Hirsutism in women

Hirsutism in women is the problem of having too much hair on the face or body. In women with hirsutism, the hair is coarse and pigmented, and grows in areas where men tend to grow hair (lower face, chest, back and abdomen).

For each woman, it is a matter of personal preference how much hair she considers to be too much, and this tends to be influenced by her culture and ethnicity.

Treatments for hirsutism are available, including hair removal methods, medicines to reduce hair growth and treatments for any underlying causes.

Symptoms

Hirsutism can affect just one area, or several areas. Affected areas may include the:

• lower face (top lip and chin);
• eyebrows;
• nipples and chest;
• abdomen;
• back; and
• inner thighs.

Women with hirsutism may also have thicker, longer or darker hair on the arms and legs.

Excess hair growth is often first noticed in the teenage years. It usually becomes more noticeable with age, especially following menopause.

What causes hirsutism?

Hair grows from tiny hair follicles. Men and women have the same number and distribution of follicles. The hair on most parts of women’s bodies is very thin, pale and almost invisible (this type of hair is called vellus hair). But under the stimulus of male hormones (known as androgens) the vellus hair can become coarser and darker, making it more obvious. This type of course, dark hair is known as terminal hair.

All women have small amounts of androgens (male hormones) in their circulation, made primarily in the ovaries and adrenal glands. When androgens are produced in excess, or there is an unusual sensitivity to normal levels, hirsutism is likely to occur.

Causes of excess androgen production can include:

• a condition called polycystic ovary syndrome (PCOS).

Rarer causes include:

• tumours of the ovary or adrenal gland;
• Cushing’s syndrome (where there is an excess of the hormone cortisol in the body);
• congenital adrenal hyperplasia (a genetic condition affecting the adrenal glands); and
• certain medicines.

In many cases of hirsutism, no abnormality of the hormones is found and it may be that in those women the hair follicles are more sensitive to normal amounts of androgen.

Risk factors

Your risk of hirsutism may be increased if you have other family members who are also affected.

Being overweight may make your hirsutism worse because it may increase the amount of androgens your body makes.

Tests and diagnosis

Your doctor will ask about your symptoms and any medicines you are taking that may be causing or contributing to your hirsutism. They will perform a physical examination looking for excessive hair growth and any underlying causes of hirsutism.

In many cases, the diagnosis of hirsutism can be made on the basis of the appearance of hirsutism. There is a visual scale, called the Ferriman-Gallwey scale, which can be used to determine the severity of hirsutism in women.

In women with additional symptoms (including irregular periods) or in those with severe or recent onset of hirsutism, blood tests may be recommended.

Blood tests to measure the levels of male hormones (androgens) such as testosterone may be recommended. Depending on the results of initial blood tests, further blood tests measuring the levels of different hormones may be recommended to work out if there is an underlying cause for your hirsutism.

An ultrasound scan of the ovaries may be recommended if your doctor suspects you may have polycystic ovary syndrome (PCOS). A CT scan to check your adrenal glands may also be recommended.

Treatment for hirsutism

Treatmentcosmetic hair removal measures

Hair removal

Once hair has developed into terminal hair it cannot change back. Cosmetic methods may be used to remove the excess visible hair. Cosmetic hair removal can be used on its own, or in combination with medicines that are used to reduce terminal hair regrowth in affected areas.

There is a range of different hair removal methods, some of which have longer-lasting results than others. Cost, effectiveness, convenience and side effects should be taken into account when choosing the hair removal method that’s best for you. Your doctor or pharmacist can advise you.

Hair removal methods (including self-care methods) include:

• electrolysis;
• laser hair removal;
• waxing;
• plucking;
• shaving; and
• depilatory creams.

Laser hair removal has long-lasting effects, but it can be expensive and multiple treatments are needed. Laser hair removal works best when removing dark hair from pale skin.

Many people believe that shaving results in faster, thicker hair regrowth but this, in fact, is not the case.

Some hair removal methods, such as waxing, plucking or shaving, can result in inflamed hair follicles (folliculitis), and painful pustules may develop.

Some women may choose to bleach, rather than remove, excess hair. Bleaching tends to have better cosmetic results in women with fair skin.

Creams

Eflornithine is a cream that can be used together with cosmetic hair removal to treat hirsutism of the face and the area under the chin. It is available on prescription in Australia. Applying cream to the affected area can help slow regrowth of unwanted thick, dark hair. It can take about 6 weeks for the desired effect to be noticeable.

Eflornithine (brand name Vaniqa) works by inhibiting an enzyme that is needed for hair to grow. You need to keep using eflornithine to achieve ongoing effects – hair growth will return several weeks after stopping treatment.

Side effects may include:

• stinging or burning if applied to broken skin;
• skin irritation and redness; and
• acne.

Oral medicines

Women with hirsutism found to have high levels of male hormones can be treated with oral medicines to prevent further unwanted hair appearing. Medicines may take about 6 months to reduce hirsutism by thinning the hair and slowing the growth of hair. These medicines often need to be continued for several years.

The medicine your doctor recommends will depend on:

• whether you are planning a pregnancy in the near future; and
• whether you have been through menopause.

Women who do not wish to become pregnant and have not been through menopause can be treated with the oral contraceptive pill (OCP). The combined oral contraceptive pill contains the female hormones oestrogen and progestin (a synthetic form of progesterone), and can help treat hirsutism by reducing the amount of androgens (male hormones) produced by the ovaries.

The pill can also help regulate menstrual periods in women with an irregular cycle.

Some formulations of the pill contain a progestin that has specific anti-androgenic properties (cyproterone or drospirenone). These formulations are helpful in the treatment of hirsutism. Brands of OCP that contain cyproterone include Brenda-35 ED, Diane-35 and Juliet-35 ED.

Cyproterone can also be given on its own (brand names Androcur, Cyprone, Cyprostat). Spironolactone (brand names include Aldactone, Spiractin) is another antiandrogen medicine that can be used alone or in combination with the oral contraceptive pill to treat hirsutism.

Antiandrogen medicines should not be used in women who are pregnant or planning a pregnancy.

Women who have been through menopause may be treated with combined hormone replacement therapy (HRT). Your doctor will be able to discuss the risks and benefits of HRT with you.