Getting a handle on hirsutism

By Allison Evans, Assistant Managing Editor, February 1, 2022

Far from being simply protein filaments, hair can occupy a central role in a person’s identity, sense of well-being, and overall quality of life. Hirsutism — a condition in which excess hairs grow in a male-patterned distribution — affects 5-10% of women and can be devastating to patients.

Hirsutism is often a manifestation of an underlying systemic issue, predominantly polycystic ovary syndrome (PCOS) or idiopathic hyperandrogenism, which account for more than 85% of cases, said Rachel V. Reynolds, MD, FAAD, assistant professor and vice chair of dermatology at Harvard Medical School. Less common causes include idiopathic hirsutism, adrenal hyperplasia, androgen-secreting tumors, medications, as well as other endocrinopathies, such as Cushing syndrome and thyroid dysfunction. 

Women with hirsutism have increased follicular-based 5α-reductase activity, which is locally stimulated by androgens, insulin, and insulin-like growth factor. Increased levels of 5α-reductase foster the conversion of testosterone to dihydrotestosterone, which stimulates hair growth, Dr. Reynolds and her colleague wrote in a JAAD CME article on PCOS.

Screening for polycystic ovary syndrome

PCOS is a common endocrine disorder affecting up to 8% of women of reproductive age, said Dr. Reynolds. Because dermatologists frequently see patients with cutaneous manifestations of PCOS, including acanthosis nigricans, hirsutism, acne, and alopecia, they can play a key role in its diagnosis and management. The hallmark clinical features of PCOS are hyperandrogenism, oligo- or anovulation, and polycystic ovaries seen on an ultrasound, she said.

According to the updated 2018 clinical guideline on the Evaluation and Treatment of Hirsutism in Premenopausal Women published by the Endocrine Society, all women who have unwanted dark, coarse hair growing on the face, chest, or back should undergo testing for PCOS and other underlying health issues (doi: 10.1001/jama.2018.2611). Experts also suggest that all women with hirsutism undergo blood tests for testosterone and other androgens. “The basic androgen panel could detect other rare causes of hirsutism, help to rule out these things, and help broaden your workup for PCOS,” Dr. Reynolds said.

If a patient has hirsutism in combination with hormonal acne, a dermatologist should do a workup for PCOS, she added. “Also, if the patient has irregular menses, family history of PCOS or metabolic syndrome, or issues with weight management — those can run concurrently with PCOS.” 

“The basic androgen panel could detect other rare causes of hirsutism, help to rule out these things, and help broaden your workup for PCOS.”

A good place to start is testing for serum testosterone, free testosterone, DHEAS, sex hormone binding globulin, prolactin, and androstenedione, Dr. Reynolds recommended. “This testing would provide a sense as to whether there is an obvious state of androgen excess.” The hirsutism guideline recommends against screening women for elevated androgen levels if they have a normal Ferriman-Gallwey score (below eight in white and Black women, and varying by ethnicity for Asian, Hispanic, and Middle Eastern women) and normal menses, as there would be a low probability of a positive result.

“However, PCOS is a diagnosis of exclusion, which means that elevated lab levels are not required to make the diagnosis. Even just the presence of clinical hyperandrogenism, meaning hirsutism and acne, may already indicate PCOS,” she said.

“Serum levels of androgens do not seem to correlate with the degree of hirsutism or acne — the sensitivity of androgen receptors and local levels of androgens play a more significant role,” Dr. Reynolds explained. This explains why many women with hirsutism and/or acne will not have an underlying endocrinopathy.

“One thing that can change the long-term presence of hirsutism for a person who has PCOS and is overweight is if they achieve weight loss,” Dr. Reynolds said. “Even weight loss of 5% of body weight can change hormonal milieu enough to improve hirsutism long term.”

If there is high clinical suspicion that a patient has PCOS, it’s important to form a multidisciplinary team, including an endocrinologist and primary care physician, Dr. Reynolds said.

Various types of hirsutism

Hirsutism can occur in the absence of PCOS, Dr. Reynolds said. About 10-15% of hirsutism cases can be attributed to idiopathic hyperandrogenemia and is characterized by normal ovulatory cycles with no other identifiable cause of elevated androgen levels. 

A patient can also have hirsutism without elevated androgen levels. Idiopathic hirsutism is defined as hirsutism in conjunction with normal ovulatory function and normal serum androgen levels. It accounts for about 5% of cases and, similar to PCOS, is also a diagnosis of exclusion. Combination treatment — including androgen suppression, peripheral androgen blockade, and cosmetic methods — is most effective.

“Sometimes it has just more to do with androgen sensitivity of the hair follicles of the androgen-sensitive areas like the face, the breast, the abdomen, and the lower back,” Dr. Reynolds explained. 

Importantly, the updated clinical guideline now recognizes and recommends treating patient-important hirsutism, which is hair growth that causes distress in the absence of an abnormal hirsutism score, said Deborah, A. Scott, MD, FAAD, assistant professor of dermatology at Harvard Medical School, director of the Laser & Skin Health Center, and co-director of the PCOS Program at Brigham and Women’s Hospital. This addition acknowledges the significant impact this condition can have on a patient’s well-being and that the risks associated with first-line treatments are relatively low for most women.

Pharmacologic options

When treating patients with hirsutism, the goal of medical treatment is to first address any causal hormonal imbalance, slow down or stop excessive hair growth, and improve patients’ appearance and quality of life, Dr. Scott said. 

Because androgens play a critical role in hirsutism, hormone-modulating medications are typically used in the treatment of hirsutism, including combined oral contraceptives (COCs), spironolactone, finasteride, dutasteride, and flutamide. COCs are considered first-line treatment for hirsutism for women who are not seeking to become pregnant. Unfortunately, women who are looking to conceive or are pregnant are unable to use any of the pharmacologic options. Instead, they must rely on hair-removal methods.

Studies suggest that treatment may be more effective when spironolactone or finasteride is added to COCs, particularly for patients with treatment-resistant hirsutism. The current guidelines recommend against using combination therapy until the condition persists after six months of monotherapy.

A 2015 Cochrane Systematic Review found that 100 mg per day of spironolactone was more effective than placebo for reducing unwanted hair. A meta-analysis comparing antiandrogens in hirsute women, including some with PCOS, found all treatment groups had significantly lower hirsutism scores compared with placebo.

“We’ve had an increase in comfort level with dermatologists using spironolactone and oral contraceptive pills to treat hormone-related acne,” said Dr. Reynolds. “These are the same medications that we use to treat hirsutism.” 

“As dermatologists, we must be sensitive to the psychosocial implications of hirsutism and be prepared to treat these patients with compassion and expertise.”

“What we see is that spironolactone may work quickly for acne, say, within three months, but with hirsutism, it takes a little bit longer — closer to six months. You have to be more patient. Doses required to control hirsutism, especially in patients with PCOS, tend to be higher than what is needed to treat acne,” Dr. Reynolds said.

While studies suggest that flutamide can be an effective treatment for hirsutism, it is not recommended because of the risk of hepatotoxicity, said Dr. Scott.

In a few studies, bicalutamide, an antiandrogen similar to flutamide, was demonstrated to have efficacy in the treatment of hirsutism. While it does not have the risk of hepatoxicity seen with flutamide, more studies are needed to verify its safety and efficacy.

While there are options to target hormonal imbalances, these drugs may not completely solve the problem. “With hirsutism, the vellus hairs have been transformed into coarse, terminal hairs,” Dr. Scott said. “Although hormonal modulating agents may improve hirsutism by 30%, when you reduce hormonal stimuli, the hair growth doesn’t necessarily return to baseline. But is that enough? I don’t know.” 

Hair removal

Laser hair removal is effective for hirsutism, even in androgen excess states, Dr. Reynolds continued. “However, the results are not as robust, so it may take more treatments to achieve a desired outcome or to achieve longer intervals between visits in terms of how quickly the hair grows back. There may be a setback or a regrowth if a patient is not also using antiandrogen medications to suppress the androgen drive.”

“In addition to recommending laser hair removal, I may prescribe eflornithine,” Dr. Scott said.

Eflornithine typically kicks in after about eight weeks of using it twice per day, Dr. Reynolds noted. “It can reduce the rate of hair growth by about 30%, which can increase the intervals between hair removal procedures. It’s a complement to whatever other method patients are doing, such as waxing, plucking, shaving, or laser hair removal.”

Quality of life

“If you look at studies of women with PCOS, hirsutism has the greatest impact on their quality of life,” Dr. Scott said. “It significantly impacts their self-image and social interactions.”

Women of color with hirsutism often develop pseudofolliculitis barbae from mechanical hair removal techniques. In addition, this is frequently accompanied by post-inflammatory hyperpigmentation, Dr. Scott explained. “While many of these issues are often dismissed as being cosmetic, they’re not. They may have a significant negative impact on a patient’s quality of life.”

“As dermatologists, we must be sensitive to the psychosocial implications of hirsutism and be prepared to treat these patients with compassion and expertise,” Dr. Scott added. “Just because it’s not directly affecting a patient’s physical health doesn’t mean it’s not having a profound impact otherwise.”

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