Patient information: Hirsutism (excess hair growth)

HIRSUTISM OVERVIEW

Hirsutism refers to the growth of coarse, dark hair in areas where women typically grow fine hair or no hair at all - above the lip and on the chin, chest, abdomen, and back. This excess hair growth is caused by an increased level of male hormones (androgens). Although all women produce androgens, increased levels of androgens can lead to hirsutism.

Women with excess hair growth need to be evaluated by a healthcare provider, especially if the hair develops or worsens rapidly in a woman who is 20 years of older, or if her relatives have comparatively less hair growth. In the vast majority of cases, hirsutism is not caused by a serious medical condition; however, the cause of hirsutism should be determined and underlying conditions may need to be treated.

HIRSUTISM CAUSES

Hirsutism is caused by an excess production or action of hormones called androgens, usually within the ovaries or adrenal glands. Several different conditions can lead to hirsutism. The two most common causes of hirsutism are polycystic ovary syndrome (PCOS) and idiopathic hirsutism. Both are diagnosed by physical examination, medical and family history, and, sometimes, blood tests.

Polycystic ovary syndrome (PCOS) — Women with PCOS often have hirsutism in combination with acne, balding near the front of their head, and menstrual irregularities. PCOS is a chronic condition, but several treatments can reduce hair growth.

PCOS is also associated with other medical problems, such as infertility due to irregular menstrual cycles, obesity, diabetes mellitus, high cholesterol levels, and possibly heart disease. Effective treatments for PCOS are available. (See "Patient information: Polycystic ovary syndrome (PCOS)".)

Idiopathic hirsutism — Idiopathic hirsutism refers to hirsutism that has no identifiable cause. It is usually chronic and may be a mild variation of PCOS. A gradual, increased growth of coarse body hair is typically the only symptom in women with this condition. Menstrual cycles are normal in women with idiopathic hirsutism.

HIRSUTISM TREATMENT

The decision to treat hirsutism is sometimes a matter of personal choice. There is a wide range of "normal" amounts of body hair among women. Race and ethnicity play a major role in the growth of body hair. As an example, Asian and Native American women tend to have little body hair, whereas Middle Eastern and Mediterranean women tend to have moderate to large amounts of body hair.

Our culture also determines how much hair is cosmetically acceptable and how important it is to remove "excessive" hair. The psychological impact of hirsutism can range from annoying to severely disabling. Any woman who is troubled by hirsutism should not hesitate to ask her healthcare provider about treatment options.

Treatment expectations — The treatment of hirsutism requires patience because hair follicles have a life cycle of about six months. Most medications must be taken for three to six months before a noticeable improvement occurs. In the meantime, the existing hair can be mechanically removed or bleached, and some women continue to use these methods in combination with medication.

Your provider will monitor the progress of treatment and may repeat tests if he or she is concerned about an underlying condition. If a medication is ineffective initially, the dose or type of medication may be changed.

Duration of treatment — Hirsutism is usually treated indefinitely because, in most cases, the body continues to produce excess androgens. However, hirsutism treatments must be stopped before becoming pregnant.

Some women eventually decide that the results of treatment are not worth the time, effort, and cost, or they grow more comfortable with their body hair.

Treatment for hair growth related to PCOS — The hirsutism of PCOS and idiopathic hirsutism are treated in similar ways. The treatment of PCOS may also involve treatment of infertility, diabetes, and risk factors for cardiovascular disease. (See "Patient information: Polycystic ovary syndrome (PCOS)".)

Hair removal and lightening — Several methods can be used to physically remove or lighten excess hair so that it less noticeable. These methods can be used in conjunction with medication. However, women with hirsutism who are trying to become pregnant or are already pregnant cannot take medications for hirsutism. Pregnant women should ask their healthcare provider about the safety of the various mechanical and chemical treatment methods during pregnancy.

• Shaving — Shaving is a safe and effective method for hair removal, but may require daily sessions.
• Chemical hair removal, waxing, and bleaching — Hair removal agents and wax can be used to remove hair, and bleaches can be used to lighten hair. Depilatories and bleaches may cause skin sensitivity in some women, so be certain to follow the directions for patch testing.
• Electrolysis — Electrolysis damages individual hair follicles by inserting a very fine needle into the hair follicle and applying an electrical current; hair does not grow back after treatment. Electrolysis is best suited for treatment of small areas, although larger areas may be treated with multiple sessions over time. The treatment is safe and effective, but it can be painful and is often expensive. To find a qualified electrologist, inquire regarding the individual's training, experience, and licensing.
• Laser hair removal — Although expensive, laser hair removal is effective, faster, and less painful than electrolysis. It can often permanently reduce hair growth, particularly in those who are fair-skinned with dark hair. Most people require four to six treatments spaced approximately four to six weeks apart in order to achieve satisfactory hair removal, and maintenance treatments may be needed once every six to twelve months to remove the smaller fine hairs that grow back.
• Creams — Eflornithine hydrochloride (Vaniqua®) is a skin cream that can be used to slow the growth of unwanted facial hair in women. It does not remove hair permanently. Noticeable results take about six to eight weeks, and once the cream is discontinued, hair returns to pretreatment levels after about eight weeks.

Weight loss — Weight loss in overweight women can decrease levels of androgens and lessen hirsutism. Women with menstrual irregularities may also notice that their cycles become more regular after losing weight. (See "Patient information: Weight loss treatments".)

Medications — Several medications are available for the treatment of hirsutism. These medications can decrease the amount of body hair, stop the growth of new hair, and decrease the growth rate and coarseness of existing hair. Most of these medications must be taken for at least six months before improvement is detectable, and not all medications are equally effective in all women.

• Birth control pills — Birth control pills change the levels of several hormones, including androgens. They are usually the first choice for the treatment of hirsutism, and between 60 and 100 percent of women with hirsutism will notice improvement when taking these medications. Birth control pills can also help establish regular menstrual cycles in women who have irregular cycles or who do not menstruate at all. (See "Patient information: Hormonal methods of birth control".)

• Anti-androgens — Anti-androgens are medications that directly decrease androgen production or block the action of androgens on the hair follicle. Because these medications may cause birth defects, an effective form of birth control (eg, birth control pills) is required for sexually active premenopausal women who take antiandrogens.

• - The most commonly used anti-androgen is spironolactone. Spironolactone may be recommended, in addition to the birth control pill, if excess hair growth does not improve adequately after taking a birth control pill for 6 months. Between 60 and 70 percent of women with hirsutism will notice reduced hair growth when taking spironolactone. If the initial dose is not effective after several months of treatment, a higher dose may be recommended.
• - Finasteride (Propecia®; Proscar®) may be as effective as spironolactone in some women with hirsutism. It is not approved for use in women in the United States, but it is sometimes used "off label". However, many insurers will not cover the costs of finasteride for cosmetic reasons.
• - Cyproterone acetate reduces hirsutism in about 70 percent of women, but is currently unavailable in the United States. It is used commonly in Europe and Canada, where it is a component of a birth control pill (Diane®, Diane-35®, Dianette®).

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Polycystic ovary syndrome (PCOS)
Patient information: Weight loss treatments
Patient information: Hormonal methods of birth control

Professional Level Information:
Clinical features and diagnosis of polycystic ovary syndrome in adolescents
Clinical manifestations of polycystic ovary syndrome in adults
Definition, pathogenesis, and etiology of polycystic ovary syndrome in adolescents
Diagnosis of polycystic ovary syndrome in adults
Evaluation of women with hirsutism
Metformin for treatment of the polycystic ovary syndrome
Pathogenesis and causes of hirsutism
Treatment of hirsutism
Treatment of polycystic ovary syndrome in adolescents
Use of combination estrogen-progestin contraceptives in the treatment of hyperandrogenism and hirsutism
Use of GnRH agonists in the treatment of hyperandrogenism and hirsutism

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/ency/article/003148.htm, available in Spanish)

• The Hormone Foundation

      (www.hormone.org/Resources/patientguides.cfm)

[1-4]