What is hirsutism? Hirsutism refers to excessive growth of dark, thick and coarse hair in an individual (usually female) in a male pattern. Commonly affected areas are upper lips, chin, central chest, midline of the stomach, lower back, buttocks and front of thighs. Hirsutism affects approximately 10% of women in Western societies and is commoner in those of Mediterranean or Middle-Eastern descent. If the excessive hair is generalised and not in a gender specific pattern, the term is ‘hypertrichosis’, which means increased (‘hyper’) hair (‘trichosis’).
Is hirsutism hereditary? No, although some cases can run in families.
What causes hirsutism? Hirsutism can be caused by an increased androgen production, increased skin sensitivity to androgens, or both. Androgens are often thought of as exclusively ‘male hormones’ but, in fact both men and women produce them; men usually in greater amounts than women. In premenopausal women, the most common cause of hirsutism is due to polycystic ovary syndrome (PCOS). However, there can be no apparent underlying cause found in about a quarter of women. Most women develop more facial or body hair gradually as they get older, especially after the menopause. Rarely, hirsutism can be caused by medications such as steroids, and other hormonal disorders. Extremely rarely, hirsutism can be caused by tumours that secrete androgens. In such cases the hirsutism will be severe and appear in a very short period. Your endocrinologist may request some hormone tests, possibly an ultrasound of the pelvis (to look for PCOS). It is important to see your doctor if your hirsutism is associated with any of the following: • Developing quickly (over 1-2 years), or before puberty; • Accompanied by menstrual problems; • Associated with features suggesting an increase in androgens such as thinning of the scalp hair, baldness, or deepening of the voice; • Accompanied by obesity or diabetes.
How can hirsutism be treated? In the rare cases where there is an underlying hormonal disorder, the treatment is of the underlying disease. Treatments for hirsutism where there is no underlying cause or in association with PCOS include:
Self-care (What can I do?) • Shaving. Some people think that shaving encourages more hair growth, but this is not true. However, the stubble that follows regrowth may be undesirable. Frequent shaving can irritate your skin. • Waxing is effective for some people, but can irritate the skin and should be used with caution on the face. Scarring occasionally follows. Folliculitis (inflammation of the hair follicles) can occur with shaving, and waxing. • Depilatories (creams that remove hair) chemically dissolve hair shafts thereby leaving no stubble, but may also irritate your skin. Before using them you should first test your skin to see how sensitive it is. Always follow the manufacturer’s instructions for testing and product applications. • Bleaching creams are designed to make the dark hairs pale. They can irritate the skin and may be unsuitable for brown and black skins.
Physical treatments • Electrolysis. An electrical current is passed into a hair follicle through a needle. The aim is to destroy the hair root permanently. Electrolysis is relatively expensive and time-consuming. Before you have electrolysis, check that the practitioner uses new, disposable (not simply re-sterilised) needles. Equipment designed for electrolysis at home are not recommended. Scarring is a potential side effect of this treatment. • Laser and intense pulsed light (IPL) treatments also aim to destroy the hair root permanently. Laser treatment and IPL are expensive and several treatments are given over a period of months. This form of hair reduction must be done at a special clinic by an operator who is properly qualified. Possible side effects include redness, darkening or lightening of the skin, and scarring. Total compliance during the treatment plan is required; this will include no sun bathing (or fake tanning) and cessation of all forms of hair removal, with the exception of shaving.
Medical treatments • Eflornithine cream. This cream works by slowing hair growth. It is not a depilatory cream. It has recently been accepted for use in women for whom other medical treatments cannot be used or have been ineffective. It can be applied after any regular hair removal techniques, such as the self-care or physical methods described in the preceding paragraphs. It is left on the skin to inhibit hair growth. The cream takes two to three months of regular use to have an effect. Continued treatment is needed to maintain beneficial effects. Side effects are usually mild and include burning or stinging of the skin and acne.
• Anti-androgens. Your doctor may prescribe these to block the action ofthe androgens that can cause hirsutism. Anti-androgens usually take 4- 6 months to have an effect. Hair growth will then slow, and the hairs will gradually become thinner and less noticeable; the problem, however, tends to return when medication is stopped. Anti-androgens include: • Oral contraceptives. Some low-dose combined pills may help, and one has been designed specifically to have an anti-androgenic activity. Side effects include spotting (bleeding between periods), tender breasts, nausea and headaches, especially in the first few months. The oral contraceptive pill is not suitable for everyone. • Cyproterone. Combined with an oral contraceptive this can help women with hirsutism. Larger doses of cyproterone (i.e. 50 to 200 mg for 10 days each cycle) can be used for more severe hirsutism. Side effects include weight gain, depression, blood clotting in veins of legs and loss of libido. • Spironolactone. This is used more commonly in the USA than in the UK. It works as an anti-androgen but also increases the amount of urine that is passed – in other words it is also a water tablet (diuretic). Spironolactone (50 to 200 mg daily) can slowly reduce excessive hair growth. Side effects include tender breasts, irregular menstruation and liver damage. • Finasteride. Used at the dose to treat benign prostatic hyperplasia (5mg), rather than male-pattern baldness (1mg). This drug blocks the enzyme that makes testosterone into the active androgen dihydrotestosterone. It appears to be as effective as spironolactone, but is not licensed for treating hirsutism in the UK. Its usage should be restricted to postmenopausal women.
N.B. An important side effect of all anti-androgen drugs is that they can harm an unborn male baby if you take them while you are pregnant. For this reason, they must not be taken unless you are using effective contraception.