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Editors
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.