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BASICS

Description

  • Excessive coarse, pigmented terminal hair in male distribution on body and face.
  • Can be ethnic or due to androgen excess.
  • Commonly seen in PCOS (hirsutism, acne, menstrual irregularities, obesity).

Epidemiology

  • Prevalence: 5-10% of reproductive-age women.

Etiology and Pathophysiology

  • Increased androgenic hormones from ovaries, adrenals, or peripheral conversion.
  • Idiopathic (increased peripheral androgen binding).
  • Can be secondary to androgen-secreting tumors or medication use.
  • Multifactorial genetics.

Risk Factors

  • Family history, ethnicity (Ashkenazi Jews, Mediterranean).
  • Obesity.

General Prevention

  • Counseling for late-onset CAH carriers.

Commonly Associated Conditions

  • PCOS (most common cause)
  • Acne
  • Central obesity
  • Virilization (rapid onset, clitoromegaly, balding, deep voice).

DIAGNOSIS

History

  • Onset, severity, progression.
  • Weight, BMI.
  • Psychosocial impact.
  • Menstrual and fertility history.
  • Severe acne, virilization.
  • Medication review (valproic acid, testosterone, danazol, glucocorticoids).
  • Galactorrhea presence.

Physical Exam

  • Hair growth in chin, neck, sideburns, lower back, sternum, areola, abdomen, shoulders, buttocks, perineum, inner thighs.
  • Acne, striae, acanthosis nigricans.
  • Virilization signs.
  • Ferriman-Gallwey scale (0–4 in 9 areas; >8 positive; 8-15 mild, 16-25 moderate, >25 severe).

Differential Diagnosis

  • PCOS (72-82%)
  • Idiopathic hyperandrogenemia (6-15%)
  • Idiopathic hirsutism (4-7%)
  • Late-onset/non-classic CAH (2-4%)
  • Androgen-secreting tumors (0.2%)
  • Thyroid dysfunction, hyperprolactinemia
  • Cushing syndrome, acromegaly
  • Medication side effects.

Diagnostic Tests

  • Early morning 17-hydroxyprogesterone for NCCAH screening.
  • PCOS diagnosis: 2/3 criteria—menstrual dysfunction, hyperandrogenemia, polycystic ovaries.
  • Random total testosterone; repeat with free testosterone if normal but clinical suspicion remains.
  • Testosterone >150-200 ng/dL → imaging for ovarian/adrenal tumors.
  • Metabolic screening (fasting glucose, lipids, waist circumference, BP).
  • Prolactin, FSH, LH, TSH if amenorrheic.
  • DHEA-S if virilization.

TREATMENT

General Measures

  • Tailored to patient preference and psychosocial impact.
  • Decrease new hair growth and improve metabolic profile.
  • Weight loss for overweight/obese.
  • Treat associated acne.
  • Provide contraception as needed.

Medications

First Line

  • Oral contraceptives to suppress ovarian androgen production and increase SHBG; improve menstrual irregularities.
  • Use progestins with antiandrogenic properties (norgestimate, desogestrel, drospirenone).
  • Eflornithine cream (Vaniqa): topical, slows facial hair growth (indefinite use).
  • Combination of OCPs and antiandrogens reserved for severe cases or after 6 months OCP failure.

Second Line

  • Antiandrogens (with OCPs):
  • Spironolactone 50-200 mg/day (monitor potassium; avoid in pregnancy).
  • Finasteride 2.5-7.5 mg/day (off-label; pregnancy Category X).
  • Cyproterone (not available in US).
  • Leuprolide 3.75 mg IM monthly (side effects: bone loss, dryness, avoid in pregnancy).
  • Flutamide not recommended (hepatotoxicity).
  • Cosmetic hair removal: temporary (shaving, waxing) or permanent (laser preferred; electrolysis for light hair).

Pregnancy Considerations

  • Related infertility possible.
  • Hormonal treatments contraindicated.
  • Provide contraception as needed.

Complementary Medicine

  • Glycyrrhiza uralensis and Paeonia lactiflora may lower androgen levels (limited evidence).

ONGOING CARE

  • Monitor medication side effects.
  • Encourage low-calorie, low-glycemic diet in PCOS patients.

PATIENT EDUCATION

  • Hormonal treatments prevent new hair growth but do not reverse existing hair.
  • Cosmetic removal may be needed for present hair.
  • Treatment takes at least 6 months.

PROGNOSIS

  • Good for halting new hair growth.
  • Moderate to poor for reversing existing hair.

COMPLICATIONS

  • PCOS-related: dysfunctional uterine bleeding → anemia, endometrial hyperplasia, cancer risk.
  • Androgen excess may worsen lipid profile, cardiac risk, and bone density.

REFERENCES

  1. Martin KA, Anderson RR, Chang RJ, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(4):1233-1257.

  2. Matheson E, Bain J. Hirsutism in women. Am Fam Physician. 2019;100(3):168-175.

  3. Goodman NF, Cobin RH, Futterweit W, et al; American Association of Clinical Endocrinologists, American College of Endocrinology, Androgen Excess and PCOS Society. Guide to the best practices in evaluation and treatment of PCOS—part 1. Endocr Pract. 2015;21(11):1291-1300.

  4. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. ACOG practice bulletin no. 194: polycystic ovary syndrome. Obstet Gynecol. 2018;131(6):e157-e171.

  5. Williams T, Moore JB, Regehr J. Polycystic ovary syndrome: common questions and answers. Am Fam Physician. 2023;107(3):264-272.

  6. Arentz S, Abbott JA, Smith CA, et al. Herbal medicine for PCOS and hyperandrogenism: review of lab evidence with clinical findings. BMC Complement Altern Med. 2014;14:511.