (2022), "Hirsutism", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29262139, retrieved 2022-09-15
  19. 1 2 3 4 5 Bode, David; Seehusen, Dean A.; Baird, Drew (2012-02-15). "Hirsutism in Women". American Family Physician. 85 (4): 373–380. PMID 22335316.
  20. ↑ Witchel SF, Oberfield SE, Peña AS (August 2019). "Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls". J Endocr Soc. 3 (8): 1545–1573. doi:10.1210/js.2019-00078. PMC 6676075. PMID 31384717.
  21. ↑ Legro, Richard S.; Arslanian, Silva A.; Ehrmann, David A.; Hoeger, Kathleen M.; Murad, M. Hassan; Pasquali, Renato; Welt, Corrine K. (December 2013). "Diagnosis and Treatment of Polycystic Ovary Syndrome: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 98 (12): 4565–4592. doi:10.1210/jc.2013-2350. ISSN 0021-972X. PMC 5399492. PMID 24151290.
  22. 1 2 Mihailidis, John; Dermesropian, Racha; Taxel, Pamela; Luthra, Pooja; Grant-Kels, Jane M. (2015-06-04). "Endocrine evaluation of hirsutism". International Journal of Women's Dermatology. 1 (2): 90–94. doi:10.1016/j.ijwd.2015.04.003. ISSN 2352-6475. PMC 5418744. PMID 28491965.
  23. ↑ Ferriman, D.; Gallwey, J. D. (November 1961). "Clinical assessment of body hair growth in women". The Journal of Clinical Endocrinology and Metabolism. 21 (11): 1440–1447. doi:10.1210/jcem-21-11-1440. ISSN 0021-972X. PMID 13892577.
  24. ↑ Ferriman D, Gallwey JD (November 1961). "Clinical assessment of body hair growth in women". J. Clin. Endocrinol. Metab. 21 (11): 1440–7. doi:10.1210/jcem-21-11-1440. PMID 13892577.
  25. ↑ Cheewadhanaraks, Sopon; Peeyananjarassri, Krantarat; Choksuchat, Chainarong (May 2004). "Clinical diagnosis of hirsutism in Thai women". Journal of the Medical Association of Thailand = Chotmaihet Thangphaet. 87 (5): 459–463. ISSN 0125-2208. PMID 15222512.
  26. ↑ Escobar-Morreale, H. F.; Carmina, E.; Dewailly, D.; Gambineri, A.; Kelestimur, F.; Moghetti, P.; Pugeat, M.; Qiao, J.; Wijeyaratne, C. N.; Witchel, S. F.; Norman, R. J. (March 2012). "Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society". Human Reproduction Update. 18 (2): 146–170. doi:10.1093/humupd/dmr042. ISSN 1460-2369. PMID 22064667.
  27. ↑ Di Fede G, Mansueto P, Pepe I, Rini GB, Carmina E (2010). "High prevalence of polycystic ovary syndrome in women with mild hirsutism and no other significant clinical symptoms" (PDF). Fertil. Steril. 94 (1): 194–7. doi:10.1016/j.fertnstert.2009.02.056. hdl:10447/36367. PMID 19338993.
  28. ↑ d'Alva, Catarina B.; Abiven-Lepage, Gwenaelle; Viallon, Vivian; Groussin, Lionel; Dugue, Marie Annick; Bertagna, Xavier; Bertherat, Jerôme (2008-11-01). "Sex steroids in androgen-secreting adrenocortical tumors: clinical and hormonal features in comparison with non-tumoral causes of androgen excess". European Journal of Endocrinology. 159 (5): 641–647. doi:10.1530/EJE-08-0324. ISSN 0804-4643. PMID 18708437. S2CID 6342456.
  29. ↑ Martin, Kathryn A; Anderson, R Rox; Chang, R Jeffrey; Ehrmann, David A; Lobo, Rogerio A; Murad, M Hassan; Pugeat, Michel M; Rosenfield, Robert L (2018-03-07). "Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society* Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 103 (4): 1233–1257. doi:10.1210/jc.2018-00241. ISSN 0021-972X. PMID 29522147.
  30. 1 2 Barrionuevo, Patricia; Nabhan, Mohammed; Altayar, Osama; Wang, Zhen; Erwin, Patricia J; Asi, Noor; Martin, Kathryn A; Murad, M Hassan (2018-03-07). "Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis". The Journal of Clinical Endocrinology & Metabolism. 103 (4): 1258–1264. doi:10.1210/jc.2017-02052. ISSN 0021-972X. PMID 29522176. S2CID 3783739.
  31. 1 2 Williams H, Bigby M, Diepgen T, Herxheimer A, Naldi L, Rzany B (22 January 2009). Evidence-Based Dermatology. John Wiley & Sons. pp. 529–. ISBN 978-1-4443-0017-8.
  32. 1 2 Erem C (2013). "Update on idiopathic hirsutism: diagnosis and treatment". Acta Clinica Belgica. 68 (4): 268–74. doi:10.2143/ACB.3267. PMID 24455796. S2CID 39120534.
  33. 1 2 Müderris II, Bayram F, Ozçelik B, Güven M (February 2002). "New alternative treatment in hirsutism: bicalutamide 25 mg/day". Gynecological Endocrinology. 16 (1): 63–6. doi:10.1080/gye.16.1.63.66. PMID 11915584. S2CID 6942048.
  34. 1 2 3 4 van Zuuren, Esther J; Fedorowicz, Zbys; Carter, Ben; Pandis, Nikolaos (2015-04-28). "Interventions for hirsutism (excluding laser and photoepilation therapy alone)". Cochrane Database of Systematic Reviews. 2015 (4): CD010334. doi:10.1002/14651858.CD010334.pub2. ISSN 1465-1858. PMC 6481758. PMID 25918921.
  35. 1 2 Ekback, Maria Palmetun (2017). "Hirsutism, What to do?" (PDF). International Journal of Endocrinology and Metabolic Disorders. 3 (3). doi:10.16966/2380-548X.140. ISSN 2380-548X.
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  37. 1 2 3 4 5 Somani N, Turvy D (2014). "Hirsutism: an evidence-based treatment update". Am J Clin Dermatol. 15 (3): 247–66. doi:10.1007/s40257-014-0078-4. PMID 24889738. S2CID 45234892.
  38. ↑ Wolf, John E.; Shander, Douglas; Huber, Ferdinand; Jackson, Joseph; Lin, Chen-Sheng; Mathes, Barbara M.; Schrode, Kathy; the Eflornithine HCl Study Group (January 2007). "Randomized, double-blind clinical evaluation of the efficacy and safety of topical eflornithine HCl 13.9% cream in the treatment of women with facial hair: Eflornithine treatment for unwanted facial hair". International Journal of Dermatology. 46 (1): 94–98. doi:10.1111/j.1365-4632.2006.03079.x. PMID 17214730. S2CID 10795478.
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  41. ↑ Adam Ostrzenski (2002). Gynecology: Integrating Conventional, Complementary, and Natural Alternative Therapy. Lippincott Williams & Wilkins. pp. 86–. ISBN 978-0-7817-2761-7.
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  43. ↑ Mongioi, A.; Maugeri, G.; Macchi, M.; Calogero, A.; Vicari, E.; Coniglione, F.; Aliffi, A.; Sipione, C.; D'Agata, R. (February 1986). "Effect of gonadotrophin-releasing hormone analogue (GnRH-A) administration on serum gonadotrophin and steroid levels in patients with polycystic ovarian disease". Acta Endocrinologica. 111 (2): 228–234. doi:10.1530/acta.0.1110228. ISSN 0001-5598. PMID 3082098.
  44. ↑ Karakurt F, Sahin I, Güler S, et al. (April 2008). "Comparison of the clinical efficacy of flutamide and spironolactone plus ethinyloestradiol/cyproterone acetate in the treatment of hirsutism: a randomised controlled study". Adv Ther. 25 (4): 321–8. doi:10.1007/s12325-008-0039-5. PMID 18389188. S2CID 23641936.
  45. ↑ Taylor SI, Dons RF, Hernandez E, Roth J, Gorden P (December 1982). "Insulin resistance associated with androgen excess in women with autoantibodies to the insulin receptor". Ann. Intern. Med. 97 (6): 851–5. doi:10.7326/0003-4819-97-6-851. PMID 7149493.
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