Diagnosis of Hirsutism and Hypertrichosis
Treatment for Hirsutism and Hypertrichosis
Overview
Hirsutism is defined as the abnormal growth of terminal (coarse) hair in women following a male pattern distribution. This includes the growth of hair on areas such as the face, chest, back, and inner thighs. Normally, these areas exhibit vellus (fine, light) hair in women, but in hirsutism, the hair becomes thick and pigmented, resembling male hair growth patterns. The onset of hirsutism is often during or after puberty and is commonly associated with hormonal imbalances, particularly involving androgens, the male sex hormones.
What is Hypertrichosis?
In contrast to hirsutism, hypertrichosis refers to excessive hair growth that can occur in both males and females, independent of androgen levels. Hypertrichosis can involve both terminal and vellus hair and may be localized to certain body parts or be widespread. This condition is not linked to hormonal disturbances and can occur at birth (congenital hypertrichosis) or be acquired later in life. While hirsutism is driven by hormonal imbalances, hypertrichosis arises due to genetic factors or other non-hormonal triggers, making the two distinct conditions.
Who Gets Hirsutism?
The prevalence and presentation of hirsutism can vary widely depending on cultural, ethnic, and genetic factors. In certain ethnic groups, such as women of Mediterranean, South Asian, and Middle Eastern descent, higher hair density is often considered normal. However, when excessive hair growth is abnormal for a woman’s age, race, and familial characteristics, it is classified as hirsutism. Genetic predisposition plays a significant role, as does hyperandrogenism, which can arise from various underlying causes, including polycystic ovary syndrome (PCOS), adrenal or ovarian tumors, and certain medications.
Hypertrichosis: A Broader Condition
Hypertrichosis is less commonly encountered than hirsutism and can present either as a congenital or acquired condition. Congenital hypertrichosis can result in extensive hair growth over the entire body or in localized areas, often linked to specific genetic mutations. Acquired hypertrichosis may occur due to systemic conditions such as porphyria, malnutrition, or the use of medications like cyclosporine and phenytoin. It may also develop after physical trauma or chronic irritation of the skin.
Symptoms of Hirsutism
Hirsutism is characterized by the presence of thick, dark hair on areas where women typically do not grow terminal hair, such as the face (moustache and beard area), chest, lower abdomen, back, and thighs. In more severe cases, hirsutism may be accompanied by signs of virilization, which include a deepening voice, balding, acne, decreased breast size, increased muscle mass, and clitoromegaly. These additional symptoms suggest elevated androgen levels and warrant further investigation for possible underlying endocrine disorders.
When to Seek Medical Advice
Women who notice excessive hair growth on their face or body should consult with a healthcare provider, especially if the hair growth is rapid, severe, or accompanied by other symptoms of virilization. A thorough medical assessment can help identify whether the hirsutism is due to benign conditions like PCOS or more serious causes, such as adrenal or ovarian tumors. Referral to an endocrinologist or dermatologist may be necessary for specialized hormonal and dermatological evaluation.
Causes of Hirsutism
The primary cause of hirsutism is an excess of androgens or increased sensitivity of hair follicles to these hormones. Common causes include:
- Polycystic Ovary Syndrome (PCOS): This is the most frequent cause of hirsutism and is characterized by irregular menstrual cycles, obesity, infertility, and the presence of multiple ovarian cysts. PCOS often results in a slow progression of hirsutism over time.
- Cushing Syndrome: Excessive cortisol production, either from the adrenal glands or from long-term use of corticosteroid medications, can lead to hirsutism.
- Congenital Adrenal Hyperplasia (CAH): This genetic disorder affects the adrenal glands’ ability to produce cortisol and aldosterone, leading to increased androgen production and subsequent hirsutism.
- Medications: Drugs such as minoxidil, danazol, anabolic steroids, and testosterone supplements can increase androgen levels and result in excessive hair growth.
- Androgen-Secreting Tumors: Although rare, tumors of the adrenal glands or ovaries can cause marked increases in androgens, leading to hirsutism and virilization.
In many cases, no specific cause is identified, and the condition is termed “idiopathic hirsutism.”
Risk Factors for Hirsutism
Several factors can increase the likelihood of developing hirsutism, including:
- Family History: Genetic predisposition plays a significant role, especially in conditions like PCOS and congenital adrenal hyperplasia.
- Ethnicity: Women of Mediterranean, Middle Eastern, and South Asian descent tend to have more body hair naturally, which can be mistaken for hirsutism.
- Obesity: Excess weight can exacerbate hirsutism by increasing insulin resistance and stimulating androgen production.
Diagnosis of Hirsutism and Hypertrichosis
Hirsutism is typically diagnosed using the Ferriman-Gallwey scoring system, which assesses hair growth in nine specific body areas. A score of 8–14 indicates mild hirsutism, while a score above 15 suggests moderate to severe hirsutism. A general medical examination may reveal other signs of underlying hormonal imbalances, such as acne, obesity, acanthosis nigricans, or signs of virilization.
Blood tests are often conducted to measure androgen levels, including testosterone and dehydroepiandrosterone sulfate (DHEA-S). In cases where adrenal or ovarian tumors are suspected, imaging studies such as ultrasound or CT scans may be necessary. For women with signs of insulin resistance or hyperandrogenism, testing for PCOS and congenital adrenal hyperplasia is recommended.
Treatment for Hirsutism and Hypertrichosis
The treatment of hirsutism depends on its severity, underlying cause, and the patient’s preferences. Treatment options include:
- Lifestyle Changes: Weight loss can help reduce insulin resistance and lower androgen levels, particularly in women with PCOS.
- Physical Methods of Hair Removal:
- Shaving: A simple, temporary method of hair removal.
- Waxing and Depilatory Creams: These methods offer longer-lasting results but can irritate sensitive skin.
- Electrolysis and Laser Hair Removal: These are more permanent solutions but may require multiple treatments and can be expensive.
Medications:
- Oral Contraceptives: Birth control pills can regulate menstrual cycles and reduce androgen production, thereby decreasing hair growth.
- Anti-Androgens: Medications like spironolactone, cyproterone acetate, and finasteride can block androgen receptors and reduce hair growth.
- Topical Eflornithine: This cream slows facial hair growth and is particularly useful for mild cases of hirsutism.
- Metformin: Often prescribed for women with PCOS, metformin improves insulin sensitivity and can indirectly reduce androgen levels.
- Hormonal Therapy: For severe cases, hormone therapy with glucocorticoids or gonadotropin-releasing hormone agonists may be necessary.
Complications of Hirsutism
The psychosocial impact of hirsutism can be profound, leading to embarrassment, low self-esteem, and depression. In cases where hirsutism is caused by underlying endocrine disorders, complications can include infertility (as in PCOS), metabolic syndrome, and increased cardiovascular risk.
Long-Term Outlook and Prevention
Hirsutism tends to persist or worsen with age, especially if related to genetic predispositions or chronic conditions like PCOS. Prevention of hirsutism is not possible, but managing risk factors such as obesity and insulin resistance can reduce its severity. Early diagnosis and treatment of hormonal imbalances, such as in PCOS or Cushing syndrome, can also prevent the progression of hirsutism.
For individuals with hypertrichosis, the prognosis depends on the underlying cause. In cases of acquired hypertrichosis due to medications or systemic conditions, hair growth may subside once the offending agent is discontinued or the primary condition is treated.
Conclusion
Hirsutism is a common and distressing condition affecting many women. While it is often benign, it can be a sign of underlying endocrine disorders that require medical attention. A combination of lifestyle changes, physical hair removal methods, and medical treatments can effectively manage the symptoms of hirsutism. For women with hypertrichosis, addressing the underlying cause is key to managing excessive hair growth. Early intervention and proper management can significantly improve the quality of life for affected individuals.
References
Cleveland Clinic. (n.d.). Hirsutism. Retrieved from https://my.clevelandclinic.org/health/diseases/9194-hirsutism
DermNet NZ. (n.d.). Hirsutism. Retrieved from https://dermnetnz.org/topics/hirsutism
Mayo Clinic. (n.d.). Hirsutism. Retrieved from https://www.mayoclinic.org/diseases-conditions/hirsutism/symptoms-causes/syc-20354938
National Health Service (NHS). (n.d.). Hirsutism. Retrieved from https://www.nhs.uk/conditions/hirsutism
