Hirsutism

What is it?

Hirsutism is excessive hair growth in certain areas of a woman's face and body, such as the mustache and beard area, that creates a "male pattern" of hair. Women normally can have fine, pale, faintly visible hair in these areas, but heavy hair growth in a male pattern with coarse or colored hair is not expected.

Normal patterns of hair growth and hair distribution vary widely, determined mostly by racial background. For example, whites as a group have more facial and non-scalp hair growth than do blacks or Asians, and white women of Mediterranean heritage normally have more hair growth than do women from Nordic countries.

Hirsutism in women means that hair follicles are being over-stimulated by testosterone or other androgen hormones. Androgens are the dominant sex hormones in men. Women normally have low levels of androgens. Hirsutism can be caused by abnormally high levels of androgens or abnormal stimulation of hair follicles even when androgen levels are normal.

In some cases, the extra androgen comes from medications  such as certain progestins used in some brands of birth control pills  or bodybuilding steroids that contain androgens or have some effects similar to androgens. Other medicines may indirectly cause the body to manufacture extra androgen hormones. These include some medicines to treat nausea, schizophrenia, agitation, epileptic seizures, migraine headaches, bipolar disorder, aggression and high blood pressure, as well as estrogens and opiate medications.

Occasionally, the overproduction of androgen hormones is caused by an abnormality in the ovaries, the adrenal glands or the pituitary gland of the brain.

Some excessive hair growth does not fit the pattern of growth triggered by androgen hormones (for example, hair between the eyes, on the forehead, on the temples or high on the cheeks of the face). This hair growth, called hypertrichosis, can be caused by thyroid problems or by anorexia nervosa. It also can result from long-term use of certain oral medications, including cyclosporin (Neoral, Sandimmune, SangCya), phenytoin (Dilantin), minoxidil (Loniten), and penicillamine (Cuprimine, Depen).

Symptoms

A woman with the mildest form of hirsutism may notice significant growth of hair that is mature (the same color as scalp hair) on the upper lip, chin, sideburn area, around the nipples or lower abdomen. More advanced hirsutism will cause mature hair to grow on the upper back, shoulders, sternum and upper abdomen. It most often begins during puberty. If hirsutism starts before or after puberty, the cause could be hormonal and the woman should be evaluated by a doctor.

Diagnosis

Your doctor will ask you about your medical history with special attention to your menstrual cycles. He or she also will examine you. If you have a normal cyclic pattern of menstrual periods, the hirsutism is most likely genetic (inherited). If your menstrual cycles are irregular and have always been irregular, the cause could be polycystic ovary syndrome.

If the hirsutism and menstrual irregularity are new, you will need to be evaluated for a potentially more serious condition, such as a tumor of the ovary, adrenal glands or pituitary gland. This is especially important is you are skipping periods. If you have mild hirsutism and don't have any symptoms that suggest you are significantly overproducing androgen hormones, you may not need any additional testing.

If you need more testing, you are likely to have several blood tests:

• The hormones testosterone and dehydroepiandrosterone may be measured to check for signs of polycystic ovary syndrome, ovary tumors, adrenal gland tumors, adrenal gland hormone deficiencies (causing overgrowth, or hyperplasia, of the adrenal glands) or tumors that can stimulate the adrenal glands.
• The hormone prolactin may be measured to check for signs of a tumor in the pituitary gland.
• Blood sugar and cholesterol levels may be tested, because diabetes and high levels of cholesterol commonly are associated with some causes of hirsutism.

Depending on the results of these tests, your doctor may order additional hormone tests to help clarify the reason you are producing too much androgen by evaluating the function of your adrenal gland and pituitary gland. In some cases, your doctor will want to see a picture of one or more organs. Commonly used tests are magnetic resonance imaging (MRI) of the brain, a computed tomography (CT) scan of the adrenal glands or an ultrasound of the ovaries.

Expected duration

Most causes of hirsutism create a tendency to have lifelong excessive hair growth. However, many women will have a satisfactory response to medical treatment if they continue the therapy for several months or longer. A few causes of hirsutism (such as tumors that produce androgen hormones or tumors in the pituitary gland) can be cured with surgical treatment, radiation or both.

Cosmetic treatments can remove unwanted hair temporarily, and may limit hair regrowth in treated areas.

Prevention

Most causes of hirsutism are beyond a woman's control. You should avoid unnecessary medicines that are known to cause hirsutism.

Treatment

If a specific cause of hirsutism is diagnosed, your doctor may suggest appropriate treatment for that cause. For women who are overweight, losing weight may reduce androgen levels and improve hirsutism. For all women with hirsutism, cosmetic treatments and medical treatments that decrease the levels of androgens or their impact on hair follicles can be helpful:

• Plucking, shaving, waxing, chemical hair softeners (depilatory creams) – While these are all effective treatments for mild hirsutism, they can irritate the skin, and must be repeated for continued success. Waxing need be done every four to six weeks. The other treatments more frequently.
• Laser hair-removal techniques – Laser techniques use light to generate heat inside hair follicles, which destroys the ability of hair to grow from the follicle. Laser treatment is more effective in some skin types than in others, and it does not prevent new hair follicles from forming. Because the light used targets pigment in hairs, this technique works better on dark hairs than on light hairs. It is expensive, time-consuming and requires the professional services of a dermatologist, plastic surgeon or private spa. However, it lasts longer than the techniques described above.
• Electrolysis – This also destroys the ability of the follicles to grow hair by using electricity to generate heat within the hair follicles. Electrolysis has become less popular than laser treatment because it is more likely to leave small areas of scarring.
• Estrogen containing medicines – Several medicines can alter the impact of androgen hormones on the body and skin. Combination birth control pills (containing both estrogen and progesterone) can counterbalance the masculine effects of androgen hormones and decrease the production of testosterone by the ovary. Hirsutism may improve after 6 to 12 months of consistent use of birth control pills.
• Anti-androgen medicines – These can work alone or in combination with birth-control pills. The most commonly used medicine is spironolactone (Aldactone), although others are available. It is unsafe to take anti-androgen medicines during pregnancy.

When to call a professional

If you have excessive, male-pattern hair growth or unusually rapid growth of male-pattern hair in a short period of time, you should see a medical professional. Also discuss hirsutism with a doctor if you have any symptoms of overproduction of androgens:

• menstrual periods that are infrequent, irregular or absent
• acne that is difficult to manage
• deepening of the voice
• a receding scalp line or thinning hair in your head's crown area
• decreased breast size or enlargement of the clitoris.

Discuss hirsutism with your doctor if you have other symptoms that may suggest an underlying problem in the ovaries, adrenal glands or pituitary gland, including:

• obesity (commonly seen in the most common cause of androgen excess, polycystic ovarian syndrome)
• darkened, thickened skin (andquot;velvetlike") in your armpits, groin or neck area
• easy bruising, weight gain in your midsection or muscle weakness
• leakage of milk or other fluid from your nipples when you are not breast-feeding
• high blood pressure, high blood sugar or a cholesterol problem
• hirsutism prior to puberty or hirsutism that occurs suddenly.

Because some medical problems resulting in hirsutism run in families, talk to your doctor if you have these symptoms, even if your hirsutism is typical for your female relatives.

Prognosis

Most cases of hirsutism can be treated successfully with medication and cosmetic attention. It may require time and persistent use of these therapies, but most cases will respond to a combined approach.

Additional info

American Academy of Dermatology
https://www.aad.org/

American College of Obstetricians and Gynecologists
https://www.acog.org/