Hirsutism in Premenopausal Women

Publication Date: March 7, 2018

Key Points

Key Points

  • Hirsutism is common, occurring in 5 to 10 percent of all women.
  • Hirsutism is usually a sign of an underlying endocrine disorder (most commonly polycystic ovary syndrome [PCOS]). Women who present with hirsutism should therefore be offered an endocrine evaluation followed by appropriate therapy.
  • Hirsutism is associated with personal distress, anxiety and depression. It is important for clinicians to take their patients’ cosmetic concerns seriously.
  • Treatment options include pharmacologic therapy (starting with combination oral estrogen-progestin contraceptives for most), direct hair removal methods such as photoepilation/laser, or both.
  • Photoepilation (hair removal using laser and intense pulsed light) is most effective for women with light skin and dark hair. It is less effective and sometimes associated with complications in women with darker skin, especially those with Middle Eastern and Mediterranean ancestry.

Table 1. Definitions of Terms Used in This Guideline

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Term Definition
Hirsutism Hirsutism is excessive terminal hair that appears in a male pattern (excessive hair in androgen-dependent areas; i.e., sexual hair) in women.
Ferriman–Gallwey score The modified Ferriman–Gallwey score is the gold standard for evaluating hirsutism. Nine body areas most sensitive to androgen are assigned a score from 0 (no hair) to 4 (frankly virile), and these separate scores are summed to provide a hormonal hirsutism score (Fig. 1).
Local hair growth This is unwanted localized hair growth in the absence of an abnormal hirsutism score.
Patient-important hirsutism Unwanted sexual hair growth of any degree that causes sufficient distress for women to seek additional treatment.
Hyperandrogenism Hyperandrogenism (for the purposes of this guideline) is defined as clinical features that result from increased androgen production and/or action.
Idiopathic hirsutism This is hirsutism without hyperandrogenemia or other signs or symptoms indicative of a hyperandrogenic endocrine disorder.

Diagnosis

...iagnos...

...crine Society (ES) suggests testing for elevated...


...where serum total testosterone levels are norma...


...s screening hyperandrogenemic women for nonc...

...n hirsute patients with a high ris...


ES suggests against testing for elevated androge...


...re 1. Ferriman–Gallwey Hirsutism Scori...


.... Evaluation and Treatment of Hirsut...

...gure 2 Notes Local sexual hair growth (i.e., i...


Treatment

Treatm...

...women with patient-important hirsutism despite...

...o then desire additional cosmetic benef...

...ute women with obesity, including...


...rmacological Treatments...

Initial Therapies

...ority of women with hirsutism who are no...

...men with hirsutism, ES suggests against an...

..., for women who are not sexually active, have und...

...most women, ES does not suggest one oral c...

...h hirsutism at higher risk for veno...

...ient-important hirsutism remains d...

...ot suggest one antiandrogen over another. (...

...r, we recommend against the use of flutamide bec...

For all pharmacologic therapies fo...

...ith severe hirsutism causing emotional distres...

...S suggests against combination therapy...

...2. Oral Contraceptives (OCs) and Associated Ven...

...androgens Used for the Treatment of...

...her Drug Therapies...

...against using insulin-lowering drugs...

...against using gonadotropin-releasing hormone...

...gainst the use of topical antiandrogen th...


...ct Hair Removal Method...

...women who choose hair removal therapy, ES sugg...

...or who choose photoepilation treatment,...

...ns should warn Mediterranean and Mid...

...r women who desire more rapid response to photoepi...

...with known hyperandrogenemia who ch...