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Hirsutism: An Overview

Hirsutism – characterized by the excessive growth of coarse terminal hair in androgen-sensitive body parts, is a prevalent endocrine condition affecting up to 10% of young females. Polycystic ovary syndrome (PCOS) and idiopathic hirsutism account for 90% of cases. 

Patients with hirsutism often require additional evaluations and treatment plans. Mechanical hair removal and lifestyle modifications are the first-line management strategies. Laser and phototherapy are increasingly popular. 

If not contraindicated, the combined contraceptive pill is the initial medical treatment of choice, followed by anti-androgen therapy. Emerging treatments include inositol and vitamin D, especially for PCOS patients. It is important to discuss treatment options with patients, regardless of the clinical severity – to address potential underlying psychosocial concerns.

Hair is an integral part of the integumentary system, serving multiple functions such as thermoregulation, barrier protection, pheromone, sebum, or sweat production, and influencing social interactions. Hair follicles are categorized into vellus and terminal hair. Vellus hair is fine, thin, and lightly pigmented, covering most of the body. Terminal hair is coarse, thick, and pigmented, covering the scalp, forming eyebrows and eyelashes, and developing in the underarms and pubic area during puberty.

Generalized excess body hair growth in both genders is termed hypertrichosis. Hirsutism, however, is defined as the excessive growth of coarse, terminal hair in androgen-sensitive areas such as the chin, upper lip, chest, upper arms, lower back, and thighs, predominantly affecting women. It is a common endocrine dysfunction seen in women of reproductive age and can also be present in trans-feminine individuals. The primary complaints include aesthetic concerns and irregular menses, but the psychosocial impact of hirsutism and other androgen excess pathologies cannot be overlooked.

Hirsutism affects approximately 5-10% of the population, with a higher prevalence among Afro-Caribbean, Hispanic, Mediterranean, Middle Eastern, and South Asians. A holistic approach should be used to identify underlying pathologies and address psychological concerns. 

This condition precipitates from increased testosterone production or heightened follicular androgen sensitivity. Androgenic steroids like testosterone and dihydrotestosterone (DHT) transform vellus hair into terminal hair in various body areas. Elevated androgen levels during puberty cause vellus hair to become larger terminal follicles with a prolonged active growth phase. Hyperandrogenism in hirsutism can stem from various sources, including ovarian or adrenal pathologies, androgen-secreting tumors, or idiopathic origins. The primary ovarian cause is PCOS, while adrenal causes include Cushing's syndrome and congenital adrenal hyperplasia (CAH). Obesity, insulin resistance, and other hormonal imbalances may also be contributory.

Evaluating hirsutism requires a thorough history and physical examination – to assess symptoms and signs of clinical hyperandrogenism. 

Treatment depends on symptom severity, psychological impact, and family planning considerations. Primary interventions include lifestyle changes such as diet, exercise, and weight loss. Medical professionals must recognize the psychological burden of hirsutism and offer treatment options without prejudice, regardless of the clinical presentation.

Hirsutism can be classified as mild, moderate, or severe based on clinical assessment, but this classification may not fully capture the psychosocial and psychosexual impact experienced by these patients.

Source: Armata I, Prakash A. Obstetrics, Gynaecology & Reproductive Medicine. 2024 Feb 12.