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Excessive Hair Growth (Hirsutism)

Definition and pathogenesis

  • Hirsutism is defined as excessive male-pattern body hair growth in women.
  • In about half of the cases excessive hair growth is caused by an overproduction of androgens.

Causes of hyperandrogenism

  • Polycystic ovarian syndrome (PCOS Amenorrhoea) is the most common cause of excessive androgen production.
  • Congenital adrenal tumours and other androgen-producing tumours Pituitary Tumours are rare and usually have different symptoms at presentation.
    • Cushing's syndrome, hyperprolactinaemia, acromegaly, thyroid disorders
      • Cushing's syndrome Cushing's Syndrome is associated with both hypertrichosis and hirsutism.
  • The use of androgenic and anabolic steroids; see also Steroid Doping

Investigations

  • The development of hirsutism: age, weight gain, discontinuation of oral contraceptives
    • Sudden onset or progression is suggestive of a tumour, but a slow onset does not exclude a tumour.
  • Localisation of hirsutism and differentiation from hypertrichosis
    • Female hyperandrogenism should be suspected if hair growth occurs in the following areas:
      • face: moustache, beard, cheeks
      • chest wall: scapular region and in between the breasts
      • abdomen: midline, upwards from the navel or between the pubic hair and the navel
      • limbs: hair growth on the internal aspects of the thighs is abnormal.
    • Hypertrichosis denotes a generalised condition of excessive growth of body hair. It is not associated with androgens.
      • Genetic and ethnic factors
      • Begins after puberty, exacerbated by weight gain and discontinuation of oral contraceptives
      • Glucocorticoids, phenytoin, ciclosporin and minoxidil may cause hypertrichosis.
  • Clinical signs of virilism
    • Deepening of voice
    • Clitoromegaly
    • Temporal hair recession
  • Menstruation and fertility
  • Other possible endocrine abnormalities

Investigation and treatment strategy

  • Non-androgen-mediated hair growth
    • The location of hair growth is not suggestive of androgen-mediated hirsutism, i.e. mainly on legs and arms, normal menstrual cycle and no signs of virilism.
    • No further investigations are needed.
    • Treatment options: no treatment, local treatment or oestrogen + an antiandrogen
  • Slight androgen-mediated hair growth and regular menstruation is suggestive of idiopathic hirsutism.
    • No further investigations are needed.
    • Treatment trial: local treatment or oestrogen + an antiandrogen
  • More vigorous androgen-mediated hair growth
    • Serum testosterone must be determined, as well as serum prolactin if the menstrual cycle is irregular. Cushing's syndrome Cushing's Syndrome must be ruled out (short 1.5 mg dexamethasone test).
    • In practice, serum testosterone < 5 nmol/l and dehydroepiandrosterone sulphate < 20 µmol/l rule out an androgen-producing tumour.
  • Further investigations are carried out if hair growth progresses, if there are signs of virilism or markedly abnormal laboratory results.
  • If Cushing's syndrome or a rare tumour is suspected a referral should be made to a specialist in internal medicine.
  • An increased serum testosterone value, irregular menstrual cycle and infertility warrant a referral to a gynaecologist.

Treatment

  • Treatment options are often limited. Weight reduction reduces risk factors. Drug treatment is often unsatisfactory.

Local treatment

  • Shaving (does not accelerate hair growth)
  • Laser and photoepilation Laser and Photoepilation for Unwanted Hair Growth: light energy is focused onto the dark hair root which is destroyed by heat, thus inhibiting hair growth. After 3-4 treatment sessions, hair growth may permanently decrease by up to 30%. Treatment is usually well tolerated, but expensive.

Drug treatment

Related Keywords ⬆

ATC Code:

G03HB01

G04CB01

H02AB02

A10BA02

L02BB01

C03DA01

D11AX16

Primary/Secondary Keywords