Overview

Hirsutism is a condition when women have excessive hair on the face and body. This condition sometimes is due to an underlying problem. Your doctor is most likely to refer you to an endocrinologist (hormonal disorders) and dermatologist (skin-related issues) for the treatment.

Hirsutism is a frequent clinical concern in women, and the therapy is determined by the underlying reason. The illness is frequently linked to low self-esteem. Hirsutism is caused by a combination of circulating androgen levels, local androgen levels, and the susceptibility of the hair follicle to androgens. 

What is Hirsutism?

Hirsutism is the development of dark or coarse hair on the body and face of women in a male-like pattern. It arises due to an excess of male hormones called androgens in a female's body.

The most prevalent causes of hirsutism are polycystic ovarian syndrome and idiopathic hirsutism. The history and physical examination of a woman are particularly essential in determining whether or not she has excessive hair growth.

The idiopathic form of hirsutism affects the great majority of women, and it is diagnosed by exclusion. A serum testosterone level of more than 200 ng/dL indicates an adrenal or ovarian malignancy. The degree of excess hair growth displayed by the patient, as well as the pathophysiology of the illness, should be considered while treating hirsutism. Lifestyle therapy, androgen suppression, peripheral androgen blocking, and aesthetic treatments are all options for treatment. 

Causes of Hirsutism

Hirsutism has a variety of reasons. The problem might be ovarian or adrenal in origin, tumorous or not. Some instances are shown below.

Hyperandrogenic Hirsutism

Hirsutism is most commonly caused by ovarian or adrenal androgen hyperproduction. Tumor-related hyperandrogenism, which is typically severe, must be separated from non-tumor-related hyperandrogenism, which is generally mild or moderate.

Polycystic Ovary Syndrome (PCOS) 

It is the most frequent cause of hirsutism, accounting for over 75% of all instances. It affects 5% to 10% of women throughout their genital activity phase, and 20% to 25% of teenage girls. It is a diverse and complicated condition with unclear cause, defined by ovarian stroma hyperplasia and the termination of follicular development with an accumulation of tiny follicles under the cortex.

Hirsutism begins throughout puberty and is associated by menstruation irregularities, weight gain, dyslipidemia, insulin resistance, acne, and acanthosis nigricans. The patient complains of spaniomenorrhea (a cycle that lasts more than 35 days), oligomenorrhea (infrequent menstruation), and infertility. The ovaries can grow in size. It's possible that you have hypothyroidism or liver illness.

Androgen-Secreting Tumors  

Ovarian or adrenal tumor-induced hyperandrogenism is uncommon. Only 0.2 percent of all occurrences of hirsutism are caused by it. Because these androgen-secreting tumors are self-contained, they are not reliant on the hypothalamic-pituitary axis. About half of them are cancerous, and plasma androgen levels are abnormally high in these situations. They're also to blame for virilization, hirsutism, and a pelvic or abdominal lump that develops quickly.

Congenital Adrenal Hyperplasia 

The most prevalent adrenal etiology of hyperandrogenism is a common autosomal recessive condition characterized by a partial 21-hydroxylase deficiency. Its incidence varies substantially depending on the patients' ethnicity. As a result, it is more prevalent among Ashkenazi Jews (3.7 percent) and Central Europeans (2 percent), but rare among Caucasians.Congenital Adrenal Hyperplasia, like PCOS, can cause hirsutism, oligomenorrhea, acne, infertility, alopecia, and primary amenorrhea after puberty.

Non-Hyperandrogenic Hirsutism

• Medications

Androgens, glucocorticoids, progestins, estrogen antagonists (clomiphene, tamoxifen), minoxidil, cyclosporine, danazol, diazoxide, phenytoin, D-penicillamine, and interferon are just a few of the medicines that can induce hirsutism.

It's vital to remember that drugs including acetazolamide, phenytoin, latanoprost, streptomycin, psoralen, minoxidil, cyclosporine, and diazoxide can induce hypertrichosis.

• Endocrinopathies 

Endocrinopathies are rarely to blame for hirsutism, and the clinical picture is dominated by other, more specific symptoms and signs:

• Adrenocorticotrophic hormone is required for Cushing syndrome (ACTH). Because of the stimulating effect of ACTH on the reticulated region, it might promote excessive androgen production, causing hirsutism. Hypercorticism's characteristics are frequently highlighted.
• Isolated hirsutism is seldom caused by hyperthyroidism or hypothyroidism.
• Amenorrhea, galactorrhea, infertility, and hirsutism are all symptoms of hyperprolactinemia.
• Isolated hirsutism can also be caused by acromegaly.

Others Causes

Pregnant ladies (physiological prolactin secretion) and postmenopausal women both have moderate hirsutism (relative hyperandrogenism due to the cessation of ovarian estrogen production).

• Idiopathic Hirsutism

Idiopathic hirsutism is hirsutism that occurs in the absence of regular menstruation, normal ovarian morphology, or normal plasmatic androgen levels. It's an exclusionary diagnosis made after all other possibilities have been ruled out. It accounts for around 10% of all hirsutism cases and 50% of moderate hirsutism cases. It might be related to androgen hypersensitivity of pilosebaceous follicle receptors and peripheral conversation generated by the ten-fold more active 5-reductase of testosterone to dihydrotestosterone on the follicle-sebaceous unit. This has a hereditary component and is common in women of East Indian and Mediterranean descent.

Polycystic ovary syndrome

PCOS, or polycystic ovarian syndrome, is the most common endocrine-metabolic condition in reproductive-aged women.

Currently there are four recognized phenotypes of PCOS: 

1. Hyperandrogenism+oligo-anovulation+polycystic ovarian morphology; 
2. Hyperandrogenism+oligo-anovulation; 
3. Hyperandrogenism+polycystic ovarian morphology; and
4. Oligo-anovulation+polycystic ovarian morphology, each with different long-term health and metabolic implications. 

When diagnosing PCOS, clinicians should explicitly state the patient's phenotype. Polycystic ovarian syndrome is a complicated, strongly hereditary polygenic condition. PCOS has been linked to pathophysiological changes in gonadotropin secretion and action, ovarian folliculogenesis, steroidogenesis, insulin secretion and action, and adipose tissue function, among other things.

Glucose intolerance and type 2 diabetes mellitus; hepatic steatosis and metabolic syndrome; hypertension, dyslipidemia, vascular thrombosis, cerebrovascular accidents, and possibly cardiovascular events; infertility and obstetric complications; endometrial atypia or carcinoma, and possibly ovarian malignancy; and mood and psychosexual disorders are all risks for women with PCOS.

A thorough history and physical examination, assessment for the presence of hirsutism, ovarian ultrasonography, and hormonal testing to confirm hyperandrogenism and oligo-anovulation as needed, as well as to rule out similar or mimicking disorders, are all part of the evaluation of patients suspected of having PCOS.

Therapeutic decisions in PCOS are based on the phenotype, concerns, and objectives of the patient, and should be centered on these factors.

1. Suppressing and counteracting androgen secretion and action,
2. Improving metabolic status, and 
3. Improving fertility.

Despite tremendous advances in understanding the etiology and diagnosis of the condition over the last 20 years, many practitioners continue to misdiagnose and misunderstand the disorder. 

Pathogenesis

Hirsutism is caused by an increase in either hair follicle production or sensitivity to circulating androgen (testosterone). The majority of testosterone is produced by the ovaries or the adrenal glands (80 percent ). A minor quantity of circulating testosterone is produced in the liver, skin, and adipose tissue by the conversion of androgenic precursors, mostly androstenedione (derived from the ovaries and adrenals) and dihydroepiandrosterone (DHEA—derived from the adrenals).

However, the active androgen is just 1-2 percent of testosterone in free form. Biologically inactive, around 98-99 percent is attached to steroid hormone binding globulin (SHBG), cortisol binding globulin, or nonspecifically to albumin and other proteins. The enzyme 5-alpha reductase type 2 isoenzyme found in the outer root sheath of hair follicles converts only free testosterone to dihydrotestosterone .

This isoenzyme is found in abundance in the testes, prostate, and beard and genital hair follicles. DHT causes vellus hair to terminalize and the anagen phase to be prolonged, resulting in longer, thicker hairs. Exaggerated peripheral 5-alpha reductase activity, androgen receptor polymorphisms, or altered androgen metabolism are thought to cause IH with normal androgen levels.

Symptoms of Hirsutism

It is essential to see a doctor if you have symptoms of hirsutism. They are:

• Presence of stiff and dark body hair where women do not have hair commonly, like face, chest, inner thighs, etc.
• Increased growth of facial hair on women.

Virilisation is a process that develops due to high levels of androgen, primarily testosterone, in a woman's body. Signs and symptoms may include:

• Deepening of the voice.
• Balding.
• Development of acne.
• Reduced breast size.
• A rise in muscle mass.
• Enlargement in the size of the clitoris.

Disorders like PCOS, Cushing syndrome and some tumors are capable of causing hirsutism.

Diagnosis of Hirsutism

Unless a tumor cause is suspected, the basic biological examination is conducted in the early follicular phase (third to sixth day of the cycle, early morning, fasting) and after ceasing probable oral contraception for two or three cycles.

It comprises 

• Total testosterone,
• Dehydroepiandrosterone sulfate (DHEAS),
• Delta4-androstenedione (delta4A), 
• Luteinizing hormone (LH) / 
• Follicle-stimulating hormone (FSH), 
• 17-hydroxyprogesterone (17-OHP), 
• Steroid hormone-binding globulin (SHBG).

The stimulating thyroid hormone (TSH) and prolactinemia (PRL) are included in the case of menstrual cycle disorders. A brief dexamethasone suppression test (Cushing syndrome), an adrenocorticotropic hormone (ACTH) stimulation test, and a longer dexamethasone suppression test (late adrenogenital syndrome), a glucose tolerance test, or the HOMA index can be added to the workup based on the clinical results (insulin resistance syndrome).

Idiopathic hirsutism is considered an excluding diagnosis. This group includes around 15% to 50% of hirsutism sufferers. It follows the same pathophysiology as primary androgenetic alopecia.

Treatment of Hirsutism

The therapy for hirsutism starts with a thorough explanation of the problem's etiology and reassurance that the patient is not losing her femininity. The underlying condition is then treated with direct intervention, if possible. Other cosmetic or systemic therapy may be required if hirsutism persists (or if the patient has idiopathic hirsutism). Cosmetic remedies may be adequate in certain circumstances.

Others may require more acute cosmetic treatment because to the delayed development of systemic therapy. Combining systemic medication, which takes time to work, with mechanical depilation (shaving, plucking, waxing, depilatory creams) or light-based (laser or pulsed-light) hair removal is the most successful technique.

Medications

• Oral contraceptives (OC)

Hirsutism is caused by additional androgen production in your body which estrogen and progestin containing medicines can treat. They are known as birth control pills. It is given to those women who do not want to become pregnant. Nausea and headaches are common side-effects.

• Anti-androgens

The primary motive of anti-androgens is to prevent androgens from attaching to its receptors in your body. Your doctor will prescribe them after a six-month course of OCs if needed. Generally, anti-androgen spironolactone used to treat hirsutism. Results are usually modest and may take at least six months to become noticeable. Menstrual irregularity is the possible side-effect. And, as these medications may cause birth defects, it is very important to use contraception while taking them.

• Topical cream

A cream called Eflornithine (Vaniqa) works specifically for excess growth of facial hair on women. Your doctor will advise you to apply the cream on the affected area of your face twice a day. Many patients use this with laser therapy to increase the responsiveness of the treatment.

Procedures

Procedures provide results that last longer than self-care methods.

• Laser therapy

This procedure uses a highly concentrated beam of light which is passed over your skin to damage the hair follicles to prevent any further growth of hair. You may need to have multiple treatments. This is known as photo epilation and is preferable for black, brown, and auburn-haired women. In women with hirsutism, laser treatment has been demonstrated to relieve sadness and anxiety as well as remove unwanted hair. In many cases, hirsutism may be treated with laser alone, without the need of medicines.

• Electrolysis

Your doctor will insert a tiny needle into each hair follicle which emits an electric current. This electric current destroys the hair follicles. This process also requires multiple treatments. It is a preferable option for naturally blond or white-haired women.

It is a painful yet effective way of treatment. Your doctor will likely apply a numbing cream to reduce the discomfort.

Many women also follow a self-care approach to get rid of unwanted hair and try various methods such as:

• Plucking
• Shaving
• Waxing
• Depilation
• Bleaching

Hirsutism Prevention 

Hirsutism is not preventable, but some common precautionary measures you must be aware of are:

• Consult your doctor immediately if you witness any changes in your body weight after taking the prescribed medications.
• Oral contraceptives (OC) should be taken by women who do not want to become pregnant in the course of treatment.
• OCs can cause uterine bleeding.
• Some cosmetic measures like bleaching and chemical depilatories can cause skin irritation, folliculitis, and scarring.
• Be aware of the side effects from various lasers if you are dark-skinned or tanned.

Dietary regulations

Your doctor and healthcare provider will ask you to follow a dietary regime.

• Do consume antioxidant food products like fruits and vegetables. Fruits like blueberries, cherries, and tomatoes and vegetables like broccoli, spinach, and potatoes are high in antioxidants.

For more information see: The truth about high fiber foods

• Do not over consume refined food products like white bread, pasta, sugar, etc.

For more information see: Delicious effects of fast food to your daily life

• Ensure to use healthy oils for cooking. Olive oil or vegetable oil are healthy oils.
• Eat less red meat.
• Avoid alcohol consumption.
• Say a big no to smoking.
• Do drink 6 to 8 glasses of water per day.

For more information see: How can you tell you are dehydrated?

• Reduce the intake of trans-fats found in cookies, cakes, fries, etc.

Complications of Hirsutism

Hirsutism can cause emotional depression and make you feel self-conscious. It is not known to cause any physical complications. However, hormonal imbalance can lead to hormone-related disorders.

Your doctor is likely to diagnose PCOS if you are suffering from irregular periods along with Hirsutism. Some medications used to treat Hirsutism increases the risk of birth defects. The doctor will advise you to avoid pregnancy during the treatment process.

Differential Diagnosis

Hypertrichosis is a diffuse increase of hair forming down in areas not dependent on androgens (often the cheeks and arms). It may be the consequence of an excess of glucocorticoids, the taking of certain drugs (phenytoin, penicillamine, ciclosporin, minoxidil, diazoxide), and systemic disorders (anorexia nervosa, hypothyroidism, porphyria, dermatomyositis). Hypertrichosis is often due to a familial or ethnic character and has a prepubertal onset.

Lanugo is a very thin, villous, and non-pigmented hair located anywhere on the body. Hypertrichosis is characterized by an excessive growth of hair affecting normally hairy areas in women.

Frequently Asked Questions (FAQs)

1. Can Hirsutism be cured permanently?

Yes, Hirsutism can be treated successfully by following the treatment plan provided by your doctor. Oral medications combined with topical treatment and laser or electrolytic procedures are used to permanently reduce or remove the unwanted hair on the body of a woman.

2. Does Hirsutism get worse with age?

Sex hormones like estrogen and progesterone eventually get better as a woman ages, which eases her PCOS. However, increased androgen levels in the body of a woman persist, and Hirsutism continues even after menopause. Symptoms like unwanted facial hair, body hair, and balding worsen with age.

3. What is the best treatment for Hirsutism?

The best treatment for Hirsutism is to combine medical procedures like laser or electrolysis with oral medications.

4. Can PCOS change your facial features?

The polycystic ovarian syndrome can very well change the facial features by causing increased growth of unwanted facial hair and acne. This is due to an imbalance in the sex hormones.

Conclusion 

Hirsutism is a prevalent medical disorder that affects women of all ages. It affects around 5-10% of women and is a prevalent cosmetic concern in dermatological outpatient departments. Hyperandrogenism, which can be ovarian or adrenal, is the major reason. It might be caused by a rare metabolic condition, a medicine, or just be idiopathic. Hirsutism has a significant mental impact, particularly in young women.

Treatment for hirsutism necessitates a thorough clinical examination and study. The majority of women are advised to use oral contraceptives as a kind of pharmaceutical treatment. If the reaction isn't satisfactory after six months, an antiandrogen may be required. Monotherapy with antiandrogens is not advised unless sufficient contraception is used. Photoeplilation using lasers is the primary method for ladies seeking hair removal treatment.