Background

Hirsutism can be explained as the excessive growth of hair of male pattern in females after puberty. This affects the facial region and other parts of body that are dependent on androgens like beard and mustache, buttocks, thighs, and pubic hair. For a dermatologic consultation hirsutism might be the common reason among different factors. No matter what causes it, emotional stress can be very severe due to this condition, paving way to rule out the cause and treat the issue. 

Epidemiology

The exact prevalence of hirsutism is not known. It could be 10% or even more than 50%. The impact of this condition on a person’s mental health is influenced by social and cultural backgrounds. In fact, there are some communities where having less hair is seen a major aspect of female attractiveness such tat even slight hirsutism may be considered very serious while in other communities, significantly higher levels could still be acceptable.  

Hirsutism seems to be most frequent among people with darker skin. It can also occur in men but is difficult to notice. If children have hirsutism, then it means they are going through puberty earlier than expected. It can also occur in women after withdrawal of oral contraceptive pills.  

Anatomy

Pathophysiology

Excess hair growth in women is called hirsutism. The sensitivity of the hair follicle to androgens and the level of androgens in the body are affected by this condition. The skin can convert testosterone, a type of androgen, into dihydrotestosterone which is more active through a 5α-reductase enzyme. There are two isoenzymes of this enzymes, type 1 located in the chromosome 5 and type 2 located on the chromosome 2. The skin and hair follicles contain androgen receptor sites. After ruling out any external intake of androgen, hirsutism results from either excessive secretion of these hormones by the ovaries or adrenal glands or increased skin sensitivity to normal levels of androgens. 

Etiology

This condition of excessive hairiness in women is often due to high levels of androgens. The ovaries or adrenal glands are usually responsible for this, although there can be other causes as well. Tumours that produce hormones such as testosterone can lead to severe cases, but most cases should be differentiated from non-tumour hyperandrogenism. PCOS being the most common cause affects 5% to 10% of women during their age of genital activity. 

At the end of follicular maturation, there are small follicles in the cortex and hyperplasia of the ovarian stroma. Nonclassic Congenital Adrenal Hyperplasia (NCAH) is a common autosomal recessive disease characterized by sudden virilization, hirsutism and pelvic or abdominal mass. 

Various medications can cause hirsutism, such as androgens, glucocorticosteroids, progestins, estrogen antagonists among others. Endocrinopathies, for instance Cushing syndrome, hyperthyroidism, hyperprolactinemia, and acromegaly are rare causes of isolated hirsutism. Other causes include moderate hirsutism in pregnant or postmenopausal women while idiopathic hirsutism is associated with regular menses and normal ovary morphology together with normal plasma androgen levels. 

Genetics

Prognostic Factors

Hirsutism can have considerable adverse consequences on an individual’s well-being, and women with hirsutism caused by malignancies often face a poor prognosis. Moreover, postmenopausal women experiencing hirsutism are at an increased risk of developing osteoporosis and fractures, which can significantly impact their health.

Clinical History

Age of onset: Idiopathic hirsutism and other minor causes of hirsutism generally do begin at puberty. On the other hand, when hirsutism begins in women who are middle aged or older, it is indicative of an adrenal or ovarian tumor. 

Family history: A patient with a family history of hirsutism may have congenital adrenal hyperplasia (CAH), but idiopathic hirsutism and polycystic ovary syndrome (PCOS) could be familial too.  

Severity of hirsutism and progression rate: Most often, history of benign variant of hirsutism consists of pubertal onset with a gradual increase over many years. This is often the case with PCOS-related hirsutism. If there is a history of sudden severe hirsutism or virilization signs, consider an androgen-secreting tumor. 

Puberty and andrachne: Since development of pubic hair relies on adrenal androgens, early development suggests CAH. By contrast, ovarian hyperandrogenism is associated with normal adrenarche followed by delayed menarche or menstrual irregularities. 

Physical Examination

When considering hirsutism with a peripubertal onset and slow progression, the medical history might suggest either primary hirsutism or non-neoplastic secondary hirsutism. Late onset or rapid course of the condition, signs of virilization, elevated hormonal levels are indicative for adrenal (adenomas), ovarian(arrhenoblastoma), or pituitary (prolactinoma) tumors. The history of cycle disorders is an important sign for secondary hirsutism (100% in case of tumors, 75% in polycystic ovaries, 0%-25% late-onset adrenogenital syndrome). 

Another general feature is sexual hair that changes its density and properties especially on middle parts of body. The most frequently damaged areas include face, chest, areolas, white line, buttocks, sacrum , inner thighs and external genitalia. Hirsutism severity can be determined according to Ferriman-Gallwey system which assesses nine sections of the body. Within each one assigns points from 1 to 4 according to hair density ranging from absent to significant growth. Then the total scores can be calculated; if it exceeds the abnormal range then it should be considered as being over 7 – maximum score is equal to 36. Acne is always accompanied by other common features like menstrual irregularities, temporal recession of the hairline and frontal alopecia. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Androgen-secreting adrenal tumors 

Exogenous androgens 

Idiopathic hirsutism 

Androgen-secreting ovarian tumors 

Iatrogenic cushing syndrome 

PCOS (polycystic ovary syndrome) 

Congenital adrenal hyperplasia 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Combined oral contraceptive pills are commonly prescribed as a first-line treatment for hirsutism. They can help regulate hormone levels, reduce androgen production, and slow hair growth. Medications such as spironolactone or cyproterone acetate can block the effects of androgens on hair follicles, reducing hair growth. 

These medications are often combined with oral contraceptives for enhanced effectiveness. Prescription eflornithine creams can be applied directly to the affected areas to slow hair growth. In cases where hirsutism is associated with conditions like polycystic ovary syndrome (PCOS), maintaining a healthy weight through a balanced diet and regular exercise can help improve hormonal balance. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

For the management or reduction of hirsutism, various dietary, body mass control, stress relieving methods, enough sleep, environmental and lifestyle changes, medical and cosmetic interventions, and regular checkups can be employed. A balanced diet comprising of fruits, vegetables, whole grains, and lean proteins can be helpful in hormone regulation as well as overall health maintenance. Insulin levels can also be controlled through low glycemic index foods and healthy fats which manage hormones too. To keep hormonal balance regular physical activities are necessary along with techniques that lowers tress and self-monitoring. 

Use of oral contraceptives

Ethinyl estradiol, levomefolate and drospirenone: This is a combination of estrogen and progestins which suppresses the production of androgens from ovaries. 

Norgestimate and ethinyl estradiol: This is a combination of progestin and estrogen that acts by suppressing the ovarian synthesis of androgens. 

Ethinyl estradiol and drospirenone: It is a combination of estrogen and progestins which suppresses the production of androgens from ovaries. 

Ethinyl estradiol and norethindrone acetate: This is a combination of estrogen and progestins which suppresses the production of androgens from ovaries. 

Use of glucocorticoids

Prednisone: This drug might inhibit the synthesis of androgens that is ACTH-dependent via negative feedback. 

Dexamethasone:  This drug might inhibit the synthesis of androgens that is ACTH-dependent via negative feedback. Lower doses of this drug like 0.25mg can be more effective with lesser side effects. 

Use of selective aldosterone antagonists

Spironolactone: This drug reduces the production of testosterone. It can be combined with oral contraceptives for additive effects. 

Use of 5alpha-reductase inhibitors

Finasteride: It is a specific inhibitor of the cellular enzyme which in involved in the conversion of testosterone to androgen 5-alpha-dihydrotestostereone. It is as effective as spironolactone in treating hirsutism. It should be used only in postmenopausal women who cannot become pregnant.  

Non-pharmacologic treatment: Clinicians use cosmetic approaches that are appropriate for hypertrichoses and such cosmetic approaches can also be used as an effect of drug treatment that occurs only after 1 to 2 years which includes shaving or hair removal discoloration by hydrogen peroxide, chemical depilation (p. thioglycolates). By applying eflornithine topically and on twice daily basis, one can hinder the growth of their fine hairs. It’s rare to have electrolysis being administered nowadays compared to before except when dealing with hard white hairs. 

Surgical excision: In case of a tumor, surgery may be necessary and if there is severe hyperandrogenism in women during menopause or perimenopause, removal of ovaries also might be considered. 

use-of-phases-of-management-in-treating-hirsutism

Treatment of hirsutism demands a comprehensive approach with a concentrated plan of action. Nurse practitioners and other primary care professionals should also provide detailed education to clients about drug regimen compliance as well as time-intensive diagnostic processes. Consultation by psychologists might be necessary. Dermatologic nurses educate patients and do treatment monitoring. The pharmacist should be able to educate the person about pharmacological treatments as well as their limits, as well as make sure they check on drugs that contribute to the conditions. With an informed consent, the clinician should be able to provide treatment options and begin therapy. 

Medication

Future Trends

Media Gallary

References

Hirsutism – StatPearls – NCBI Bookshelf (nih.gov)