Hirsutism

"Hirsute" redirects here. For the botanical term, see Indumentum.

Hirsutism
A woman with hirsutism, as depicted in the Nuremberg Chronicle (1493)
Classification and external resources
Specialty	Dermatology, endocrinology
ICD-10	L68.0
ICD-9-CM	704.1
DiseasesDB	20309
MedlinePlus	003148
eMedicine	med/1017 derm/472
Patient UK	Hirsutism
MeSH	D006628

Hirsutism is the excessive hairiness on women in those parts of the body where terminal hair does not normally occur or is minimal — for example, a beard or chest hair. It refers to a male pattern of body hair (androgenic hair) and it is therefore primarily of cosmetic and psychological concern. Akin to the modern day hypertrichosis (werewolf syndrome) or the historical figure wild man. Hirsutism is a medical sign rather than a disease and may be a sign of a more serious medical condition, especially if it develops well after puberty. The amount and location of the hair is measured by a Ferriman-Gallwey score.

Signs and symptoms

Photo of Annie Jones, a bearded lady, taken by Charles Eisenmann around 1900. The cause of Jones' hypertrichosis is unknown.

Hirsutism affects members of any gender, since rising androgen levels can cause excessive body hair, particularly in locations where women normally do not develop terminal hair during puberty (chest, abdomen, back, and face). The medical term for excessive hair growth that affects any gender is hypertrichosis.

Causes

Hirsutism can be caused by either an increased level of androgens, the male hormones, or an oversensitivity of hair follicles to androgens. Male hormones such as testosterone stimulate hair growth, increase size and intensify the growth and pigmentation of hair. Other symptoms associated with a high level of male hormones include acne, deepening of the voice, and increased muscle mass.

Growing evidence implicates high circulating levels of insulin in women for the development of hirsutism. This theory is speculated to be consistent with the observation that obese (and thus presumably insulin resistant hyperinsulinemic) women are at high risk of becoming hirsute. Further, treatments that lower insulin levels will lead to a reduction in hirsutism.

It is speculated that insulin, at high enough concentration, stimulates the ovarian theca cells to produce androgens. There may also be an effect of high levels of insulin to activate insulin-like growth factor 1 (IGF-1) receptor in those same cells. Again, the result is increased androgen production.

Signs that are suggestive of an androgen-secreting tumor in a patient with hirsutism is rapid onset, virilization and palpable abdominal mass.

The following may be some of the conditions that may increase a woman's normally low level of male hormones:

• Polycystic ovary syndrome (PCOS), the most common cause
• Congenital adrenal hyperplasia, in turn mostly caused by 21-α hydroxylase deficiency
• Cushing's disease
• Growth hormone excess (acromegaly)
• Tumors in the ovaries
• adrenal gland cancer, Von Hippel–Lindau disease
• Insulin resistance
• Stromal hyperthecosis (SH) - in postmenopausal women
• Obesity: As there is peripheral conversion of androgens to estrogen in these patients, this is the same mechanism as polycystic ovary syndrome, PCOS.
• Use of certain medications such as tetrahydrogestrinone, phenytoin, minoxidil
• porphyria cutanea tarda

Diagnosis

One method of evaluating hirsutism is the Ferriman-Gallwey score which gives a score based on the amount and location of hair growth on a woman.

Diagnosis of patients with even mild hirsutism should include assessment of ovulation and ovarian ultrasound (because of the high prevalence of polycystic ovary syndrome), as well as 17-hydroxyprogesterone (because of the possibility of finding nonclassic 21-hydroxylase deficiency).

Other blood value that may be evaluated in the workup of hirsutism include:

• the androgens testosterone and dehydroepiandrosterone sulfate
• thyroid-stimulating hormone
• prolactin

If no underlying cause can be identified, the condition is considered idiopathic.

Treatment

Many women with unwanted hair seek methods of hair removal. However, the causes of the hair growth should be evaluated by a physician, who can conduct blood tests, pinpoint the specific origin of the abnormal hair growth, and advise on the treatment.

Medication

Medication include:

• Spironolactone: Antialdosterone antiandrogenic compound.
• Cyproterone acetate: A progestin that also has strong antiandrogenic action. In addition to single form, it is also available in some formulations of combined oral contraceptives.

• Metformin: Antihyperglycemic drug used for diabetes mellitus. However, it is also effective in treatment of hirsutism associated with insulin resistance (e.g. polycystic ovary syndrome)
• Eflornithine: Blocks putrescine that is necessary for the growth of hair follicles
• Flutamide: Androgen receptor antagonist. The most effective treatment that was tested is the oral flutamide for one year. Seventeen of eighteen women with hirsutism treated with combination therapy of flutamide 250 mg twice daily and an oral contraceptive pill had a rapid and marked reduction in their hirsutism score. Amongst these, one woman with pattern hair loss showed remarkable improvement.
• Combination oral contraceptives

Other methods

• Epilation
• Waxing
• Shaving
• Laser hair removal
• Electrolysis

• Lifestyle change, including reducing excessive weight and addressing insulin resistance, may be beneficial. Insulin resistance can cause excessive testosterone levels in women, resulting in hirsutism. One study reported that women who stayed on a low calorie diet for at least six months lost weight and reduced insulin resistance. Their levels of Sex hormone-binding globulin (SHBG) increased, which reduced the amount of free testosterone in their blood. As expected, the women reported a reduction in the severity of their hirsutism and acne symptoms.

See also

• Ferriman-Gallwey score
• Petrus Gonsalvus
• Androgenic hair
• Pubic hair
• Hypertrichosis
• Hair removal
• Laser hair removal
• Bearded lady
• Trichophilia
• Polycystic ovary syndrome (PCOS)

External links

• Why the Bearded Lady Was Never a Laughing Matter: Hirsutism
• The Bearded Lady