Hirsutism is the growth of terminal (thick) hair in male pattern in females. It is often, but not always, a manifestation of hyperandrogenism.

Basics: Androgens have a profound effect on many components of the skin like the hair, sebaceous glands (oil glands), apocrine glands (responsible for normal body odour), dermal collagen and subcutaneous fat. Androgens are normally secreted at puberty and are responsible for certain characteristics seen at puberty (growth of axillary and pubic hair, secretion of sebum, change in the voice etc.)

According to the sensitivity to androgens, body hair can be divided into

• Independent of androgen influence - Eyebrows, eye lashes, lanugo hair (fine body hair)

• Sensitive to small amounts of androgens produced by adrenals - axillary and pubic hair

• Sensitive to high levels of androgens as seen in males and some females - hair on the face, chest, upper pubic triangle, ears

Hirsutism results from both increased production of and increased sensitivity of the hair follicles to androgens. Increased androgens could be of ovarian or adrenal origin.

The causes of hirsutism are:

Mild hirsutism without other signs of hyperandrogenism:

• Stress
• Pregnancy
• Menopause
• Puberty

Hirsutism with other signs of hyperandrogenism:

• Ovarian causes - PCOD (common), tumors
• Adrenal  causes - congenital adrenal hyperplasia, tumors
• Cushing's syndrome - pituitary origin, adrenal tumors, ectopic ACTH
• Prolactinoma
• Gonadal dysgenesis
• Drugs - anabolic steroids, oral contraceptives with androgenic progesterones
• Obesity

Most common cause of hirsutism is polycystic ovarian syndrome (PCOD). A small proportion of patients with hirsutism may not have hormonal abnormalities (idiopathic, racial, familial).

Signs and symptoms of hyperandrogenism which may or may not be associated with hirsutism are:

• Cutaneous virilism - Acne (severe), seborrhoea, androgenic alopecia (loss of hair in male pattern)
• Systemic virulism - amenorrhoea, oligomenorrhoea, cliteromegaly, loss of female body contour, coarsening of the skin
• Other signs - obesity, striae, acanthosis nigricans (thick, dark skin over the neck and other body folds)

The accompanying symptoms and signs are of vital importance in investigating the cause of hirsutism.

Diagnostic Approach:

History should be elicited regarding:

• Duration of hirsutism
• Onset - sudden/gradual
• Family history of similar complaints
• Menstrual cycles
• Associated signs and symptoms (baldness of the scalp, acne, striae etc.)
• History of drug intake (oral contraceptives with androgenic progesterone, anabolic steroids, corticosteroids)

Look for the following on clinical examination:

• Body contour
• Fat distribution (trunkal obesity, buffalo hump, moon face)
• Hair over the scalp (baldness)
• Hair over body areas
• Acne (particularly severe acne)
• Seborrhoea (oily complexion)
• Thickened skin over the neck (acanthosis nigricans)
• Striae
• Genital examination

The following investigations should be done based on the clinical details; no investigations are required in cases of long standing mild hirsutism with regular menstrual cycles and no other associated features of hyperandrogenism.

• Serum testosterone (Total and free)
• Serum FSH, LH, Prolactin
• Dehydroepiandrosterone sulfate (DHEAS) - for adrenal causes
• ACTH and Cortisol (Cushing's syndrome)
• Urinary 17 keto steroids
• Ultra sound examination of the abdomen
• Special tests like dexamethasone suppression test, ACTH stimulation test etc. may be needed in some cases

Treatment:

Physical modalities

• Temporary: Shaving, waxing, hydrogen peroxide bleaching, depilation with chemicals
• Permanent: Electrolysis, laser epilation (permanent hair reduction)

Medical treatment:

• Ovarian suppression - oral contraceptives, cyproterone acetate, Gonadotrophin releasing hormone agonists
• Androgen suppression - glucocorticoids
• Androgen receptor blockers - spironolactone, flutamide, cyproterone acetate
• 5α reductase inhibitors - Finasteride

Any underlying cause (tumors) should be treated accordingly.

Hirsutism		Hirsutism - After Laser
Hirsutism		Hirsutism - After three electrolysis