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Saturday, August 23, 2025

Excessive hair growth (hirsutism)


Introduction

Hirsutism is defined as excessive, male-pattern hair growth in women, typically involving the face (chin, upper lip), chest, abdomen, back, and thighs. Unlike generalized hypertrichosis (excess hair growth anywhere on the body, not necessarily androgen-dependent), hirsutism reflects increased androgen activity.

It affects up to 5–10% of women of reproductive age, with significant psychosocial impact including low self-esteem, anxiety, and depression. While often benign (e.g., familial tendency, mild PCOS), it may rarely indicate serious conditions such as androgen-secreting tumors.

Pathophysiology

  • Androgens (testosterone, androstenedione, dehydroepiandrosterone sulfate – DHEAS) stimulate transformation of vellus (fine) hair into terminal (thick, pigmented) hair in androgen-sensitive areas.

  • Hirsutism may result from:

    • Increased androgen production (ovarian or adrenal).

    • Increased peripheral sensitivity of hair follicles to androgens.

    • Reduced sex hormone-binding globulin (SHBG), leading to higher free testosterone.

Causes of Hirsutism

1. Polycystic Ovary Syndrome (PCOS) – most common

  • Features: irregular menses, infertility, obesity, acne, insulin resistance.

  • Elevated LH:FSH ratio, increased androgens, polycystic ovaries on ultrasound.

2. Idiopathic/Familial Hirsutism

  • Normal ovulatory cycles, androgen levels often normal.

  • Likely due to increased skin sensitivity to androgens.

3. Endocrine Disorders

  • Congenital adrenal hyperplasia (CAH): Excess adrenal androgens due to enzyme deficiency (commonly 21-hydroxylase).

  • Cushing’s syndrome: Cortisol excess with associated androgen overproduction.

  • Hyperprolactinemia: May coexist with PCOS.

  • Hypothyroidism: Rare cause, can worsen androgen effects.

4. Androgen-Secreting Tumors (Ovarian or Adrenal)

  • Rapid onset, severe hirsutism, virilization (deep voice, clitoromegaly, muscle mass).

  • Require urgent evaluation.

5. Medications

  • Anabolic steroids, danazol, minoxidil, phenytoin, cyclosporine.

Clinical Features

  • Hair growth in male-pattern distribution: upper lip, chin, chest, abdomen, back, thighs.

  • Acne, oily skin.

  • Menstrual irregularities (oligomenorrhea, amenorrhea).

  • Signs of virilization (severe cases): deepening of voice, clitoromegaly, male-pattern baldness.

Diagnostic Approach

1. History

  • Age at onset, progression rate.

  • Menstrual/obstetric history.

  • Drug history.

  • Family history.

2. Physical Examination

  • Distribution and severity of hair (Ferriman–Gallwey scoring system).

  • Signs of virilization.

  • BMI, waist circumference, signs of insulin resistance.

3. Laboratory Tests

  • Total and free testosterone (elevated in ovarian causes).

  • DHEAS (elevated in adrenal causes).

  • LH/FSH ratio (in PCOS).

  • 17-hydroxyprogesterone (for CAH).

  • Cortisol tests (dexamethasone suppression, 24-h urinary cortisol for Cushing’s).

  • Prolactin, TSH if menstrual disturbance present.

4. Imaging

  • Pelvic ultrasound (PCOS, ovarian tumor).

  • CT/MRI abdomen (adrenal tumor).

Management and Treatment

Treatment depends on severity, underlying cause, and patient preference (cosmetic vs. fertility concerns).

A. General and Cosmetic Measures

  • Weight loss & exercise: In obese women with PCOS, reduces insulin resistance and lowers androgen levels.

  • Cosmetic options:

    • Shaving, waxing, depilatory creams.

    • Bleaching (for mild facial hair).

    • Laser hair removal or electrolysis (long-term reduction).

B. Pharmacological Therapy

1. Combined Oral Contraceptives (COCs) – first-line in PCOS-related hirsutism

  • Mechanism: Suppress ovarian androgen production and increase SHBG.

  • Common formulations:

    • Ethinylestradiol 30–35 mcg + Levonorgestrel 150 mcg orally once daily

    • Ethinylestradiol 30 mcg + Drospirenone 3 mg orally once daily

  • Drospirenone has anti-androgenic effect, beneficial in hirsutism.

2. Anti-Androgens (used when COCs insufficient, often in combination)

  • Spironolactone:

    • 50–100 mg orally twice daily.

    • Blocks androgen receptors and inhibits androgen synthesis.

    • Side effects: hyperkalemia, menstrual irregularities (use with contraception).

  • Cyproterone acetate:

    • 50–100 mg orally once daily (not available everywhere).

    • Strong anti-androgenic activity.

  • Flutamide:

    • 250 mg orally once daily.

    • Potent androgen receptor blocker, but risk of hepatotoxicity → monitor liver function.

  • Finasteride:

    • 5 mg orally once daily.

    • Inhibits 5-alpha reductase, reducing dihydrotestosterone (DHT).

    • Teratogenic (must use contraception).

3. Insulin-Sensitizing Agents

  • For PCOS with insulin resistance.

  • Metformin:

    • 500 mg orally two to three times daily with meals.

    • Improves ovulation and reduces androgen levels.

4. Corticosteroids (for congenital adrenal hyperplasia)

  • Hydrocortisone: 15–25 mg/day orally in divided doses.

  • Dexamethasone: 0.25–0.5 mg orally at bedtime.

  • Suppresses adrenal androgen overproduction.

5. Gonadotropin-Releasing Hormone (GnRH) Analogues

  • Reserved for resistant cases.

  • Leuprolide depot: 3.75 mg intramuscular monthly.

  • Suppresses ovarian androgen production.

C. Treatment of Secondary Causes

  • Cushing’s syndrome: Surgical removal of adrenal/pituitary tumor.

  • Androgen-secreting tumors: Surgical resection (urgent).

  • Hypothyroidism: Levothyroxine replacement (starting 25–50 mcg daily, titrated).

  • Hyperprolactinemia: Dopamine agonists (e.g., Cabergoline 0.25 mg orally twice weekly).

Prognosis

  • PCOS/idiopathic hirsutism: Good response to long-term therapy (6–12 months).

  • Adrenal/ovarian tumors: Curable if detected early.

  • CAH: Requires lifelong corticosteroid therapy, prognosis good with compliance.

  • Cushing’s: Prognosis depends on cause and success of treatment.

Complications

  • Psychological distress, depression, social isolation.

  • Infertility (in PCOS).

  • Increased risk of metabolic syndrome, diabetes, endometrial hyperplasia (in PCOS).

  • Drug side effects (hepatotoxicity, teratogenicity, hormonal disturbances).

Patient Education

  • Hirsutism often requires long-term treatment (6–12 months) for visible improvement.

  • Contraception is essential when using anti-androgens.

  • Lifestyle changes (diet, weight reduction) are crucial in PCOS.

  • Cosmetic procedures can complement medical therapy.

  • Sudden severe hirsutism with virilization = urgent evaluation for tumor.




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