Hirsutism is defined as the presence of terminal hair growth following a similar pattern to that developing in androgen-dependent sites in men after puberty (Figure 19-15).15,16 Two to eight percent of the American population are considered to have hirsutism depending on the chosen cutoff for the Ferriman–Gallwey score, a scoring system in which 9 androgen-sensitive sites (upper lip, chin, chest, upper and lower abdomen, arms, thighs, upper back, and lower back) are assessed, with a maximum grade of 4 points for each area. The degree of hair growth in each area is graded from 1 (minimal terminal hair growth) to 4 (frank virilization). The scores are then summed with a total score of 8 or more indicating hirsutism.
Hirsutism. Excess terminal hair growth in the linea alba (Reproduced with permission from Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, Calver LE, eds. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012. Figure 17-2B).
Hirsutism may be inherited. It is well known that East Asian, North Asian, and Southeast Asian populations have less body hair and a lower incidence of hirsutism than do Caucasians, or those of West Asian or Middle Eastern descent. Hirsutism may also be drug induced or associated with aging.
Hirsutism can also be caused by any of the following:
An increase in the actual amount of androgens produced by any of the three major sources of androgens: the ovaries, adrenal glands, or skin.
An increase in androgen receptor sensitivity at the level of the hair follicle.
Enhanced activity of 5-α reductase.
Two ovarian causes of hirsutism include polycystic ovarian syndrome and ovarian tumors. Two adrenal gland causes include congenital adrenal hyperplasia with 21-hydroxylase deficiency being most common and adrenal gland tumors. Other less common causes of congenital adrenal hyperplasia include 11β-hydroxylase deficiency and 3β-ol-dehydrogenase deficiency.
Women with hirsutism will present with concerns about increased dark hair growth on any or all of the following areas: upper lip, chin, chest, upper and lower abdomen, arms, thighs, upper back, and lower back.
The examination should be directed toward describing (1) the location and amount of excess terminal hair growth using the Ferriman–Gallwey scale and (2) identifying other signs of androgen excess including the following:
In addition to checking a testosterone level and when indicated, dihydrotestosterone and dehydroepiandrosterone sulfate levels, the following may be useful in ruling out a secondary cause of hirsutism:
Dexamethasone suppression test
Follicle stimulating hormone
Diagnosis and Differential Diagnosis
Hirsutism can be end organ specific (hair follicle androgen excess only), inherited or associated with ovarian or adrenal gland disease. Hirsutism may also be associated with hyperprolactinemia, acromegaly, postmenopausal androgen therapy, thyroid dysfunction, and use of anabolic steroids.
13.9% Eflornithine (Vaniqa) cream is FDA approved for the management of hirsutism and is applied topically twice a day. Several other medications can also be used off-label to treat hirsutism. The risk/benefit ratio of each of these drugs needs to be carefully considered when prescribing any of the following for the medical management of hirsutism.
Medications prescribed for hirsutism include spironolactone, finasteride, flutamide, cyproterone acetate as well as leuprolide acetate, bromocriptine, and metformin. Any combination or oral contraceptives can be used but those with non-androgenic progestins are considered to be the best. Adrenal gland suppression of androgen production can be obtained with dexamethasone or prednisone.
Mechanical treatments are also available for managing hirsutism. These include epilation with tweezing, waxing, sugaring or threading, chemical depilation, bleaching, electrolysis, light treatment with intense pulse light (IPL), the diode, or Nd:YAG laser. The latter can be safely and effectively used to treat individuals with light and darker-skin pigmentation.
Indications for Consultation
A consultation to dermatology should be requested when the hair disease is difficult to diagnosis or if the hair loss or excessive hair growth are progressing despite appropriate therapy. If anxiety about hair loss and change in body image are the main problems, consider referral to psychology or psychiatry. If androgen excess with associated scalp hair thinning and hirsutism persists despite appropriate therapy, a referral to endocrinology is recommended.
The Cicatricial Alopecia Research Foundation (CARF) www.carfintl.org supports research and provides excellent information for patients with any cicatricial or scarring alopecia.
The National Alopecia Areata Foundation (NAAF) www.naaf.org supports research and patients and families dealing with alopecia areata.
The North American Hair Research Society (NAHRS) www.nahrs.org/Cached-Similar is another source of information.