Patient education: Hirsutism (excess hair growth in women) (Beyond the Basics)

HIRSUTISM OVERVIEW — Hirsutism refers to the growth of coarse, dark hair in areas where women typically grow fine hair or no hair at all: above the lip and on the chin, chest, abdomen, and back. This excess hair growth is caused by an increased level of male hormones (androgens). Although all women produce androgens, increased levels of androgens can lead to acne and hirsutism. This article focuses on hirsutism.

Women with excess hair growth need to be evaluated by a health care provider, especially if the hair develops or worsens rapidly, or if her relatives have comparatively less hair growth. In the vast majority of cases, hirsutism is not caused by a serious medical condition; however, the cause of hirsutism should be determined, and underlying conditions may need to be treated.

HIRSUTISM CAUSES — Hirsutism is caused by an excess production or action of hormones called androgens, secreted by the ovaries or adrenal glands and produced locally in the hair follicle. Several different conditions can lead to hirsutism. The two most common causes of hirsutism are polycystic ovary syndrome (PCOS) and idiopathic hirsutism. Both are diagnosed by physical examination, medical and family history, and sometimes blood tests.

Polycystic ovary syndrome — Women with PCOS often have hirsutism in combination with irregular menstrual cycles. Instead of the normal 25- to 35-day menstrual cycle length, women with PCOS have cycle lengths that are >35 days; many women have fewer than six cycles per year. When cycles are this irregular, it usually means that a woman is not ovulating on a regular basis. Women with PCOS may also have acne and balding near the front of the head. PCOS is a chronic condition, but several treatments can reduce hair growth.

PCOS is also associated with other medical problems, such as infertility (due to irregular menstrual cycles), overweight/obesity, type 2 diabetes mellitus, high cholesterol levels, sleep apnea, depression, anxiety, and possibly heart disease (although this is not proven). Effective treatments for PCOS are available. (See "Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics)".)

HIRSUTISM TREATMENT — The decision to treat hirsutism is sometimes a matter of personal choice. There is a wide range of "normal" amounts of body hair among women. Race and ethnicity play a major role in the growth of body hair. As an example, Eastern Asian and Native American women tend to have little body hair, whereas Southern Asian, Middle Eastern, and Mediterranean women tend to have moderate to large amounts of body hair.

Although it is normal for women to have some amount of facial and body hair, popular culture reinforces a standard in which women should have little or no body hair. Women with hirsutism have high rates of depression and anxiety (independent of obesity and a PCOS diagnosis) that improve with treatment. Any woman who is troubled by hair growth should speak to her provider about potential treatment options.

Treatment expectations — The treatment of hirsutism requires patience because hair follicles have a life cycle of approximately six months. Most medications must be taken for six months before a noticeable improvement occurs. In the meantime, the existing hair can be mechanically removed or bleached, and some women continue to use these methods in combination with medication.

Your provider will monitor the progress of treatment and may repeat tests if he or she is concerned about an underlying condition. If a medication is ineffective initially, the dose or type of medication may be changed.

Duration of treatment — In women, androgen hormone concentrations decrease with age. Women in their 20s may need multiyear treatment to control the hirsutism. Women in their 30s and 40s have decreasing androgen concentrations; some women find that hormonal therapy is no longer necessary, but this is not true for all women. Hormonal treatments for hirsutism must be stopped before becoming pregnant.

Treatment for hair growth related to PCOS — The treatment of PCOS may also involve lifestyle changes including weight loss, treatment of infertility, diabetes, and risk factors for cardiovascular disease. (See "Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics)".)

Hair removal and lightening — Several methods can be used to physically remove or lighten excess hair so that it less noticeable. These methods can be used in conjunction with medication. However, women with hirsutism who are trying to become pregnant or are already pregnant cannot take medications for hirsutism. Pregnant women should ask their health care provider about the safety of the various mechanical and chemical treatment methods during pregnancy. Electrolysis and laser are both called "permanent hair reduction" techniques. However, for women with PCOS, hair will grow back after either treatment, unless medication to suppress hair growth is also taken (a birth control pill or antiandrogen).

●Shaving – Shaving is a safe and effective method for hair removal but may require daily sessions.

●Chemical hair removal, waxing, and bleaching – Hair removal agents and wax can be used to remove hair, and bleaches can be used to lighten hair. Depilatories and bleaches may cause skin sensitivity in some women, so be certain to follow the directions for patch testing.

●Electrolysis – Electrolysis damages individual hair follicles by inserting a very fine needle into the hair follicle and applying an electrical current. Electrolysis is best suited for treatment of small areas, although larger areas may be treated with multiple sessions over time. The treatment is safe and effective, but it can be painful and is often expensive. To find a qualified electrologist, inquire regarding the individual's training, experience, and licensing.

●Laser hair removal – Although expensive, laser hair removal is effective, faster, and less painful than electrolysis. It can often permanently reduce hair growth, particularly in those who are fair-skinned with dark hair. Most people require four to six treatments spaced approximately four to six weeks apart in order to achieve satisfactory hair removal, and maintenance treatments may be needed once every six to twelve months to remove the smaller fine hairs that grow back.

●Creams – Eflornithine hydrochloride (brand name: Vaniqa) is a skin cream that can be used to slow the growth of unwanted facial hair in women. It does not remove hair permanently. Noticeable results take approximately six to eight weeks, and once the cream is discontinued, hair returns to pretreatment levels after approximately eight weeks. Eflornithine cream may cause skin to redden. Prior to applying the cream over a larger area of the face, applying the cream to a small area of skin can test for this side effect.

Weight loss — Weight loss in overweight women can decrease levels of androgens and lessen hirsutism. Women with menstrual irregularities may also notice that their cycles become more regular after losing weight. (See "Patient education: Losing weight (Beyond the Basics)".)

Medications — Several medications are available for the treatment of hirsutism. These medications can decrease the amount of body hair, stop the growth of new hair, and decrease the growth rate and coarseness of existing hair. Most of these medications must be taken for at least six months before improvement is detectable, and not all medications are equally effective in all women.

●Birth control pills (combination estrogen-progestin oral contraceptives) – Birth control pills lower the levels of androgens. They are usually the first choice for the treatment of hirsutism, and between 60 and 100 percent of women with hirsutism will notice improvement when taking these medications. Birth control pills can also help establish regular withdrawal bleeding in women who have irregular cycles or who do not menstruate at all. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

●Antiandrogens – Antiandrogens are medications that directly decrease androgen production or block the action of androgens on the hair follicle. Because these medications may cause birth defects, an effective form of birth control (eg, birth control pills) is required for sexually active premenopausal women who take antiandrogens.

•The most commonly used antiandrogen is spironolactone. Spironolactone may be recommended, in addition to the birth control pill, if excess hair growth does not improve adequately after taking a birth control pill for six months. If the initial dose is not effective after several months of treatment, a higher dose may be recommended.

•Finasteride (sample brand names: Propecia, Proscar) is another option that is effective in some women, but it is not approved for use in women in the United States and is often not covered by insurers. Cyproterone acetate is an effective antiandrogen that is unavailable in the United States. It is used commonly in Europe and Canada, where it is a component of a birth control pill (sample brand names: Diane, Diane-35, Dianette).

●Combination therapy – Over time, many women find that a multipronged approach that includes direct hair removal (such as laser), suppression of androgen production with estrogen-progestin birth control pills, and androgen blockade with an antiandrogen (spironolactone) may produce the maximal reduction in bothersome hair growth. When undergoing laser hair removal, it is important to be on a medication such as the birth control pill to prevent hair regrowth.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Hirsutism (excess hair growth in women) (The Basics)
Patient education: Polycystic ovary syndrome (The Basics)
Patient education: Sertoli-Leydig cell tumor (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics)
Patient education: Losing weight (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Definition, clinical features, and differential diagnosis of polycystic ovary syndrome in adolescents
Clinical manifestations of polycystic ovary syndrome in adults
Etiology and pathophysiology of polycystic ovary syndrome in adolescents
Diagnosis of polycystic ovary syndrome in adults
Evaluation of premenopausal women with hirsutism
Metformin for treatment of the polycystic ovary syndrome
Pathophysiology and causes of hirsutism
Management of hirsutism in premenopausal women
Treatment of polycystic ovary syndrome in adolescents

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/ency/article/007622.htm, available in Spanish)

●Hormone Health Network

(www.hormone.org/diseases-and-conditions/hirsutism)

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