Excessive hair growth in women is common and due to a broad spectrum of causes. Management options comprise different pharmaceuticals, epilation methods, and aesthetic approaches. Because excessive hair growth in women may cause psychological and psychosocial problems, a holistic treatment approach, including support and emotional coping strategies, should be recommended. In this article, diagnostic procedures and treatment options for excessive hair growth in female patients are discussed.
Key Points
- •
Excessive hair growth in women can present as localized or diffuse hypertrichosis or as hirsutism with a male pattern hair growth distribution.
- •
Excessive hair growth in hirsute women can be due to adrenal, ovarian, or central endocrine abnormalities or also be drug induced or of idiopathic origin.
- •
Hirsutism can present an important psychological burden with loss of self-esteem and loss of femininity.
- •
Management of excessive hair should comprise a holistic approach, including pharmaceuticals, epilation methods, and aesthetic approaches, and emotional coping as well as lifestyle modifications.
Introduction
Excessive hair growth in women is not uncommon. Approximately 5% to 10% of women in reproductive age are hirsute with a Ferriman-Gallwey score higher than 8 ; more than 40% of all women experience some degree of unwanted facial hair during their lifetime. Excessive hair growth, especially in the face, can represent an important psychological burden with loss of self-esteem and loss of femininity to many women. Still, excessive female hair has not gained much attention in medical research.
Excessive hair growth in women can be the result of various causes, including adrenal, ovarian, or central endocrine abnormalities and also can be drug induced or of idiopathic origin. Considering the broad pathogenic spectrum, the diagnostic work-up is crucial for success in managing these patients, including the choice of the adequate treatment. Thus, the panel of treatments options is likewise broad and ranges from pharmaceuticals to physical, chemical, and laser epilation combined with psychological coping strategies. The central task for every treating doctor is to rectify any causal hormonal balance to slow down or stop excessive hair growth and improve the esthetic appearance of female patients, thereby positively affecting their quality of life.
Introduction
Excessive hair growth in women is not uncommon. Approximately 5% to 10% of women in reproductive age are hirsute with a Ferriman-Gallwey score higher than 8 ; more than 40% of all women experience some degree of unwanted facial hair during their lifetime. Excessive hair growth, especially in the face, can represent an important psychological burden with loss of self-esteem and loss of femininity to many women. Still, excessive female hair has not gained much attention in medical research.
Excessive hair growth in women can be the result of various causes, including adrenal, ovarian, or central endocrine abnormalities and also can be drug induced or of idiopathic origin. Considering the broad pathogenic spectrum, the diagnostic work-up is crucial for success in managing these patients, including the choice of the adequate treatment. Thus, the panel of treatments options is likewise broad and ranges from pharmaceuticals to physical, chemical, and laser epilation combined with psychological coping strategies. The central task for every treating doctor is to rectify any causal hormonal balance to slow down or stop excessive hair growth and improve the esthetic appearance of female patients, thereby positively affecting their quality of life.
Diagnosing excessive hair growth
Excessive hair growth in women presents clinically as hypertrichosis (localized or diffuse) or hirsutism ( Table 1 ). Hypertrichosis has a broad clinical presentation and depends on ethnic factors, frequently with no pathologic background. It is androgen independent and presents with generalized or localized vellus hair growth distributed in a nonsexual pattern over the body. Hypertrichosis may be familial, drug related, or due to different metabolic or other nonendocrine disorders, such as anorexia nervosa. In many cases, cosmetic treatments may be the most suitable.
| Hypertrichosis | Hirsutism |
|---|---|
| Male and female | Only female |
| Independent of age | Onset at puberty or later |
| Terminal or vellus hair | Terminal hair in male pattern distribution |
| Non–androgen-dependent body sites | Androgen-dependent body sites |
In cases of hirsutism, the clinical characteristics in female patients present as excess terminal (coarse) hairs with a male pattern distribution. The clinical history, including ethnic factors and complete physical examination, should be established to confirm the male pattern hair growth. Disorders that may potentially contribute to excessive hair growth, such as ovulatory dysfunction, adrenal hyperplasia, diabetes, or thyroid hormone abnormalities, should be excluded. Hirsutism also can be caused by nonandrogenic factors or excessive androgen, although nonandrogenic causes are rare. Androgenic causes include polycystic ovary syndrome (PCOS), affecting 70% to 80% of hirsute women; rarely, hyperandrogenic insulin-resistant acanthosis nigricans syndrome and 21-hydroxylase–deficient nonclassic adrenal hyperplasia; and, very rarely, ovarian or adrenal androgen-secreting neoplasms.
When diagnosing female patients with excessive hair growth, the negative impact on patient quality of life and possible psychological and psychosocial distress, especially in cases of facial hair, should also be taken into consideration. Complaints may include depression, social phobia, or body dysmorphic disorders. Therefore, an interdisciplinary holistic treatment approach, which includes, in addition to pharmacologic management and possible cosmetic hair removal methods, emotional coping strategies and ongoing support and lifestyle modifications, may be advisable.
The Skin Academy hirsutism subgroup developed a diagnostic evaluation form in 2009 for women with excessive hair growth, which is used in Europe, especially in the United Kingdom, Germany, and Switzerland. The diagnostic evaluation form has 3 parts (history, clinical examination, and investigations), each divided into subsections.
History
In the history section, factors, such as patient age, ethnicity, family history, and medication, are taken into consideration. Non-neoplastic hirsutism is usually seen at puberty with increasing androgen secretion after weight gain or after discontinuing oral contraceptives. In regards to patients’ ethnic background, it should be determined what kind of hair growth is deemed normal and excessive. Furthermore, the speed of onset of the hair growth is assessed; in most women, a slow physiologic depilation is seen after menopause. Facial hair, on the contrary, tends to increase.
In some women, hirsutism rapidly develops or worsens in puberty, particularly if there are disturbances in androgen production. Rapid onset or worsening of hirsutism may be a sign of neoplasia-induced androgen excess. Some medications, for example, danazol; anticonvulsant drugs, such as valproic acid; and anabolic or androgenic steroids taken by athletes and patients with endometriosis or sexual dysfunctions, can cause hirsutism. The regularity of the menstrual cycle should be found out and the presence of PCOS ruled out. Most women with at least a 2-fold increase in androgen levels experience some degree of hirsutism or symptoms, such as acne vulgaris, seborrhea, and pattern alopecia. If no hyperandrogenemia is present, the condition is called idiopathic hirsutism.
Clinical Examination
In the clinical examination section, the distribution of hair on the face and the body as well as the androgen dependency of the hairs is assessed. If excessive hair grows on the upper back, shoulders, and upper abdomen, an increase in androgen production should be suspected. If the hair growth is mild (8–15 in the Ferriman-Gallwey score, depending on a patient’s ethnic background) and a patient’s menstrual cycle is regular, the hirsutism is likely idiopathic. This is the case in 5% to 15% of hirsute women, and in some of them the skin and hair follicles’ 5α-reductase activity is overactive, which results in hirsutism, although circulating androgen levels are normal.
Because increased androgen levels may also lead to pilosebaceous responses, such as acne, excessive sebum secretion, or diffuse or localized loss of hair, a dermatologic examination is mandatory. Obesity, a common feature often associated with PCOS, is assessed by calculating the body mass index, (weight/height 2 ).
Thickening and darkening of the skin on the neck and inguinal region are assessed, because they may be a sign of acanthosis nigricans, related to high blood insulin levels or obesity. The genetic disorder, hyperandrogenic insulin-resistant acanthosis nigricans, includes many different genetic syndromes, from which approximately 3% of hyperandrogenic women suffer. Insulin resistance is also common in PCOS, which is one of the most common causes of hirsutism, and can lead to hyperglycemia and dyslipidemia.
The Ferriman-Gallwey score helps assess the extent of a patient’s hirsutism; if the score is at least 8, a woman is considered hirsute. Although well known, the Ferriman-Gallwey score has limitations: it is subjective and can be time-consuming. If, however, a clinician has experience with the method, it can be a good documentation technique in hirsute patients.
Patients should also be asked about quality-of-life changes and examined for symptoms of depression (such as sleeping difficulties, loss of energy, and drive). Feelings of disgust; changes in sexual activity, life behavior, and life-events; and signs of body dysmorphic disorder should also be evaluated. If necessary, additional counseling or psychotherapy should be considered.
Investigations
Laboratory investigations should include a free androgen index to assess biochemical hyperandrogenemia; in cases of a normal total testosterone level, a diagnosis of idiopathic hirsutism is more likely but does not rule out other origin of androgen excess. In addition, prolactin, 17 hydroxyprogesterone, and a 24-hour urine cortisol to exclude Cushing syndrome, should be tested. In women with absent or irregular menstruation, pregnancy should be ruled out before initiating any treatment. Thyroid function should be assessed, although hypothyroidism is usually more the cause of coarsening of the hair rather than androgen excess–induced hirsutism. PCOS is the most likely explanation for hirsutism but, nevertheless, other likely causes, such as hyperprolactinemia, should be ruled out. Pelvic ultrasound, preferably transvaginal, including an examination of the ovaries, adrenal glands, or both, helps in examining possible presence of neoplasms.
Medical treatment of hirsutism
Medical treatment of hirsutism aims at correcting any hormonal imbalances, thereby improving patient quality of life. The choice of therapy depends on the underlying cause, the location and extent of excessive hair growth, patient preferences, and access and affordability of the products. Monotherapy with oral contraceptices that have antiandrogenic activity is recommended as a first-line treatment of hirsutism for most premenopausal women. If a patient shows no clinical improvement, a combination therapy of oral contraceptives with antiandrogens is recommended. Any pharmacologic therapy for hirsutism, however, should be continued for 6 to 9 months before changing either dosage or drug category.
In women who also suffer from both hyperandrogenism and insulin resistance, insulin sensitizers also improve hirsutism. Topical eflornithine is used in conjunction with systemic medications or with laser epilation or photoepilation. Classification of different treatment options are summarized in Table 1 and guidelines on the medical treatment options for hirsutism in Tables 2 and 3 .
| Medical treatment of hirsutism: classification by the working mechanism of the different drugs | |
| Antiandrogens |
|
| Enzyme inhibitors |
|
| Insulin-sensitizing agents |
|
| Gonadotropin-releasing hormone analogs |
|
| Adjuvants to medical treatment | |
| Epilation methods |
|
a Rosiglitazone was withdrawn from the European and Swiss markets in 2010 due to increased cardiovascular risks; Pioglitazone withdrawn in France 2011.
| Drug | Dosage | Schedule |
|---|---|---|
| CPA | 2–100 mg | Cycle days 5–14 (combination with estrogens needed in women with uterus), also available as a combination oral contraceptive pill b : 2 mg CPA + 35 μg ethinyl estradiol |
| CMA | 1–2 mg | Available only as a combination oral contraceptive pill b either as an OCP with 2 phases—first phase 1 mg CMA + 50 μg ethinyl estradiol and second phase 2 mg CMA + 50 μg ethinyl estradiol—or as a single-phase OCP 2 mg CMA + 30 μg ethinyl estradiol for 21 d |
| Dienogest | 2 mg | Available only as a combination oral contraceptive pill b : 2 mg dienogest + 30 μg ethinyl estradiol |
| Drospirenone (DRSP) | 3 mg | Available only as a combination oral contraceptive pill b : 3 mg DRSP + 30 μg ethinyl estradiol or 3 mg DRSP + 20 μg ethinyl estradiol |
| Spironolactone | 50–200 mg/d | Continuously a, c |
| Flutamide | 62.5–500 mg/d | Continuously a |
| Finasteride | 1–5 mg/d | Continuously a |
| Metformin | 1000–2000 mg/d | Continuously |
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
