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
- Endocrine Society (ES) suggests testing for elevated androgen levels in all women with an abnormal hirsutism score. (2|⊕⊕○○)
- In those cases where serum total testosterone levels are normal, if sexual hair growth is moderate/severe or sexual hair growth is mild but there is clinical evidence of a hyperandrogenic endocrine disorder (such as menstrual disturbance or progression in spite of therapy), ES suggests measuring an early morning serum total and free testosterone by a reliable specialty assay. (2|⊕⊕○○)
- ES suggests screening hyperandrogenemic women for nonclassical congenital adrenal hyperplasia (NCCAH) due to 21-hydroxylase deficiency by measuring early morning 17-hydroxyprogesterone levels in the follicular phase or on a random day for those with amenorrhea or infrequent menses. (2|⊕⊕○○)
- In hirsute patients with a high risk of congenital adrenal hyperplasia (positive family history, member of a high-risk ethnic group), ES suggests this screening even if serum total and free testosterone are normal. (2|⊕⊕○○)
- ES suggests against testing for elevated androgen levels in eumenorrheic women with unwanted local hair growth (i.e., in the absence of an abnormal hirsutism score) because of the low likelihood of identifying a medical disorder that would change management or outcome. (2|⊕⊕○○)
Figure 1. Ferriman–Gallwey Hirsutism Scoring System
Ferriman D, Gallwey JD. J Clin Endocrinol Metab. 1961;21(11):1440–1447.
Each of the nine body areas most sensitive to androgen is assigned a score from 0 (no hair) to 4 (frankly virile). These separate scores are summed to provide a total hormonal hirsutism score. Generalized hirsutism (score ≥8) is abnormal in the general US population, whereas locally excessive hair growth (score <8) is a common normal variant. The normal score is lower in some Asian populations and higher in Mediterranean populations (see full text guidelines). Reproduced from Hatch et al. Am J Obstet Gynecol. 1981;140(7):815–830.
Figure 2. Evaluation and Treatment of Hirsutism in Premenopausal Women
Figure 2 Notes
- Local sexual hair growth (i.e., in the absence of an abnormal hirsutism score) that is not accompanied by clinical evidence of a hyperandrogenic endocrine disorder does not require an endocrine workup before embarking on dermatologic therapy (cosmetic or direct hair removal measures).
- Elevated androgen levels should be ruled out in women with hirsutism or any degree of sexual hair growth who also have clinical evidence of a hyperandrogenic endocrine disorder.
- Clinical evidence of menstrual irregularity, infertility, galactorrhea, signs or symptoms of hypothyroidism, Cushing syndrome, acromegaly, central obesity, acanthosis nigricans, clitoromegaly, or sudden-onset or rapid-progression hirsutism suggests the presence of a hyperandrogenic endocrine disorder.
- PCOS is the most common hyperandrogenic disorder associated with hirsutism. However, androgen-secreting tumors and NCCAH are other major causes that clinicians should consider.
- Drugs that cause hirsutism include anabolic or androgenic steroids (a consideration in athletes, users of dietary supplements, patients with sexual dysfunction, or in patients with a partner who uses testosterone gel) and valproic acid (a consideration in patient with neurologic disorders).
- An accurate and specific assay, such as mass spectrometry, is the best choice for assessing serum total testosterone concentrations.
- Norms are standardized for early morning, when levels are the highest, and for days 4–10 of the menstrual cycleᵃ when ovarian follicle development is the most comparable to that of women with hyperandrogenic anovulation; clinicians should interpret marginal values obtained at other times accordingly.
- Women with mild hirsutism, a normal total testosterone level, a pelvic ultrasound showing normal ovarian morphology (if performed), and no clinical evidence of other hyperandrogenic endocrine disorders have idiopathic hirsutism, which may be responsive to OC therapy. However, if the serum total testosterone is normal in the presence of moderate or severe hirsutism or if there is clinical evidence of PCOS or other endocrine disorder, clinicians should test serum-free testosterone levels.
- Assessing free testosterone levels using high-quality testosterone and SHBG or equilibrium dialysis assays with well-defined reference intervals is the single most useful, clinically sensitive marker of androgen excess in women.
- A simultaneous assay of early-morning 17-hydroxyprogesterone is indicated in subjects at high risk for NCCAH.ᵃ
- Progression of hyperandrogenism in the presence of a normal serum-free testosterone is very unusual, and clinicians should thoroughly reevaluate these patients.
- Unless fertility is an issue, demonstrating polycystic ovary morphology to diagnose ovulatory PCOS is unlikely to affect management.
ᵃ See Section 5, Androgen Testing Remarks in the full text guideline.
Adapted from Martin KA et al. J Clin Endocrinol Metab. 2008;93(4):1105–1120. Diagnosis
