Hirsutism in Premenopausal Women

Last updated April 8, 2022

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

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

...Diagn...

...ety (ES) suggests testing for elevate...


...those cases where serum total testoste...


...screening hyperandrogenemic women for no...

...ute patients with a high risk of congenital adren...


...suggests against testing for elevated andro...


...rriman–Gallwey Hirsutism Scoring System Ferrim...


...igure 2. Evaluation and Treatment of Hirsutism i...

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


Treatment

...Treatment...

...t women with patient-important hirsutism de...

...ho then desire additional cosmetic...

...te women with obesity, including those with...


...Pharmacologic...

...Initial Therap...

...majority of women with hirsutism who are not...

For most women with hirsutism, ES su...

...for women who are not sexually active, h...

...ES does not suggest one oral contraceptiv...

...en with hirsutism at higher risk for veno...

If patient-important hirsutism remains despite...

...es not suggest one antiandrogen over anoth...

...recommend against the use of flutamide because of...

...harmacologic therapies for hirsutism, ES sug...

...th severe hirsutism causing emotion...

...suggests against combination therapy as a st...

...le 2. Oral Contraceptives (OCs) and...

...e 3. Antiandrogens Used for the Treat...

...Other Drug Thera...

...S suggests against using insulin-lowering drugs...

...suggests against using gonadotropin-rele...

...sts against the use of topical antia...


...Direct Ha...

...en who choose hair removal therapy, ES...

...or women of color who choose photoe...

...ians should warn Mediterranean and Mid...

...omen who desire more rapid response to photoep...

...with known hyperandrogenemia who choose hair re...