Hirsutism

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Hirsutism is excessive body hair on parts of the body where hair is normally absent or minimal. The word is from early 17th century: from Latin hirsutus meaning "hairy".^[2] It usually refers to a male pattern of hair growth in a female that may be a sign of a more serious medical condition,^[3] especially if it develops well after puberty.^[4] Cultural stigma against hirsutism can cause much psychological distress and social difficulty.^[5] Discrimination based on facial hirsutism often leads to the avoidance of social situations and to symptoms of anxiety and depression.^[6]

Hirsutism is usually the result of an underlying

Hirsutism affects between 5 and 15% of women across all ethnic backgrounds.[8] Depending on the definition and the underlying data, approximately 40% of women have some degree of facial hair.^[9] About 10 to 15% of cases of hirsutism are idiopathic with no known cause.^[10]

Causes

The causes of hirsutism can be divided into endocrine imbalances and non-endocrine etiologies. It is important to begin by first determining the distribution of body hair growth. If hair growth follows a male distribution, it could indicate the presence of increased androgens or hyperandrogenism. However, there are other hormones not related to androgens that can lead to hirsutism. A detailed history is taken by a provider in search of possible causes for hyperandrogenism or other non-endocrine-related causes. If the distribution of hair growth occurs throughout the body, this is referred to as hypertrichosis, not hirsutism.^[11]

Endocrine causes

Endocrine causes of hirsutism include:

• Ovarian cysts such as in polycystic ovary syndrome (PCOS), the most common cause in women.^[12]
• adrenal hyperplasia due to pituitary adenomas (as in Cushing's disease).^[13]
• Inborn errors of steroid metabolism such as in congenital adrenal hyperplasia, most commonly caused by 21-hydroxylase deficiency.^[13]
• pituitary tumors.^[13]

• Familial: Family history of hirsutism with normal androgen levels.[14]
• Drug-induced: medications were used before the onset of hirsutism. The recommendation is to stop the medication and replace it with another.^[15]
  • Minoxidil^[16][17]
  • progestins^[14][15]
• Valproic acid and methyldopa^[14][15]
• Pregnancy: Due to changes in hormone production^[18]
• menstrual cycles and levels of conventionally tested androgens (testosterone, androstenedione, and dehydroepiandrosterone sulfate) are normal.^[19] Around 10 to 15% of women with hirsutism have idiopathic hirsutism.^[10] Idiopathic hirsutism may be due to increased production of dihydrotestosterone (DHT) in hair follicles and hence may actually still be due to hyperandrogenism.^[10] It may be detectable by measurement of DHT or DHT metabolites.^[10]
  • Rice et al. 2016 propose that idiopathic hirsutism is caused by epigenetic inheritance of discordant epigenetic markers. It is testable with current technology.[20]

Diagnosis

Hirsutism is a clinical diagnosis of excessive androgenic, terminal hair growth.

Treatment of hirsutism is indicated when hair growth causes patient distress. The two main approaches to treatment are pharmacologic therapies targeting androgen production/action, and direct hair removal methods including electrolysis and photo-epilation. These may be used independently or in combination.[30]

Pharmacologic therapies

Common medications consist of antiandrogens,

• Bicalutamide: A pure antiandrogen.^[32][33][34] It is effective similarly to flutamide but is much safer as well as better-tolerated.^[32][33][34]
• progestin are supported by the evidence.^[35][1] They are functional antiandrogens. In addition, certain birth control pills contain a progestin that also has antiandrogenic activity.^[36] Examples include birth control pills containing cyproterone acetate, chlormadinone acetate, drospirenone, and dienogest.^[36][37]
• Cyproterone acetate: A dual antiandrogen and progestogen.^[38] In addition to single form, it is also available in some formulations of combined oral contraceptives at a low dosage (see below).^[38] It has a risk of liver damage.
• Eflornithine: Blocks putrescine that is necessary for the growth of hair follicles.^[39]
• Finasteride and dutasteride: 5α-Reductase inhibitors.^[37] They inhibit the production of the potent androgen DHT.^[37] A meta-analysis showed inconsistent results of finasteride in the treatment of hirsutism.^[35]
• Flutamide: A pure antiandrogen.^[38] It has been found to possess equivalent or greater effectiveness than spironolactone, cyproterone acetate, and finasteride in the treatment of hirsutism.^[40][38] However, it has a high risk of liver damage and hence is no longer recommended as a first- or second-line treatment.^{[41][42][37][43]} Flutamide is safe and effective.^[35]
• GnRH analogues: Suppress androgen production by the gonads and reduce androgen concentrations to castrate levels.^[44]
• Metformin: Insulin sensitizer. Antihyperglycemic drug used for diabetes mellitus and treatment of hirsutism associated with insulin resistance (e.g. polycystic ovary syndrome). Metformin appears ineffective in the treatment of hirsutism, although the evidence was of low quality.^[35]
• antimineralocorticoid with additional antiandrogenic activity at high dosages^[45][38]

• Electrology
• Epilation
• Laser hair removal
• Lifestyle change, including reducing excessive weight and addressing insulin resistance, may be beneficial. Insulin resistance can cause excessive testosterone levels in women, resulting in hirsutism.^[46]
• Shaving
• Waxing

See also

• Androgenic hair
• Bearded lady
• Ferriman-Gallwey score
• Hair removal
• Hypertrichosis
• Laser hair removal
• Petrus Gonsalvus
• Polycystic ovary syndrome (PCOS)
• Pubic hair
• Social model of disability
• Trichophilia

References