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...


...here serum total testosterone levels ar...


...ests screening hyperandrogenemic women for noncl...

...rsute patients with a high risk of...


...ts against testing for elevated androgen levels i...


...rriman–Gallwey Hirsutism Scoring SystemFerriman...


...ure 2. Evaluation and Treatment of Hirsutis...

...Local sexual hair growth (i.e., in the...


Treatment

...eatmen...

...ith patient-important hirsutism despite c...

...o then desire additional cosmetic benefi...

...irsute women with obesity, including those...


Pharmacological Treatment...

...al Therapies...

...the majority of women with hirsutism who ar...

...with hirsutism, ES suggests against antiandrog...

...owever, for women who are not sexually active, hav...

..., ES does not suggest one oral contraceptive ove...

...h hirsutism at higher risk for venous thromboembo...

...f patient-important hirsutism remains...

...ggest one antiandrogen over another. (2-L)699...

...we recommend against the use of flutamide...

...pharmacologic therapies for hirsutism, ES s...

...nts with severe hirsutism causing emotional dist...

...wever, ES suggests against combination the...

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

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

...ther Drug Thera...

...ggests against using insulin-lowering drugs for...

...ts against using gonadotropin-releasing hormon...

...ests against the use of topical antiandroge...


...ir Removal Method...

For women who choose hair removal th...

...of color who choose photoepilation treatment...

...cians should warn Mediterranean and Middle...

...desire more rapid response to photoepilat...

For women with known hyperandrogene...