Hirsutism resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Hirsutism is a common endocrinological and dermatological complaint that is defined as a condition that results in the presence of excessive amounts of dark coarse hair (terminal hair) in a male-like pattern distribution in females. It usually appears in chin, upper lip, chest, back and anterior thighs. Hirsutism presents in 5-10% of females in reproductive age. Hirsutism is different from hypertrichosis that defined as excessive hair growth all over the body with no sexual distribution and it is not an androgen-dependent condition. Underlying androgen disorders are the most common causes of hirsutism and polycystic ovary syndrome (PCOS) accounts for nearly 70-80% of these conditions. Pharmacological therapy or direct hair removal methods is considered as initial therapy for women with mild hirsutism without underlying endocrine disorders. Lifestyle modifications are also recommended in obese patients with PCOS.
Causes
Common Causes
Hyperandrogenic hirsutism
- Polycystic ovary syndrome
- Idiopathic hyperandrogenemia
- Non-classical Congenital Adrenal Hyperplasia
- Androgen-secreting tumors
Non-hyperandrogenic hirsutism
Diagnosis
Shown below is an algorithm summarizing the diagnosis of disease name according the Endocrine Society Clinical Practice guideline.
| Initial evaluation & diagnosis of hirsutism | |||||||||||||||||||||||||||||||||||||||||||||||||
| History & physical examination including pelvic examination | |||||||||||||||||||||||||||||||||||||||||||||||||
| Medication use? *Ask for anabolic or androgenic steroids (in athletes, patients who are using dietary supplements, patients with sexual dysfunction, or in patients with a partner who uses testosterone gel) and valproic acid (in patient with neurologic disorders | Discontinue medication | ||||||||||||||||||||||||||||||||||||||||||||||||
| Isolated local hair growth | Direct hair removal methods | Improvement or stable | Normal variant | ||||||||||||||||||||||||||||||||||||||||||||||
| Abnormal hirsutism score or local hair growth with symptoms suggesting hyperandrogenic endocrine disorder*? *menstrual irregularity, infertility, galactorrhea, signs or symptoms of hypothyroidism, Cushing syndrome, acromegaly, central obesity,acanthosis nigricans, clitoromegaly, or sudden-onset or rapid-progression hirsutism suggests the presence of a hyperandrogenic endocrine disorder | |||||||||||||||||||||||||||||||||||||||||||||||||
| Early morning total testosterone blood level | Progression or unstable | ||||||||||||||||||||||||||||||||||||||||||||||||
| Normal | Elevated | ||||||||||||||||||||||||||||||||||||||||||||||||
| Mild isolated hirsutism | Moderate to severe hirsutism or presence of hyperandrogenic endocrine disorder | ||||||||||||||||||||||||||||||||||||||||||||||||
| Direct hair removal methods or oral contraceptive | |||||||||||||||||||||||||||||||||||||||||||||||||
| Improvement or stable | Progression or unstable | Free testosterone blood level | |||||||||||||||||||||||||||||||||||||||||||||||
| Normal | Elevated | Hyperandrogenemia | Full hormonal workup | ||||||||||||||||||||||||||||||||||||||||||||||
| Idiopathic hirsutism | Reevaluate if hirsutism progresses | ||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
| Initial therapy for patient with hirsutism | |||||||||||||||||||||||||||||||||||||||
| Mild hirsutism and no evidence of an endocrine disorder | Moderate or patient-important hirsutism | Severe hirsutism | |||||||||||||||||||||||||||||||||||||
| Direct hair removal methods | Pharmacological therapy | Pharmacological therapy (add direct hair removal if needed) | Combined pharmacological therapy | ||||||||||||||||||||||||||||||||||||
| • Photoepilation for women with auburn, brown, or black unwanted hair • Electrolysis for women with white or blonde hair | • Start oral contraceptives in women who are not seeking fertility ** Use oral contraceptives containing the lowest effective dose of ethinyl estradiol and a low-risk progestin for women at higher risk for venous thromboembolism (e.g., obese or >39 years old) • Start either oral contraceptives or anti-androgens in women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception | Oral contraceptives and antiandrogens | |||||||||||||||||||||||||||||||||||||
| Add an antiandrogen if hirsutism remains despite 6 months of monotherapy with an oral contraceptive | |||||||||||||||||||||||||||||||||||||||
Do's
- The content in this section is in bullet points.
Don'ts
- The content in this section is in bullet points.