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Hirsutism

Overview

Hirsutism is a common condition in which a woman develops excessive growth of thick (male pattern) hair in areas where thick hair is not usually present. It is prevalent in around 5% to 10% of women in the USA. Women usually develop thick, dark hair growth on the upper lip, chin, chest, abdomen, or back instead of fine soft normal hair. Cosmetically the condition is distressful for women and may lead to anxiety, depression, low self-esteem, etc. It may point towards excess male hormone called androgen, which may or may not be due to a serious underlying condition. The goal of treatment is to identify the underlying condition and treat the excess hair. 

Causes

Androgens are the natural male hormones. Females naturally produce little androgen, but if a woman's androgen levels increase more than normal or her hair follicles are sensitive to androgens, then hirsutism may develop. Many conditions are known to cause hirsutism. These include:

  • Polycystic ovarian syndrome (PCOS) is a condition related to hormones in which a woman produces excessive androgens. Women with PCOS may also experience acne, menstrual irregularities, diabetes, weight increase, or fertility issues.
  • The hormonal changes due to menopause may lead to excessive facial hair like mustaches and whiskers.
  • Cushing syndrome: In this condition, there is excess cortisol hormone in your body that can either be produced by the adrenals glands or by taking steroid medicines, for example, prednisone, for a long time.
  • Other serious conditions like a tumor of the ovary or adrenal gland can produce excess androgens leading to abrupt development of Hirsutism and other male features, such as deep voice, acne, or increased muscle mass.
  • Medications. Some medications can cause hirsutism as a side effect. These medicines include:

o    Anabolic steroids

o    Testosterone

o    Glucocorticoids

o    Cyclosporine

o    Minoxidil

o    Danazol

o    Phenytoin

Risk Factors

  • Hereditary Factor: Some conditions show prevalence in families and affect the hormones which cause hirsutism.
  •  Ethnicity: Women from a certain race or background like Mediterranean, Middle Eastern, or South Asian have more chances to get extra thick body hair.
  • Increased weight: In obesity,  the body tends to produce an excess of male hormones, resulting in worsening hirsutism.

Epidemiology

Around 10% of women are affected by hirsutism in the United States. Hirsutism may be present in both genders, but it is indistinguishable in men. So it presents as a medical problem only in females. Mostly hirsutism appears around puberty. If hirsutism develops in prepubertal children, it should raise the alarm about a serious underlying illness. 

Signs And Symptoms

A woman with mild hirsutism may see the extra growth of hair on the upper lip, chin, face side areas, and around the breast nipples or lower abdomen. It presents as thick mature hair or hair identical to that seen on the scalp. More progressing hirsutism will result in thicker hair to grow on the upper back, shoulders, chest, and upper abdomen and probably begins during or after puberty. A doctor should evaluate the symptoms if hirsutism is diagnosed before puberty. Along with excessive hair growth, a woman suffering from hirsutism may also experience other symptoms like:

  • Oily skin
  • Acne
  • Alopecia ( hair loss)
  • Diminishing hairline
  • Big clitoris
  • A deep heavy voice

Diagnosis

History of the symptoms and physical examination by the doctor to determine the severity of the abnormal hair growth and find out other physical signs that may be present with the hair growth, such as acne, is crucial in diagnosis.

Certain tests are advised if excessive hair growth is diagnosed as hirsutism. These include blood tests to detect increased hormone levels such as androgens, androstenedione, DHEA-S, and testosterone, thyroid function tests including thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), prolactin.

Imaging studies may also be performed, such as ultrasound of the ovaries to further evaluate Polycystic Ovary (PCO) or tumors. Other tests may also be performed to assess ovaries and adrenal glands, to rule out other medical conditions. 90% of the cases are due to PCOS and idiopathic hirsutism. 

Differential Diagnosis

Hirsutism can be due to some other conditions that need to be diagnosed to make efficient progress towards solving the case. These conditions may include;

·         Adrenal Tumors

·         Ovarian Tumors

·         Congenital Adrenal Hyperplasia

·         Exogenous Androgens

·         Iatrogenic Cushing Syndrome

·         Polycystic Ovary Syndrome 

Treatment

Treatment for hirsutism is not necessary if there is no endocrine disorder. Treating underlying disorder, developing a self-care routine for extra hairs, and trying various therapies and medications helps in managing.

Medications

It may take up to six months for the medicines to become effective;

·         Oral contraceptives pills. Birth control pills or other hormonal contraceptives that contain estrogen and progestin are used to treat hirsutism caused by excess androgen production. Oral contraceptives are a very effective treatment for hirsutism in women who don't wish to become pregnant. Nausea and headache may be the associated side effects.

·         Anti-androgens. These types of medicines block androgens from sticking to their receptors in the body. They're sometimes prescribed after six months on oral contraceptives, only if the oral contraceptives are not effective enough. The commonly used anti-androgen medicine for treating hirsutism is spironolactone. It takes at least six months to notice the change. The associated side effect includes menstrual irregularity. As these drugs can cause birth defects, it is crucial to use contraception methods while consuming them.

·         Topical cream. Eflornithine (Vaniqa) is a prescription cream particularly used for excessive facial hair growth in women. It's applied directly to the affected area two times a day. It helps reduce new hair growth but does not clear existing hair completely. It can be used commonly with laser therapy for good results.

Some hair removal methods concomitantly used with medical treatment may show profound results and may include:

·         Laser therapy. A ray of highly concentrated light (laser) is crossed over the skin to destroy hair follicles and prevent hairs from growing back (photoepilation). Multiple treatments may be required. For people who have unwanted hair that is black, brown, or auburn, Photo-epilation is usually a better option than electrolysis.

Consult with a health professional about the risks and benefits of the various lasers used to remove hair. People who have tanned or darkly pigmented skin are at high risk of side effects from certain lasers, for example, discoloration (darkening or lightening) of their normal skin tones, blistering, and inflammation.

·         Electrolysis. In this treatment, a tiny needle is inserted into each hair follicle. The needle emits a pulse of electric current to destroy the follicle permanently. Multiple treatments must be required. Electrolysis is a better option in people with natural blonde or lighter hair color than laser therapy. Electrolysis is worthy treatment but can be very painful. Anesthetic cream spread on skin before treatment might significantly reduce the discomfort.

Prognosis

Hirsutism requires continuous treatment. None of the treatments is completely helpful to get rid of hair, but they do influence the hair growth and make it grow more slowly and significantly reduce the amount of hair. Any treatment regimen that works best for any case differently must be understood. Once an effective treatment is established, it may be continued for a prolonged duration.

Lifestyle Modifications

Most of the conditions that can lead to hirsutism cannot be prevented. There is only little one can do like;

·         Avoid taking steroids for any purpose other than medical illness.

·         Try to lose weight if you are obese by adopting a well-balanced diet with calorie deficit and regular exercise.

·         Try methods for removing hair like plucking, shaving, waxing, laser therapies, etc.

·         Consult a doctor if you feel hirsutism is affecting your mental health or self-esteem.

Our clinical experts continually monitor the health and medical content posted on CURA4U, and we update our blogs and articles when new information becomes available. Last reviewed by Dr.Saad Zia on May 20, 2023. 

References

HIRSUTISM: EVALUATION AND TREATMENT - PMC (nih.gov)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856356/

Hirsutism in Women | AAFP

https://www.aafp.org/pubs/afp/issues/2019/0801/p168.html

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