Hirsutism is a common condition characterised by the presence of coarse and dark hair in people assigned female at birth (AFAB) in a male-like distribution; affecting areas where hair is normally absent or minimal, such as the face, chest, abdomen, and back.1 Hirsutism is a source of psychological distress and social embarrassment for some people AFAB due to the growth of unwanted hair. Moreover, excess hair can be coupled with physical disturbances like inflammation and acne. It is important to consider the causes and treatment of hirsutism to help alleviate the symptoms and improve the quality of life.
Causes of hirsutism
Hirsutism is caused by the excess production of hormones called androgens. Hair follicles respond to androgens by growing thick hair. Hirsutism can be caused by a variety of factorssuch as genetic predisposition, hormonal imbalance, medical conditions, or certain medications.2 Lifestyle factors such as stress and obesity may contribute to hirsutism and worsen the situation. Some contributing factors to hirsutism are described below:
PCOS is a chronic medical disorder associated with hormonal imbalance in which the ovaries overproduce androgens, affecting hair growth and causing hirsutism in combination with irregular menstrual cycles.3
- Ovarian and adrenal tumors4
Androgen-producing tumors that produce extremely high androgen levels may develop in the ovaries or adrenal glands. These tumors are characterized by hirsutism, increased muscle mass, deepening of the voice, and male-like balding.
NCAH is an inherited disorder that causes the adrenal glands to overproduce androgens.5 Non-classical adrenal hyperplasia is considered the most common adrenal gland abnormality that results in hirsutism.
An unusual multisystem disorder affecting people AFAB and characterised by hyperandrogenism, insulin resistance, and acanthosis nigricans.6 In cases of insulin resistance, the pancreas produces more insulin, and due to excessively high levels of insulin, the ovaries are dramatically stimulated to overproduce androgens, resulting in hirsutism, irregular ovulation, and acne.
- Sensitive hair follicles
One of the causes of hirsutism may be oversensitivity of the hair follicles to male hormones.
Hirsutism may be caused by medications such as anabolic steroids as a side effect.4
Signs and symptoms of hirsutism
The main symptom of hirsutism are excessive dark, thick, unwanted hair growth on various body parts mimicking the distribution of male hair, such as the face, chest, and back.
As hirutism is often a symptom of an underlying problem, it may be coupled with other symptoms such as:7
- Abnormal menstrual cycle
- Acne and inflammation
- Voice deepening
- Decrease in breast size
- Increasing muscle mass
- Loss of feminine body shape
Management and treatment for hirsutism
It is not only essential to identify the cause of hirsutism but also to know how to recommend the right treatment based on the main causative factor. In cases where treatment is due to an underlying hormonal disorder, the disorder is treated first. The treatment and management of hirsutism include the following:8
- Shaving: but frequent shaving can irritate the skin, causes pseudofolliculitis where the hair become trapped under the skin surface making the skin inflamed.
- Waxing: can irritate the skin and also may cause pseudofolliculitis.
- Bleaching cream: making dark hair pale.
- Depilatories: creams that chemically dissolve hair shafts but may irritate the skin.
- Physical treatments:5
- Laser treatment: destroys hair root permanently. It is expensive and multiple sessions are required over a period of months. Side effects such as redness, discoloration and scarring may occur.
- Electrolysis: hair follicles are destroyed through electrical current passing through a needle. The aim is to destroy the hair root permanently. It is relatively expensive, time consuming and painful. Scarring and infection is a potential side-effect of this treatment.
- Medical treatments:5,6
- Anti-androgens: used to block the action of androgens that causes hirsutism, including finasteride, cyproterone acetate or spironolactone. These drugs should not be used in women of childbearing age. They takeseveral months to have an effect but hirsutism tends to return when the medicine is stopped.
- Oral contraceptive pills: reduce the effect of circulating free androgens, so it reduces hirsutism.
- Elfornithine cream: it is a cream that works by slowing the cycle of hair growth. Used in combination with other hair removal methods. It takes at least 4 to 8 weeks to notice a beneficial effect. Potential side effects include skin stinging, burning, inflammation, and acne.
Diagnosis of hirsutism
The diagnosis of hirsutism should involve investigating the causative factorto know how to treat it effectively. Diagnosis may involve:9
- A Doctor's assessment and history taking, including the extent, location, and age of onsetof hair growth, including a physical examination
- Medical history: if the patient has causative disorders such as PCOS, endocrine disorders, or cancer
- Family history: hirsutism can be genetic and therefore passed down through the family
- Blood tests to measure androgen levels in the blood
- Ultrasound imaging to examine if there are abnormalities in the ovaries
Although some cases don’t have a known cause, there are risk factors that increase the chances of developing hirsutism. Some of these risk factors are:
- Family history
- Obesity increases androgen production and may cause insulin resistance
- Medical conditions such as polycystic ovaries syndrome
Even if hirsutism itself doesn't cause any specific health problems, it has a negative impact on people’s psychological and emotional lives. When hirsutism is due to a medical condition, people may suffer from other complications such as irregular periods.
How can I prevent hirsutism?
Although hirsutism may not be preventable, knowing the cause may help manage it. A healthy lifestyle, including exercising, losing weight, and following a low-calorie diet, can help with polycystic ovary syndrome.7 Some medications may cause hirsutism and stopping these can stop the hair growth.7
How common is hirsutism?
It is estimated that 5-10% of women suffer from hirsutism.1
When should I see a doctor?
Excessive hair may be a symptom of an underlying medical condition, so if you experience excessive coarse hair on your face or body, see a doctor for an assessment.
Hirsutism is considered a relatively common problem causing excessive hair growth in people AFAB. Hirsutrism can be idiopathic or caused by a variety of medical conditions such as PCOS, endocrine disorders, or cancer. If you are affected then seek medical advice because it may be due to a more serious underlying medical condition. The best way to manage hirsutism is to find the underlying cause and treat it.
- Sachdeva S. Hirsutism: evaluation and treatment. Indian J Dermatol [Internet]. 2010 [cited 2023 Jun 6];55(1):3–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856356/
- Uptodate [Internet]. [cited 2023 Jun 6]. Available from: https://www.uptodate.com/contents/hirsutism-excess-hair-growth-in-females-beyond-the-basics#H2
- Hirsutism and polycystic ovary syndrome(Booket) [Internet]. [cited 2023 Jun 6]. Available from: https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/hirsutism-and-polycystic-ovary-syndrome-booket/
- Services D of H& H. Hirsutism (Excessive hair) - women [Internet]. [cited 2023 Jun 6]. Available from: http://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hirsutism-excessive-hair-women
- Hafsi W, Kaur J. Hirsutism. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Jun 6]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470417/
- Elmer KB, George RM. HAIR-AN syndrome: a multisystem challenge. Am Fam Physician. 2001 Jun 15;63(12):2385–90.
- Hirsutism information | mount sinai - new york [Internet]. Mount Sinai Health System. [cited 2023 Jun 6]. Available from: https://www.mountsinai.org/health-library/condition/hirsutism
- British association of dermatologists [Internet]. [cited 2023 Jun 6]. Available from: https://www.bad.org.uk/pils/hirsutism/
- Hohl A, Ronsoni MF, Oliveira M de. Hirsutism: diagnosis and treatment. Arq Bras Endocrinol Metab [Internet]. 2014 Mar [cited 2023 Jun 6];58:97–107. Available from: https://www.scielo.br/j/abem/a/t5GTrmpRNGJ7nDzYkqwtmpL/