What is hirsutism?

Hirsutism is the term used for excess facial and body hair growth in women. It refers to a male pattern of hair i.e. over the moustache and beard areas, or more hair growth than usual on the arms and legs. Hairs may also grow on the chest or extend from the groin area on to the abdomen and thighs. What is considered normal for a woman and what is considered hirsute depends on factors such as culture and race.

Why is hirsutism important?

Hirsutism is not a disease and it is rarely caused by a serious illness. Unfortunately in our society, excess hair growth is considered abnormal and this can cause distress or embarrassment. At least 25% of normal middle-aged women have unwanted facial hair and many women do not realise the treatment options that are available. In some cases, hirsutism may be as a result of an underlying medical disorder. This can easily be ruled out with a medical history and some simple blood tests.

The body is completely covered with hair, except the lips, the palms of the hands and the soles of the feet. The number of hair follicles is fixed before birth and is dependent on genetic (inherited) factors. There are 2 types of hairs:

1. Terminal hairs which are thicker and found on eyebrows and head hair
2. Vellus hairs, which are fine and light. These are transformed into terminal hairs when subjected to androgens (male-type hormones)

Women have the same number of hairs on their bodies and faces as men do. The male hormone, testosterone, makes hairs grow thicker, darker and longer, so that they appear more noticeable. All women produce small amounts of testosterone and low levels of this male hormone allows terminal hairs to appear in the pubic (groin) and axillary (armpit) areas and around the brown circles of the nipple. This is normal and happens from around puberty. When there are higher levels of male hormones, terminal hairs can develop over the shoulders, over the lower back and the upper abdomen. The amount of terminal hair increases in all women with age.

Women with mild hirsutism and regular periods rarely have any underlying serious medical problem. A medical problem may be present if hirsutism is severe, if it is accompanied by irregular periods or if there are other features to suggest an increase in male hormones, such as baldness or deepening of the voice.

1. Inherited/Familial

In the vast majority of women hirsutism is inherited and may be present in other female relatives. These women tend to have normal amounts of male hormone (testosterone). The problem is that the hairs are more sensitive to small amounts of male hormone and so grow more quickly and thicker. The increased hair growth is usually first noted in late teenage years and tends to gradually get more severe as the woman gets older.

2. Racial

As seen in dark haired women e.g. from Mediterranean countries

3. Polycystic Ovarian Syndrome (PCOS)

This is a very common cause of hirsutism and may be associated with other symptoms such as acne, irregular periods, infertility and obesity. Women with PCOS also have a higher risk of developing diabetes and heart disease in later life. The condition is usually diagnosed in adulthood, but the symptoms often date back to the teenage years. Blood tests can show an imbalance between some hormones.

4. Drugs: examples include

• Phenytoin (Epanutin) used in epilepsy
• Cyclosporin used following kidney transplant and in arthritis
• Body building drugs i.e. ‘Anabolic Steroids’
• Minoxidil used for high blood pressure and as a cure for baldness

5. Over-production of male-type hormones

All women produce small amounts of androgens (‘male-type hormones’) in the adrenal glands, the ovary and in fat and muscle tissue. Hirsutism can develop if one or more of these sites increase their production. A woman may have hirsutism as the only sign of disease, or it may be one sign of ‘virilism’ (excessive male hormones). This is rare but may be due to a serious condition in either the ovaries or adrenal glands. Blood tests and abdominal scans can help with the diagnosis.

6. Congenital Adrenal Hyperplasia

In a small number of women hirsutism may be caused by a problem in the manufacture of cortisol (the body’s natural steroid) in the adrenal glands. As a result of the body’s attempt to get around this problem, the adrenal glands increase their production of male-type hormones. This condition is called Congenital Adrenal Hyperplasia and is hereditary. Often it is not diagnosed until teenage years or later in adult life. Treatment is available and involves replacing the lack of cortisol produced by the body with small amounts of steroid tablets.

Any woman experiencing difficulties in controlling body or facial hair by cosmetic methods should discuss this with a General Practitioner, as referral to an Endocrinologist (Specialist interested in hormone problems) may be beneficial. An Endocrinologist can provide reassurance, arrange appropriate investigations and discuss the options for treatment.

Blood tests can be done to check the levels of male and female hormone levels. These can usually be done at the time of visiting the outpatient clinic. Occasionally more sophisticated hormone tests are needed and these can be arranged as an outpatient at the Clinical Investigation Unit. An ultrasound of the ovaries and CT scan the adrenal glands may also be necessary in some patients.

• Bleaching makes the excessive hair less obvious.
• Depilatory creams
• Shaving: contrary to popular opinion, shaving does not make the hair grow more thickly! Electric shavers are probably better than wet type, as there is less tendency to irritate or damage the skin.
• Waxing pulls hairs out from the roots and needs to be repeated regularly.
• Epilady removes the hair by a combined cut and pull.
• Electrolysis may result in permanent hair loss, but takes time as a small area is treated every few weeks. Electrolysis can be expensive and unskilled treatment may cause scarring.
• Laser therapy is useful for facial hair removal in certain skin types; see leaflet Tayside Laser Hair Removal

 
    2. Medical Treatment

Tablets may help to slow hair growth down so that hairs become thinner and less noticeable. Tablets often take up to 12 months make a significant difference and usually need to be continued for several years at least. In most cases, hirsutism will return once tablets have been stopped.

·        Dianette. This contains oestrogen (female hormone – found in contraceptive pills) and a low dose of Cyproterone (has an anti-male hormone action – see below). It may not suit everyone, especially older women. Side effects include bleeding between periods, tender breasts, nausea and headaches, especially in the first few months.

·        Cyproterone (an anti-androgen). Anti-androgens counteract male hormones. It is necessary to prevent pregnancy during and for up to 6 months following treatment with anti-androgens as they have potential to damage a developing baby (can cause a male fetus to appear female). Cyproterone must be used along with an oral contraceptive pill to avoid this happening. Cyproterone is also available in doses that are larger and more effective than the dose found in Dianette. The main disadvantage is that higher doses are more likely to produce side effects including weight gain, depression, and loss of libido (sex drive). Higher doses should therefore only be used in cases of moderate or severe hirsutism.

·        Spironolactone is a weak diuretic (water tablet) that has some anti-androgen activity. Like Cyproterone, it should be taken along with an oral contraceptive pill to avoid pregnancy. Side effects include tender breasts and irregular periods.

·        Metformin. This drug is normally used in the treatment of diabetes. In recent years it has been shown to be beneficial in women with polycystic ovarian syndrome, who have similar metabolic problems to people with diabetes and have a greater than average chance of developing diabetes in later life. The main side effects of Metformin are nausea, abdominal cramps, flatulence and constipation. Its effectiveness in the treatment of hirsutism is still being evaluated.

·        VaniqaÒ cream (eflornithine) applied twice daily slows the growth of facial hair by inhibiting a key enzyme involved in hair growth. It is said to slow hair growth in 70% of women.

For Further Information why not try:

http://www.endo-society.org/pubrelations/patientinfo/hirsutism.htm

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Ó NHS Tayside; 2006; version 1.0

Disclaimer; no liability whatsoever is accepted for information given and all such information, especially with regard to drug usage ( UK version provided), must be checked with a person’s health provider