What is hirsutism

Hirsutism is excessive hair growth on the chin, upper lip, arms, nipples and other areas, commonly associated with excessive levels of testosterone in women. Hirsutism results in excessive amounts of dark, coarse hair with male-pattern hair growth in women.

The amount of body hair you have is largely determined by your genetic makeup. There’s a wide range of normal hair distribution, thickness and color due to differences in heredity. However, hirsutism is a medical condition that can arise from excess male hormones called androgens, primarily testosterone. It can also be due to a family trait.

However, what is considered excessive can vary depending on ethnicity and culture.

It’s relatively common, although some women may find it embarrassing or distressing to live with.

It’s often a long-term problem, but there are a number of treatments that can help keep it under control. A combination of self-care and medical therapies are available for many women with hirsutism.

Symptoms of hirsutism:

The excessive hair in hirsutism is usually thick and dark, rather than fine and fair.

It develops in areas where men often have hair, such as the:

• face
• neck
• chest
• tummy
• lower back
• buttocks
• thighs

When excessively high androgen levels cause hirsutism, other signs might develop over time, a process called virilization. Signs of virilization might include:

• Deepening voice
• Balding
• Acne
• Decreased breast size
• Increased muscle mass
• Enlargement of the clitoris

You may also have some additional symptoms, such as oily skin, irregular periods or no periods at all.

Figure 1. Hirsutism

There are a number of different treatments that can remove the excess hair in women with hirsutism, and help stop it coming back.

The main treatments are:

• Hair removal methods
• Eflornithine cream
• Oral contraceptives (birth control pills)

There are also several additional medicines that may be prescribed by a specialist if the above treatments haven’t helped.

Hirsutism causes

Hirsutism is caused by an excess of male hormones called androgens in your body, or by your body being more sensitive to these hormones.

In many cases, it’s not clear why this happens. Some women just seem to develop extra hair growth as they get older, particularly after the menopause.

Sometimes, hirsutism can occur with no identifiable cause. This happens more frequently in certain populations, such as in women of Mediterranean, Middle Eastern and South Asian ancestry.

There are several main causes of hirsutism:

• Genetics: The condition can run in families.
• Ethnicity: Women from certain cultures are more likely to have hirsutism. This includes women of Middle Eastern, South Asian, and Mediterranean descent.
• High levels of male hormones (called androgens): This is often related to a certain condition.
• Polycystic ovary syndrome (PCOS): This is an imbalance of hormone levels in a woman’s body. It causes cysts to form in the ovaries, as well as other symptoms such as irregular periods, obesity and infertility.
• Hair follicles: Some people have hair follicles that are overly sensitive to male hormones. Doctors do not know the cause of this.

At puberty, a girl’s ovaries begin to produce a mix of female and male sex hormones, causing hair to grow in the armpits and pubic area. Hirsutism can occur if the mix becomes unbalanced with too high a proportion of male sex hormones (androgens).

In younger women, the most common cause of hirsutism is polycystic ovary syndrome (PCOS), a condition that can cause irregular periods and fluid-filled sacs (cysts) on the ovaries.

Less common causes of hirsutism include:

• Cushing’s syndrome – this is caused by long-time exposure to the hormone cortisol. That causes sudden weight gain and bloating around the face and neck. It can develop from your adrenal glands making too much cortisol or from taking medications such as prednisone over a long period.
• Congenital adrenal hyperplasia – this inherited condition is characterized by abnormal production of steroid hormones, including cortisol and androgen, by your adrenal glands.
• Obesity – losing weight may help improve the symptoms in these cases
• Acromegaly – a condition in which the body produces too much growth hormone
• Medicines – such as anabolic steroids, used by some people to build muscle and improve athletic performance and medicines used to treat endometriosis – danazol, systemic corticosteroids and fluoxetine (Prozac) for depression.
• A tumor (growth) – Tumors in your ovaries or adrenal glands can that increases the production of androgens.

Risk factors for hirsutism

Several factors can influence your likelihood of developing hirsutism, including:

• Family history. Several conditions that cause hirsutism, including congenital adrenal hyperplasia and polycystic ovary syndrome, run in families.
• Ancestry. Women of Mediterranean, Middle Eastern and South Asian ancestry are more likely to develop hirsutism with no identifiable cause than are other women.
• Obesity. Being obese causes increased androgen production, which can worsen hirsutism.

Can hirsutism be prevented or avoided?

You cannot prevent or avoid hirsutism. But losing weight if you’re overweight might help reduce hirsutism, particularly if you have polycystic ovary syndrome.

Hirsutism complications

Hirsutism can be emotionally distressing. Some women feel self-conscious about having unwanted body hair. Some develop depression. Also, although hirsutism doesn’t cause physical complications, the underlying cause of a hormonal imbalance can.

If you have hirsutism and irregular periods, you might have polycystic ovary syndrome, which can inhibit fertility. Women who take certain medications to treat hirsutism should avoid pregnancy because of the risk of birth defects.

Hirsutism symptoms

The main symptom of hirsutism is unwanted hair growth on a woman’s face, chest, and back. This thick, dark hair is different from the normal, fine “baby” hair on other parts of the body.

Other symptoms of hirsutism may include:

• acne
• abnormal menstrual periods
• deepening of the voice
• increased muscle mass
• decreased breast size

You may also have some additional symptoms, such as oily skin, acne, a deep voice, irregular periods or no periods at all.

How is hirsutism diagnosed?

Contact your doctor if you have abnormal hair growth or other related symptoms. The doctor will run tests to check your hormone levels. If they are high in androgens, they may do an ultrasound to check your ovaries or a CT scan to check your adrenal gland. These tests can show if you have any tumors.

Your doctor might also examine your abdomen and do a pelvic exam to look for masses that could indicate a tumor.

Hirsutism treatment

Treatment for hirsutism usually involves techniques to remove the excess hair and treatment to help slow its growth or stop it coming back.

The main treatments are:

• home hair removal methods – such as shaving, plucking or waxing
• specialist hair removal treatments – such as laser hair removal
• eflornithine cream (Vaniqa) – a prescription cream that can help slow down the growth of facial hair
• oral contraceptives, including co-cyprindiol tablets – a type of contraceptive pill available on prescription that can help prevent excess hair growth

It may take a few months to notice the effects of treatment, so it’s important to persist with it. In many cases, treatment will need to be continued indefinitely.

Hair removal methods

There are a number of ways to remove or disguise excess hair. Some can be tried at home, while more specialist treatments are carried out in clinics.

Your doctor can advise you about the hair removal options available. You may need to try a number of methods to find one you prefer.

Home hair removal techniques

Home hair removal techniques are relatively inexpensive, although they need to be carried out regularly because the results are only temporary.

The main techniques are:

• shaving – quick and easy, and won’t make the hair grow back quicker or thicker, but may irritate your skin and there may be unpleasant stubble growth between shaves
• bleaching – can make dark hair look better in the short term, but may irritate your skin and isn’t effective if you have dark skin
• waxing, plucking or threading – can reduce regrowth if done regularly, but can be painful and may cause inflammation of the hair follicles (folliculitis) and, occasionally, scarring
• hair removal (depilatory) creams – can remove hair from large areas of skin without leaving stubble behind, but can irritate the skin and should be tested on a small area at first
• epilators (electrical hair removal devices) – can remove hair from large areas relatively easily, but can be painful and cause folliculitis

Specialist hair removal techniques

Specialist hair removal techniques may have longer-lasting results than the techniques you can try at home, although they can be expensive.

The main treatments are:

• Electrolysis (where electricity is used to destroy hair follicles) – can be a permanent solution, but may require several treatments; can also be painful and may cause scarring or changes to your skin color. This procedure can be painful and expensive. It may be needed more than once.
• Laser hair removal (where powerful beams of light are used to destroy hair) – can remove hair for longer periods than home removal methods, but the results aren’t permanent; side effects can include redness, darkening or lightening of the skin, and scarring. The procedure is expensive and may be needed multiple times. For some women, the hair growth may return.

Eflornithine cream

Eflornithine cream (Vaniqa) is a prescription medicine applied twice daily that can help treat excessive hair growth on the face and under the chin.

It can be prescribed for both premenopausal women and menopausal women, but isn’t suitable for women who are pregnant, breastfeeding or under the age of 19.

The cream helps slow down hair growth and can be used alongside the hair removal methods mentioned above.

You should notice an effect within eight weeks. Treatment will be stopped if no benefit is seen after four months.

If eflornithine cream does work, you’ll usually need to continue using it, as hair growth will return within eight weeks of stopping treatment.

Side effects of eflornithine cream can include:

• mild acne
• skin redness
• a burning or stinging sensation
• dry, itchy skin

Oral contraceptives

For hirsutism affecting large areas of the body, your doctor may prescribe oral contraceptives or co-cyprindiol (Dianette).

Co-cyprindiol is a type of combined contraceptive pill that can treat excess hair growth by blocking the effects of male hormones (androgens) in the body. It’s only suitable for premenopausal women with hirsutism.

The pills are taken once a day in cycles lasting 21 days, followed by a seven-day break before you start the next cycle. It may take around six months to see an effect.

Once your excess hair growth has improved, you’ll be advised to stop taking the pills after a further three or four months because continuous long-term treatment increases your risk of developing a blood clot.

If your hirsutism returns after you stop taking the tablets, your doctor may recommend starting treatment again or changing to a different combined contraceptive pill.

Common side effects of co-cyprindiol include:

• weight gain
• breast pain or tenderness
• irritability or low mood
• feeling sick
• tummy (abdominal) pain

Additional medicines

Your doctor may refer you to a specialist if the treatments above aren’t suitable or don’t work. There are several additional medications a specialist can prescribe if necessary.

These include:

• Anti-androgens (medicines that suppress androgens) – such as cyproterone acetate and spironolactone. These block your body from producing male hormones. They also can decrease the amount of new hair growth. However, they cannot get rid of the hair you already have. Anti-androgens take at least 3 to 6 months to work. They can cause birth defects. Do not take them if you are pregnant or trying to get pregnant.
• Finasteride – a type of medication that works by preventing testosterone (an androgen) from turning into a stronger form of testosterone inside your body’s cells
• Insulin-sensitising medication (medicines that make your body more sensitive to insulin) – metformin and pioglitazone
• Gonadotrophin-releasing hormone (GnRH) analogues (man-made hormones) – such as goserelin and leuprorelin

Many of these medicines are unlicensed for the treatment of hirsutism.

This means they haven’t undergone clinical trials for this use, but your doctor believes they’re likely to be effective. They will discuss the possible benefits and risks with you.

Hirsutism home remedies

Treatment can help cure or lessen the effects of hirsutism. There also are things you can do at home to conceal the appearance of hair growth.

• Shaving: This is the safest and easiest method to remove unwanted hair. It also is inexpensive. However, you may have to shave every day. Otherwise, you hair grows back quickly. Frequent shaving can irritate your skin. You can apply a small amount of 1% hydrocortisone cream.
• Tweezing and waxing: Tweezing only is good for removing a few stray hairs. Waxing is more effective for removing large patches of hair. It can cause brief discomfort and skin irritation.
• Bleaching: This can lighten the color of your unwanted hair to make it harder to see. Follow the directions on the product label. Bleaching can irritate your skin or cause discoloring.
• Topical creams, lotions, and gels: These products can break down your hair follicles over time. However, they can take a while to work and may not be successful. You may be allergic to the chemicals in the products. To test how sensitive your skin is, apply a small amount of cream to the inside of your wrist. Wait one day before applying the cream to other parts of your body. If you have a reaction to the cream, do not use it. Talk to your doctor about other options.

If you are overweight, lose weight and eat a healthy diet. Some women find that this helps to balance their hormones.

Women who have hirsutism may have self-esteem issues. The hair growth can be emotional and hard to deal with. It may help to get counseling or join a support group. You can ask your doctor for a recommendation.