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The Obstetrician & Gynaecologist 10.1576/toag. 2009;11:101–107 Review

Review Hirsutism in young

Authors Rebecca Swingler / Alero Awala / Uma Gordon

Key content:
• Hirsutism is a distressing condition affecting 5–15% of women.
• It is usually associated with an underlying endocrine disorder: in 70–80%
of women with hirsutism this is polycystic ovary syndrome.
• Management depends upon the cause but combines lifestyle changes and
cosmetic, physical and medical treatments.
• It takes 9–12 months for hormonal treatments to take their maximum effect.

Learning objectives:
• To learn how to assess women with hirsutism.
• To understand common and less common aetiologies.
• To be able to take a sensitive and sensible approach to management.

Ethical issues:
• To what extent should drugs not yet approved for use in women with hirsutism
be used as a treatment for this condition?
• What is the role of the gynaecologist in ensuring women on drugs such as
finasteride are using effective contraception?
Keywords endocrine disorders / hyperandrogenism / polycystic ovary syndrome /
Please cite this article as: Swingler R, Awala A, Gordon U. Hirsutism in young women. The Obstetrician & Gynaecologist 2009;11:101–107.

Author details
Rebecca Swingler MRCOG Alero Awala MRCOG Uma Gordon MD FRCOG
Specialist Registrar in Obstetrics Consultant Consultant
and Gynaecology Department of Obstetrics and Gynaecology, Bristol Centre for Reproductive Medicine,
Department of Obstetrics and Gynaecology, Watford General Hospital, Vicarage Road, Southmead Hospital, Westbury-on-Trym,
St Michael's Hospital, Southwell Street, Watford WD18 0HB, UK Bristol BS10 5NB, UK
Bristol BS2 8EG, UK
(corresponding author)

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Introduction The sensitivity of hair follicles to androgens varies

Hirsutism is the presence of terminal (coarse) hairs over the body. Hair growth in the eyelashes,
in females in a male-like pattern, affecting 5–15% eyebrows and the occipital and lateral aspects of
of women surveyed.1 It is extremely distressing, the scalp, for example, is mostly independent of
especially in young women undergoing the androgenic effects. Areas such as the pubic region
upheaval, both psychosocial and emotional, of and the axillae are sensitive to low levels of androgens,
adulthood. Hirsutism is usually associated with, or while others, like the chest, lower abdomen, face,
a sign of, an underlying endocrine disorder. It can upper thighs and lower back, need high levels of
also be an isolated condition, referred to as androgens to increase hair growth. When hairs are
idiopathic hirsutism. found in these areas, they are described as ‘male
pattern’ and in women are considered pathological.

Normal hair growth

Of the 50 million hair follicles present on the Aetiology
human body, 100 000–150 000 are found on the The causes of hirsutism can be divided broadly
scalp.2 The only parts of the body lacking hair into androgen excess, nonandrogen factors and
follicles are the palms of the hands, the soles of the idiopathic causes.
feet and the lips. Few hair follicles form after birth
and after the age of 40 years hair follicles decrease in Androgen excess
number. There are three types of hair: Polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is the most
common cause, accounting for 70–80% of women
• lanugo, a soft hair densely covering the fetus, with hirsutism.1 No single biochemical marker or
which is shed in the first 4 months postpartum
characteristic is definitive and, as such, the diagnosis
• vellus hair, which is soft, longer than lanugo hair should be based upon the revised criteria adopted
(2 cm), nonpigmented and which covers the
body by the ESHRE/ASRM-sponsored PCOS Consensus
Workshop (Rotterdam, 2004).3 Thus, the presence
• terminal hair, which is longer still, pigmented
of two out of three of the following criteria is said to
and which makes up the hair of the eyebrows,
scalp and axillary and pubic areas. be diagnostic after the exclusion of other causes:

The three phases of hair growth consist of • oligo- or anovulation

anagen, the active growing phase; catagen, the • clinical or biochemical hyperandrogenism
involuting phase, when the hair stops growing; • morphological features of polycystic ovaries on
and telogen, the resting phase, when the hair is ultrasound scans.
Insulin resistance is acknowledged as one of the
In humans, the reason why hair appears to grow possible aetiological factors.4 Insulin increases
continuously is because of disharmony in the androgen levels directly by increasing androgen
phases of hair growth; thus while some hairs are in production by the ovarian theca cells and indirectly
anagen, others are resting (telogen).2 The overall by reducing hepatic synthesis of sex hormone-
length of the hair is determined by the duration of binding globulin. Between 30–75% of women with
the anagen phase. PCOS are overweight,4 which increases their insulin
resistance and exacerbates hyperandrogenaemia.

Regulation of hair growth It is now recognised that young girls who present
The regulation of hair growth is multifactorial. A with premature growth of pubic hair, elevated
number of local and systemic factors act on the hair dehydroepiandrosterone and hyperinsulinaemia
directly and indirectly in combination with sex are at high risk of developing PCOS in the future.5
hormones, generating dermal papillae to promote
hair growth. Deficiencies in thyroid hormones and Androgen-secreting tumours
growth hormone can result in an alteration of the These can be tumours of the ovary or the adrenal
anagen:telogen ratio in scalp and body hair. glands. They are rare, accounting for between 1 in
Androgens are the most important hormones 300 and 1 in 1000 hirsute women,6 and are
regulating hair type, growth and distribution. suspected if the onset of symptoms is rapid, or if
they lead to virilisation or they are associated with
The main circulating androgen, testosterone, is cushingoid features. The best way to diagnose an
converted in the hair follicle by the enzyme androgen-secreting tumour is by clinical
5-reductase to its more potent form, presentation rather than through analysis of
dihydrotestosterone. Other, weaker androgens, such biochemical markers, as suppression and
as androstenedione and dehydroepiandrosterone, stimulation tests can be misleading.1 Examples of
are metabolised in the skin to testosterone and ovarian tumours associated with androgen excess
dihydrotestosterone, stimulating hair growth. are: arrhenoblastomas; Leydig, hilar and thecal cell

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tumours; and luteomas of pregnancy. More than presence of abnormalities, such as signs of
half of adrenal tumours associated with virilisation, thyroid enlargement, galactorrhoea,
hyperandrogenism are malignant.7 pelvic/abdominal masses, cushingoid features,
obesity and signs of systemic illness should also be
Nonclassic congenital adrenal hyperplasia established. This will help in determining the
This autosomal recessive condition is found in presence and extent of hirsutism and whether or
1.5–2.5% of hyperandrogenic women. The not it is related to an underlying endocrine
underlying enzyme defect, 21-hydroxylase problem.
deficiency, results in elevated levels of
17-hydroxyprogesterone, which is androgenic. The clinical diagnosis of hirsutism tends to be
subjective and is based upon determining, by visual
Other causes assessment of the hair type and growth, whether the
Conditions such as thyroid dysfunction, acromegaly, hair is vellus (which may be due to familial/ethnic
Cushing syndrome and hyperprolactinaemia are origins) or terminal and whether or not it follows a
causes of androgen excess, although women with male-like pattern. In 1961, Ferriman and Gallwey10
these conditions tend to present with symptoms described a method for assessing the degree of
other than hirsutism. hirsutism (see Figure 1). Using a score of 0 in the
absence of terminal hair and 4 for extensive
Hyperandrogenic insulin-resistant acanthosis terminal hair growth, they scored the density of
nigricans syndrome is an inherited condition that hair at 11 different body sites. Scores of 6 were
occurs in around 3% of women with androgen deemed significant. A modified scheme was
excess.1 It is characterised by extremely high levels introduced by Hatch et al. in 1981,11 which uses only
of insulin, resulting from severe insulin resistance. nine areas (excluding lower legs and forearms, as
Women with this condition may be severely these are less sensitive to androgens). Although
hyperandrogenic, very difficult to treat and they these scoring systems are an attempt to provide an
can even present with signs of virilisation. objective assessment of hirsutism, the perception of
the extent of excess hair growth in two women with
Drugs such as testosterone, danazol and anabolic the same Ferriman–Gallwey score, and the impact
steroids all induce hirsutism via their inherent on their lives, may be very different. The scoring
androgenic properties. schemes are typically used for research rather than
in a clinical setting.
Nonandrogen factors
Factors with unknown mechanisms of action on Mild hirsutism (Ferriman–Gallwey score 8–15),
the hair follicle include drugs that can induce excess without any other features such as menstrual
hair growth independently of androgens, such as irregularity, can be treated cosmetically and
phenytoin, minoxidil, diazoxide, streptomycin, investigated further if treatment is not effective or
high-dose corticosteroids, psoralen and hirsutism worsens. When hirsutism is moderate–
penicillamine. severe (Ferriman–Gallwey score 15), it is likely
that androgen excess is present; the possible causes
Idiopathic causes should be investigated. History and examination
A small group of women have what is termed will determine which investigations are appropriate.
idiopathic hirsutism, where all other causes of Although free testosterone levels are the most
hirsutism have been ruled out.2 These women have sensitive measure of hyperandrogenism, there is no
no detectable hormonal abnormalities, normal uniform laboratory standard and assay-specific
menses, normal ovarian appearance and no results vary.12 If a reliable free testosterone level is
evidence of adrenal or ovarian tumours. Earlier not available, then it should be calculated from a
studies have reported prevalences of 50–55%;6,8 total testosterone and sex hormone-binding
however, as diagnostic techniques continue to globulin. A very high (1.5–2 ng/ml) testosterone
improve, this subgroup of women is shrinking and level increases the likelihood of an underlying
more recent studies quote a prevalence of 6–7%.9 neoplasm and an elevated dehydroepiandrosterone
sulphate level would indicate an adrenal source, as
Evaluation ovaries do not produce it. In nonclassic congenital
This must include an in-depth history, with care adrenal hyperplasia, testosterone levels are elevated,
taken to note any drugs used, changes in weight as is 17-hydroxyprogesterone, which should be
and facial contours, the presence of acne, hair measured as an early morning sample. In PCOS
loss/balding, menstrual and reproductive history 17-hydroxyprogesterone can be slightly elevated
and relevant family history, such as premature male but levels 200 ng/dl are suggestive of nonclassic
balding and diabetes in the context of PCOS. congenital adrenal hyperplasia. Pelvic ultrasound
can help in the diagnosis of PCOS or ovarian
The extent, type and pattern of the hair growth can tumours, although normal findings may be seen in
be established by physical examination. The both of these conditions.

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Figure 1
The Ferriman–Gallwey scoring
system for hirsutism (using 9 out
of the original 11 areas initially
described by Ferriman and
Gallwey in 1961).7 Copyright ©
2005 Massachusetts Medical
Society. All rights reserved.

Management stubble—although it does not lead to an increase in

Figure 2 illustrates a pragmatic approach to the
hair growth, which is a common misconception.
evaluation of hirsutism. Using depilatory creams and bleaching are useful
for minimising local hair growth but chronic use
In young women with mild hirsutism, a detailed can lead to skin irritation. Meanwhile, plucking
consultation, with reassurance that their and waxing in androgenised areas should be
appearance is not as bad as they perceive and an discouraged, as it can result in folliculitis and
explanation of the possible causes, can be helpful ingrown hairs, which lead to skin damage.
and all that is needed. Local PCOS groups can
also be a valuable source of support. Further Physical methods
management options include lifestyle changes These can be used alone or in combination with
and cosmetic, physical and hormonal therapies. cosmetic measures.
Whilst cosmetic and hormonal therapies are
effective for as long as they are in place, more Electrolysis
permanent reductions can be achieved using This involves the destruction of individual hair
physical methods. follicles via an electrode. It needs to be
administered by an expert and it results in
permanent hair reduction. It is, however, expensive,
Weight loss and lifestyle changes time-consuming (taking from 18 months to 4 years,
Weight reduction has been shown to reduce depending on the extent of hirsutism), painful and
hyperandrogenism and insulin resistance, particularly really only practical for a limited area of affected
in overweight women with PCOS.13,14 Weight skin. It can also cause burns, depigmentation and
reduction of 5–10% can induce an improvement in scarring of skin, so it is not without adverse effects.
hirsutism by 40–55% within 6 months of weight
loss.15 In obese women with PCOS, weight loss Laser photothermolysis
programmes should be the first line of intervention, This type of laser is used to destroy hair follicles
to include a low calorie diet and an exercise without damaging nearby tissue. It is also known as
schedule over a period of at least 6 months.14,16 This ‘selective photothermolysis’ and it relies on the
requires a multidisciplinary team approach, which selective absorption of a radiation pulse by darker
may be difficult to put in place in an NHS setting coloured hairs and the penetration of the dermis. It
because of resource and financial constraints. appears that light-skinned women make the best
candidates, as they need lower radiation pulses
Cosmetic methods than darker-skinned women. Thus, to avoid skin
These include plucking, waxing, bleaching and the damage, women who are heavily tanned or
use of depilatory creams. Shaving should be naturally dark-skinned should be treated with
avoided as it leads to blunt hairs that may feel like lasers that have built-in cooling devices to offset the

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Figure 2
Algorithm for the management
of hirsutism

necessary increases in energy levels needed. An Drospirenone, the progestogen in the COCP
advantage over electrolysis is that laser treatment Yasmin® (Bayer Schering Pharma, Berks, UK) has
can cover a wider area; it is also less painful and has an antiandrogenic effect.
fewer dermatological adverse effects. It reduces
hair density permanently by 30% after three to The advantage of the COCP in women with
four sessions.7 A randomised controlled trial17 PCOS is that, not only does it reduce hirsutism,
comparing low-fluence (placebo) with high- but it also gives cycle control, acts as a
fluence laser treatment in women with PCOS contraceptive and reduces the risk of endometrial
showed that it significantly reduced the severity hyperplasia. Theoretically, however, the effects
of hirsutism. of the COCP on carbohydrate and lipid
metabolism could exacerbate the long-term
Hormonal therapy metabolic outcomes of PCOS (type II diabetes
The basis of action of hormonal therapy is either and cardiovascular disease).18 The evidence for
suppression of androgen production or blocking this is limited and contradictory19 but it has
of the action of androgens on the skin. This results highlighted the potential of insulin-sensitising
in the hairs reverting back to vellus-type hair. It agents as a safer alternative.
takes 9–12 months for the maximum effects to be
noticed because of the cyclical nature of hair Cyproterone acetate
growth. It requires patience, therefore, on the part Cyproterone acetate is a strong progestogen which,
of both women and doctors, but it can be by decreasing plasma levels of luteinising hormone,
combined with cosmetic measures. results in a lowering of testosterone and
androstenedione levels. It also acts peripherally as
The combined oral contraceptive pill an androgen antagonist and is, therefore, a
The combined oral contraceptive pill (COCP) progestational antiandrogen. Although there is a
reduces free plasma testosterone levels: the wide variation in response between women,
progestogen component suppresses luteinising cyproterone acetate can be expected to lower the
hormone and, thus, androgen production by the Ferriman–Gallwey score by 15–40% within
ovaries. The estrogen component also increases 6 months; again, maximum effects occur between
sex hormone-binding globulin production by the 6–12 months.1,7 The COCP Dianette® (Bayer
liver. Although the COCP will not reverse Schering Pharma, Berks, UK) contains 35 g of
hirsutism, it can reduce the need for shaving by ethinylestradiol and 2 mg of cyproterone acetate. A
50% and it may halt the progression of the systematic review20 found cyproterone acetate to be
condition.7 The progestogen component in COCPs as effective as other antiandrogens at treating
is of variable androgenicity and newer pills hirsutism; however, it concluded that larger, more
containing less androgenic progestogens, such as carefully designed studies are needed to compare
norgestimate and desogestrel, are available. the efficacy and safety profiles between drug

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therapies for hirsutism. Reported adverse effects Insulin sensitisers

of cyproterone acetate are weight gain, depression, Metformin hydrochloride is an oral biguanide,
fatigue and sexual dysfunction. It can also, rarely, which reduces insulin levels by inhibiting hepatic
alter liver function; liver function tests should be production of glucose and increasing the number
performed prior to commencing treatment of insulin receptors. High insulin levels in women
and after 6 months. It is thought to have a with PCOS stimulate androgen secretion by the
thromboembolic risk similar or greater than second ovaries and adrenal glands and reduce sex
generation COCPs. Although a contraceptive, hormone-binding globulin production by the liver.
Dianette is not licensed for contraceptive purposes By lowering insulin levels, metformin reduces
but only for use in the treatment of acne and androgen levels by around 20% in women with
hirsutism. For women who are resistant to long- PCOS.7 The theoretical advantages of metformin
term treatment with Dianette, a higher dose of over the COCP for treatment of hirsutism in women
cyproterone acetate (50 mg/day) combined with with PCOS are that, as well as improving hirsutism
ethinylestradiol can be effective in the short-term and acne via a reduction in hyperandrogenism, it
management of hirsutism.21 may also have long-term benefits for the prevention
of type II diabetes and cardiovascular disease. A
Spironolactone recent Cochrane review23 comparing metformin
Commonly used in the USA, spironolactone is an with the COCP found no difference in their effects
aldosterone antagonist and a mild diuretic; it is also on hirsutism and acne but there was either
an androgen inhibitor and it is structurally similar to insufficient or no data on their relative efficacy at
progesterone. It competes with dihydrotestosterone preventing type II diabetes and cardiovascular
for sites on androgen receptors. It only has disease. The results of three studies on the effect of
one-twentieth of the binding potential of metformin on hirsutism used in the meta-analysis
dihydrotestosterone, therefore, high doses of this were contradictory, although this may be due to
drug are needed to suppress hair growth.1 When differences in selection criteria. There are several
used in conjunction with the combined oral studies,24 however, that have shown improvements
contraceptive pill, however, its overall effectiveness in hirsutism in young adults and teenagers using
can be improved and effects such as dysfunctional metformin. It may be useful not only in obese
bleeding or worsening oligomenorrhoea can be women with PCOS but also in women of normal
minimised. Indeed, a Cochrane review22 found that weight,25 as it is possible that all women with PCOS,
100 mg/day of spironolactone is superior to both whether lean or obese, have reduced insulin
finasteride 5 mg/day and low-dose cyproterone sensitivity.26 Theoretically, metformin appears to be
acetate 12.5 mg/day for up to 12 months after the a treatment for hirsutism that also provides long-
end of treatment. term benefits for all women with PCOS; however,
further studies are needed to confirm this.
Finasteride is an inhibitor of the enzyme Cell cycle inhibitors
5-reductase and it is also used for the treatment Eflornithine acts to inhibit irreversibly the enzyme
of benign prostatic hyperplasia. It was thought to ornithine decarboxylase in the skin, thereby
be less effective in treating hirsutism than decreasing and/or arresting hair growth for as long
antiandrogens,7 although a recent Cochrane as it is used. It is licensed for use on the face and is
review20 suggests that it has similar effectiveness to thought to act on the hair follicle to reduce the rate
cyproterone acetate. It has very few adverse effects of growth by inhibiting keratin protein synthesis. It
or drug interactions, although feminisation of a is recommended for topical use twice a day and
male fetus is a particular concern. Women taking women can apply moisturisers or cosmetics on top
this drug should be advised of this and offered of the cream, which is rapidly absorbed by the skin,
effective contraception as well. after 5 minutes. It can also be used in combination
with laser treatment.27 The main adverse effect is a
Flutamide rash, although there is a potential for systemic
Flutamide is a nonsteroidal antiandrogen. It blocks toxicity if applied over a wide area.1,7 Acne is
androgen receptors and at high doses may decrease another common adverse effect, which can be a
the production of androgens. It is also used in the particular problem in some women. In one study1
treatment of prostate cancer. It has been found to be eflornithine was found to reduce hair growth
just as effective, if not more so, than spironolactone20 significantly in around 60% of women with facial
but adverse effects include a greenish tinge to the hirsutism. The authors wished to note that if no
urine; dry scalp and skin; and liver enzyme benefit is seen after 4 months of treatment, it
abnormalities. It is advisable to check liver function should be stopped.
whilst on this medication as, rarely, fatal hepatic
toxicity has been reported. Doses range from Gonadotrophin-releasing hormone agonists
250–500 mg/day, usually as a single dose. Concerns Studies28 have shown the use of gonadotrophin-
about the effects on the liver have limited its use. releasing hormone agonists to be an effective way of

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treating hirsutism in hyperandrogenic women, 9 Carmina E, Rosato F, Jannì A, Rizzo M, Longo RA. Extensive clinical
experience: relative prevalence of different androgen excess disorders
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They act by suppressing testosterone levels, Endocrinol Metab 2006;91:2–6. doi:10.1210/jc.2005-1457
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