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

...Diagnosis...

...ne Society (ES) suggests testing for elevated an...


...se cases where serum total testosterone lev...


...ggests screening hyperandrogenemic women for...

...nts with a high risk of congenital adrenal h...


...gests against testing for elevated androgen...


...ure 1. Ferriman–Gallwey Hirsutism Sco...


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

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


Treatment

...Treatme...

...or most women with patient-important hirsutism de...

...men who then desire additional cosmetic benefit,...

...n with obesity, including those with...


...Pharmacological Treat...

...Initial Therapi...

...rity of women with hirsutism who are not se...

...with hirsutism, ES suggests against antiandroge...

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

...most women, ES does not suggest on...

...irsutism at higher risk for venous throm...

...tant hirsutism remains despite 6 month...

...s not suggest one antiandrogen ove...

...r, we recommend against the use of fluta...

...l pharmacologic therapies for hirsutism, ES sug...

...severe hirsutism causing emotional distr...

...suggests against combination therapy...

...Contraceptives (OCs) and Associated Venous Throm...

...3. Antiandrogens Used for the Treatm...

...Other Drug...

...suggests against using insulin-low...

...ainst using gonadotropin-releasing hormone (GnRH...

...suggests against the use of topical antiandrogen t...


...Direct Hair Remo...

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

...n of color who choose photoepilation treatme...

...s should warn Mediterranean and Middle Eastern wo...

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

...ith known hyperandrogenemia who choose hair r...