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Kathryn A. Martin
The Endocrine Society recently updated its clinical practice guideline on hirsutism, the growth of hair in women in areas of the body typically known for male-pattern hair growth. The guideline states that apart from causing potential embarrassment and distress to women affected by the condition, hirsutism also is a strong indicator of underlying disease, and it now recommends that all premenopausal women with hirsutism undergo blood testing for polycystic ovary syndrome.
Hirsutism is typically quantified by the Ferriman-Gallwey score, which rates extent of hair growth on each of nine areas of the body on a scale of 1 to 4, with a total score of 8 or lower considered normal, 8 to 15 considered mild hirsutism and greater than 15 considered moderate or severe. The 2008 guideline recommended PCOS testing for only moderate to severe hirsutism, but the updated recommendations advise investigating any degree of abnormal hair growth.
The scoring system is useful, but it is not necessarily the only indicator clinicians should consider. According to Kathryn A. Martin, MD, faculty member in the reproductive endocrine unit and assistant professor of medicine at Harvard Medical School, health care providers should also consider the patient’s level of concern and distress over the unwanted hair.
“Among women with a score above 3, the majority consider themselves to have hirsutism because it bothers them,” she said. “In addition, some studies have shown that many women with scores in the ‘normal’ range have an underlying endocrine problem.”
Martin spoke with Endocrine Today about the guideline update, how hirsutism is treated, and the ethnic differences that may affect hair growth.
What constitutes hirsutism?
Martin: Hirsutism refers to terminal hair, which is the dark, coarse hair in androgen-dependent areas of the body. This means the chin, the upper lip, between the breasts. There might be hair above the belly button, or the upper or lower back, which are not normal places for women to grow hair. Hair in these areas means either the woman has a high testosterone level, or the hair follicles are sensitive to testosterone. We count up the score on the chin, the lip, the back, the stomach and several other areas and then come up with the hirsutism score. It’s hard to score because by the time women actually come to the doctor, they’re already shaved, plucked or waxed.
When we’re thinking about treating, we go by what the woman tells us about how much it bothers her. The other variable is ethnicity. For example, you and I could have the same testosterone level, and if I’m Native American and you’re Mediterranean, I will probably have one hair on my chin, and you could have hair all over your chin. The important thing physicians need to know is that if a woman comes in and says, “I have new hair growth on my chin,” and he or she sees two hairs on a Native American or East Asian woman, and that could be a big deal. The scoring system is from the 1960s, and it’s based on white women. What counts as an abnormal score is the same for white and black women — anything greater than 8. If you’re East Asian or Native American, an abnormal score is greater than 2.
The recent update to the guideline advises that all women with hirsutism get tested for PCOS. Why is that?
Martin: We recommend getting at least an initial androgen blood test because 80% of women who have hirsutism will have PCOS. It’s by far the most common cause. Good assays are more readily available now than when we published the original guideline.
You could argue that the test isn’t even needed because we know the patient has PCOS, but there are more serious conditions that can cause hirsutism. Some women will have nonclassic congenital adrenal hyperplasia, which looks like PCOS and is treated the same way until the woman wants to get pregnant. There are some high-risk groups based on ethnicity: Ashkenazi Jewish women, Hispanic women and southern Italian women all have high rates. The reason to make the diagnosis is that if the person’s partner has similar ethnicity and they both have the same mutation, their offspring could have severe disease. The “non-classic” women we see have a very mild form of congenital adrenal hyperplasia due to 21-hydroxylase deficiency, but for a baby born with the full-blown classic disease, it’s life-threatening.
How is hirsutism treated?
Martin: For women with PCOS, we do not recommend electrolysis or laser treatments alone. They need to also address the underlying hormonal problem to get a good cosmetic result. The hair will continue to grow back, and they will get frustrated. These patients usually need some sort of hormonal suppression. We always start with a birth control pill unless the patient can’t take one.
There are a lot of different reasons that hormonal contraception helps hirsutism. It lowers the testosterone level, which affects the hair follicles. We continue the pill for 6 months, and then if needed, we add spironolactone, an antiandrogen, which blocks androgen right at the level of the hair follicle. With these two medications, we get a pretty good cosmetic response. If the patient is still unsatisfied and the hair is in a small isolated area, that’s the time to add electrolysis. Laser hair removal is preferred when the hair is more diffuse and in more areas. Laser is expensive, but it is efficient, so after several treatments, patients are usually happy.
Laser can be helpful for a devastating diagnosis. The depression rates are incredibly high in these patients. They have low self-esteem. They have to worry about how they are going to shave or otherwise remove the hair because they have stubble every morning. After treatment, they feel they can go out in public, it’s just life-changing.
What are some other updates in the latest guideline?
Martin: We were a lot more liberal about recommending laser hair removal because there are a lot more data about it, and there are better and better lasers. There are still problems with laser for women with darker skin. The procedure still works best for women with light skin and dark hair, although lasers for women with darker complexions are being developed. The important piece of advice is that patients must go to a reputable place where the providers know what they’re doing. Laser still carries a potential risk in some patients for burns, scars and changes in pigmentation. Also, although it’s extremely rare, there is a serious complication seen in some Middle Eastern and Mediterranean women called paradoxical hypertrichosis. After undergoing laser treatments, these women can develop soft little hairs, like baby hair, over their entire face. It is unclear why this happens to some women, and it is difficult to treat. I would be wary about walking into a spa and having an esthetician perform laser hair removal because they may not know about this complication.
What else should physicians and patients know about hirsutism?
Martin: Patients should feel empowered to speak up. If they want treatment, they should be able to get it. If they want an evaluation, they should be able to be tested. That’s the most important message. For physicians, the message is that this is an important diagnosis. It’s common; 8% to 10% of women have hirsutism and most of them will have PCOS. Hirsutism causes such personal distress — physicians need to take it seriously, evaluate it and treat the patient until they’re satisfied. – by Jennifer Byrne
Reference:
Martin KA, et al. J Clin Endocrinol Metab. 2018;doi:10.1210/jc.2018-00241.
For more information:
Kathryn A. Martin, MD, can be reached at 55 Fruit St., Boston, MA 02114.
Disclosure: Martin reports no relevant financial disclosures.
