Hirsutism resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: S.Mojdeh Mirmomen, M.D.
Overview
Hirsutism is a common endocrinological and dermatological complaint that is defined as a condition that results in the presence of excessive amounts of dark coarse hair (terminal hair) in a male-like pattern distribution in females. It usually appears in chin, upper lip, chest, back and anterior thighs. Hirsutism presents in 5-10% of females in reproductive age [1]. Hirsutism is different from hypertrichosis that defined as excessive hair growth all over the body with no sexual distribution and it is not an androgen-dependent condition. Underlying androgen disorders are the most common causes of hirsutism and polycystic ovary syndrome (PCOS) accounts for nearly 70-80% of these conditions. Pharmacological therapy or direct hair removal methods is considered as initial therapy for women with mild hirsutism without underlying endocrine disorders. Lifestyle modifications are also recommended in obese patients with PCOS.
Causes
Common Causes
Hyperandrogenic hirsutism
- Polycystic ovary syndrome
- Idiopathic hyperandrogenemia
- Non-classical Congenital Adrenal Hyperplasia
- Androgen-secreting tumors
Non-hyperandrogenic hirsutism
Diagnosis
Shown below is an algorithm summarizing the diagnosis of hirsutism according the Endocrine Society Clinical Practice guideline [2][3].
| Initial evaluation & diagnosis of hirsutism | |||||||||||||||||||||||||||||||||||||||||||||||||
| History & physical examination including pelvic examination | |||||||||||||||||||||||||||||||||||||||||||||||||
| Medication use? Ask for anabolic or androgenic steroids (in athletes, patients who are using dietary supplements, patients with sexual dysfunction, or in patients with a partner who uses testosterone gel) and valproic acid (in patient with neurologic disorders) | Discontinue medication | ||||||||||||||||||||||||||||||||||||||||||||||||
| Isolated local hair growth | Direct hair removal methods | Improvement or stable | Normal variant | ||||||||||||||||||||||||||||||||||||||||||||||
| Abnormal hirsutism score or local hair growth with symptoms* suggesting hyperandrogenic endocrine disorder? *Symptoms include menstrual irregularity, infertility, galactorrhea, signs or symptoms of hypothyroidism, Cushing syndrome, acromegaly, central obesity, acanthosis nigricans, clitoromegaly, or sudden-onset or rapid-progression hirsutism | |||||||||||||||||||||||||||||||||||||||||||||||||
| Early morning total testosterone blood level | Progression or unstable | ||||||||||||||||||||||||||||||||||||||||||||||||
| Normal | Elevated | ||||||||||||||||||||||||||||||||||||||||||||||||
| Mild isolated hirsutism | Moderate to severe hirsutism or presence of hyperandrogenic endocrine disorder | ||||||||||||||||||||||||||||||||||||||||||||||||
| Direct hair removal methods or oral contraceptive | |||||||||||||||||||||||||||||||||||||||||||||||||
| Improvement or stable | Progression or unstable | Free testosterone blood level | |||||||||||||||||||||||||||||||||||||||||||||||
| Normal | Elevated | Hyperandrogenemia | Full hormonal workup | ||||||||||||||||||||||||||||||||||||||||||||||
| Idiopathic hirsutism | Reevaluate if hirsutism progresses | ||||||||||||||||||||||||||||||||||||||||||||||||
- Ferriman–Gallwey hirsutism scoring system.
- Each of the nine sensitive to androgen body parts (upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, arm and thigh) is assigned a score from 0-4 for absent to severe hirsutism.
- The total hirsutism score is calculated by adding separate scores from each body part. In the US, generalized hirsutism that defined as a score equal or greater than 8, is abnormal, but regionally excessive hair growth with score less than 8 considered as a common normal variant [4]. The normal score is lower and higher in Asian and Mediterranean populations, respectively.
Treatment
The below algorithm summarizes the treatment of hirsutism according the Endocrine Society Clinical Practice guideline [2].
| Initial therapy for patient with hirsutism | |||||||||||||||||||||||||||||||||||||||
| Mild hirsutism and no evidence of an endocrine disorder | Moderate or patient-important hirsutism | Severe hirsutism | |||||||||||||||||||||||||||||||||||||
| Direct hair removal methods | Pharmacological therapy | Pharmacological therapy (add direct hair removal if needed) | Combined pharmacological therapy | ||||||||||||||||||||||||||||||||||||
| • Photoepilation for women with auburn, brown, or black unwanted hair • Electrolysis for women with white or blonde hair | • Start oral contraceptives in women who are not seeking fertility ** Use oral contraceptives containing the lowest effective dose of ethinyl estradiol and a low-risk progestin for women at higher risk for venous thromboembolism (e.g., obese or >39 years old) • Start either oral contraceptives or anti-androgens in women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception | Oral contraceptives and antiandrogens | |||||||||||||||||||||||||||||||||||||
| Add an antiandrogen if hirsutism remains despite 6 months of monotherapy with an oral contraceptive | |||||||||||||||||||||||||||||||||||||||
Do's
- A trial of at least 6 months is required before making any changes in dose or type of the drug [2].
Don'ts
- Combination therapy of an oral contraceptive and antiandrogen is not recommended as an initial therapy unless the patient is suffering from severe hirsutism.
- Among the antiandrogen medications, flutamide is not recommended due to drug-induced hepatotoxicity.
References
- ↑ Barrionuevo P, Nabhan M, Altayar O, Wang Z, Erwin PJ, Asi N; et al. (2018). "Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis". J Clin Endocrinol Metab. 103 (4): 1258–1264. doi:10.1210/jc.2017-02052. PMID Review 29522176 Review Check
|pmid=value (help). - ↑ 2.0 2.1 2.2 Martin KA, Anderson RR, Chang RJ, Ehrmann DA, Lobo RA, Murad MH; et al. (2018). "Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 103 (4): 1233–1257. doi:10.1210/jc.2018-00241. PMID 29522147.
- ↑ Bode D, Seehusen DA, Baird D (2012). "Hirsutism in women". Am Fam Physician. 85 (4): 373–80. PMID 22335316.
- ↑ Mihailidis J, Dermesropian R, Taxel P, Luthra P, Grant-Kels JM (2017). "Endocrine evaluation of hirsutism". Int J Womens Dermatol. 3 (1 Suppl): S6–S10. doi:10.1016/j.ijwd.2017.02.007. PMC 5419053. PMID 28492032.