hirsutism



OVERVIEW

Definition.

Hirsutism is the technical term used to describe abnormal hair growth in women. Hirsutism is defined as excessive hair growth with a masculine distribution compared to women of the same race and age.

It is characterized by the appearance of coarse, long terminal hairs in androgen-dependent areas such as the face (moustache, beard), the front of the ears, the areola, the chest, the upper abdomen, the lower abdomen, and the upper back.

Hirsutism reflects elevated levels of androgens in the circulation or increased responsiveness to androgens in end organs such as hair follicles and sebaceous glands.

Hirsutism and hypertrichosis are two different disorders.

Hirsutism mostly refers to excessive growth of hair (terminal hair) in androgen-dependent areas in females (girls and adult females), whereas Trichotillomania is the excessive growth of hair (cuirasses, millia, and terminal hair) on any part of the body.

Typing and Classification

Clinically, it is categorized into the following 3 types according to the etiology.

Normal androgenic hirsutism

Idiopathic hirsutism accounts for about 10% of patients with hirsutism, also known as somatic or cutaneous hirsutism, with a clear tendency of family aggregation.

Endocrine disorders, such as acromegaly, and all diseases that can cause hyperprolactinemia can cause hirsutism.

Hyperandrogenic hirsutism

Polycystic ovary syndrome: It is the most important cause of hirsutism in women, accounting for 70% to 80% of patients with hirsutism.

Tumors: ovarian granulosa cell tumor, ovarian blastocytoma, adrenal adenoma, adrenal carcinoma, pituitary tumor, etc., hirsutism develops rapidly, and masculinization may occur.

Congenital adrenal hyperplasia: autosomal recessive disorder, most commonly caused by 21-hydroxylase deficiency.

Insulin resistance: high levels of insulin in the body can lead to hirsutism with acanthosis nigricans.

Drug induced hirsutism

Drug induced hirsutism, also known as medically induced hirsutism, is rare. Hairiness is limited to the face and flanks of the back and improves or disappears when medications are discontinued.

Morbidity

The incidence of hirsutism in women of childbearing age is 5% to 10%.

Causes

Causes

The occurrence of hirsutism is related to the increased level of androgens in the body or the increased sensitivity of hair follicles to androgens; part of hirsutism is related to heredity.

Genetic factors: congenital adrenal hyperplasia is an autosomal recessive disease; idiopathic hirsutism has obvious family tendency, suggesting that it may be genetically related.

Endocrine factors: acromegaly and other factors, can cause anterior pituitary hormone, adrenocorticotropic hormone, prolactin, insulin secretion increase, on the androgen metabolism.

Tumor factors: pituitary tumors, adrenal adenomas, adrenal adenocarcinomas, etc. can cause hypercortisolism (Cushing’s syndrome), which can lead to a large increase in androgens and is associated with the development of hirsutism.

Drug factors: such as testosterone, danazol, glucocorticoids, acetazolamide, phenytoin sodium, amphotericin, dihydroclonidine, minoxidil, diazepam, cyclosporine, etc., can lead to hirsutism.

Symptoms

Main Symptoms

Hair changes

Excessive hair growth and masculine distribution.

Thick, long terminal hairs appear mainly on the face, in front of the ears, areola, chest, upper abdomen, lower abdomen, and upper back.

In hirsutism caused by pituitary, ovarian, or adrenal tumors, the hairiness often appears suddenly and worsens rapidly.

In hirsutism caused by ovarian-derived androgens, the hairiness is often limited to the areola and the sides of the face and neck.

In hirsutism due to adrenal-derived androgens, it is primarily limited centrally, to the pubic triangle to the epigastric region, and from the sternal stalk to the neck and cheeks.

When the hirsutism is located only on the sides and back of the face, it is most often drug-induced hirsutism.

Loss of female sexual characteristics

Manifested by female pattern hair loss, menstrual changes or scanty menstruation, breast atrophy, and infertility.

Masculinized sexual characteristics

May be seen as a higher degree of loss of female sexual characteristics, such as amenorrhea, decreased libido, increased muscle mass, loss of curves of the female form, and coarsening of the voice.

Other symptoms

Seborrhea, facial acne, and breast milk overflow may be present.

Cushing’s syndrome may be accompanied by obesity, “full moon face”, “buffalo back”, purple streaks on the skin, and increased blood pressure.

Hyperpigmentation and velvety thickening plaques (acanthosis nigricans) may be present.

Symptoms in special populations

Female newborns with congenital adrenal hyperplasia may have typical external genital hermaphroditism, whereas male newborns may show only mild genital hyperpigmentation.

Childhood may show precocious axillary and pubic hair growth, with acne, alopecia and overgrowth of male-distributed hair occurring soon after.

Consultation

Department of Medicine

Department of Dermatologic Diseases

If excessive hair growth occurs on the face, in front of the ears, on the areola, on the chest, on the abdomen, or on the upper back, it is advisable to consult a doctor promptly.

Gynecology

If you experience an increase in hair growth all over your body, with or without obesity, acne, menstrual disorders, breast atrophy or lactation, it is recommended that you consult a doctor promptly.

Preparation

Preparation for consultation: registration, preparation of documents, FAQs

Tips

Please do not trim excess hair on your own before your visit, and avoid the use of cover-up cosmetics to avoid interfering with the doctor’s observation.

Preparation Checklist

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

When did the hair increase occur and has it worsened significantly recently?

What are the areas of increased hairiness?

Are there any abnormalities such as weight gain, acne, menstrual disorders, etc.?

Are there any comorbidities such as adrenal hyperplasia, ovarian tumors, Cushing’s syndrome, insulin resistance syndrome, acromegaly, etc.?

Any history of allergies to food, drugs or other substances?

Test results from the last three months to bring to your doctor’s appointment

Blood Tests

Free cortisol, adrenocorticotropic hormone, blood glucose, triglycerides, serum insulin

Serum Sex Hormones

Thyroid function

Ovarian ultrasound, adrenal ultrasound

Medication use in the last 3 months, bring box or package with you to the doctor if available

Androgenic or antiandrogenic agents (oral): testosterone, danazol

Glucocorticoids (oral): prednisone, methylprednisolone, dexamethasone

Diagnosis

Diagnosis is based on

Medical history

May have a history of conditions such as acromegaly.

May have pituitary tumor, adrenal adenoma, adrenal cancer, etc.

May have a history of drug use such as testosterone, danazol, glucocorticoids, etc.

May have a family history of hirsutism.

Clinical manifestations

Thick, long terminal hairs appear on the face, in front of the ears, areola, chest, upper abdomen, lower abdomen, and upper back.

May have female pattern hair loss, scanty menstruation, breast atrophy, and infertility.

There may be masculinized sexual characteristics such as amenorrhea, decreased libido, increased muscle mass, loss of curves of the female form, and coarsening of the voice.

It may be accompanied by seborrhea, facial acne, breast milk overflow, or obesity, purple lines, or hyperpigmentation and velvety thickening.

Laboratory Tests

Plasma androgen levels: plasma total testosterone, sex hormone binding globulin, free testosterone, plasma androstenedione and plasma dehydroepiandrosterone sulfate. Increased plasma dehydroepiandrosterone sulfate in female patients suggests increased adrenal-derived androgens.

Plasma 17-hydroxyprogesterone: Patients with 21-hydroxylase-deficient congenital adrenocortical hyperplasia have significantly higher basal levels of plasma 17-hydroxyprogesterone.

Serum Prolactin: Serum prolactin should be measured if menstrual disorders are present.

If manifestations of Cushing’s syndrome are present, 24-hour urine free cortisol, blood cortisol circadian rhythm, and low-dose dexamethasone suppression test should be performed for screening.

Monitor basal body temperature, luteinizing hormone (LH), follicular estrogen (FSH), and progesterone levels on days 20-22 of the menstrual cycle to clarify the presence of anovulatory menstruation.

Imaging

Patients with sudden onset of hirsutism and masculinized sexual characteristics, or prolonged severe hirsutism, require further ultrasound, CT, or magnetic resonance imaging (MRI) to help localize and characterize ovarian and adrenal tumors.

Ultrasound of the uterus and both adnexa should be routinely performed.

Polycystic ovary syndrome is seen in the presence of 12 or more small follicles in the ovary, 2 to 9 millimeters in diameter, which may be accompanied by an increase in ovarian size (>10 milliliters).

Congenital adrenal hyperplasia or suspected adrenal tumor should be treated with thin-layer enhanced CT or MRI of the adrenal glands.

Differential Diagnosis

Hypertrichosis

Excessive hair refers to an increase in the number of hairs on the surface of the body and an increase in the density of their distribution, commonly on the calves and lateral thighs.

The increase in pubic hair is not significant and there are no signs of masculinization.

Acquired Restricted Hirsutism

Hirsutism occurs primarily at sites of irritation or trauma.

The onset is often preceded by irritation such as repeated trauma, friction, scratching, or inflammation, and can also be observed at sites such as scar excision or laser hair removal.

Treatment

Hirsutism first requires removal of the cause. For those with mild clinical manifestations of hirsutism and abnormal blood biochemical test results, localized treatment can be chosen; for those with severe symptoms, extensive distribution of hairiness and abnormal blood biochemical test results, systemic drug treatment can be considered.

General treatment

Drug-induced hirsutism should stop using the drugs that cause hirsutism.

Patients with hirsutism need to pay attention to lifestyle changes, especially for overweight or obese polycystic ovary syndrome patients, diet and exercise treatment is the basis.

Localized treatments

Physical therapy

Ionization, laser and light-based hair removal methods are available.

These methods can be applied alone or as a supplement to medication, but skin irritation, folliculitis, hyperpigmentation and even scar formation may occur.

Topical medications

15% Eflornithine Hydrochloride Cream can be used to treat mild facial hirsutism with some efficacy, but it is prone to recurrence after stopping the medication.

Cosmetic treatment

6%~12% hydrogen peroxide or 20% ammonia solution can be used for hair bleaching.

Depilatories such as 2%~4% calcium mercaptoacetate can be used to remove the visible part of the hair shaft.

Excess hair can be removed with razors, tweezers, wax or beeswax, but care should be taken to protect the local skin to avoid trauma that may cause infection.

Systemic medication

Systemic medication usually takes effect after 6 to 9 months of medication and takes 12 to 24 months to achieve the best results. In order to prevent recurrence, some patients may need to take medication for life.

Because of the risk of feminization of the male fetus with antiandrogenic agents, women of childbearing age are advised to wait until treatment is completed before making plans for childbearing.

Medications need to be used as prescribed by the doctor, avoiding self-administration, dosage adjustments, or discontinuation of medications.

Oral contraceptives reduce androgen production with an effectiveness rate of only 50% or less.

They can be used as a first-line medication for people with increased testosterone levels, especially in polycystic ovary syndrome patients with a need for contraception.

Antiandrogen drugs block the action of androgens in the periphery, and the main drugs used clinically are the following:

Spironolactone

Cyproterone

Flutamide

Finasteride: Minor adverse effects, occasional headache, gastrointestinal reactions and decreased libido. Contraindicated in pregnant women.

Other treatments

Hirsutism caused by other diseases should be actively dealt with the primary disease, and hirsutism can be relieved after the primary disease is controlled, such as acromegaly.

Pituitary, ovarian and adrenal tumors, surgical resection of the tumor is the mainstay.

Prognosis

Cure

If the cause of hirsutism is clear, such as other diseases or medications, and if the cause can be removed, the hirsutism will be cured.

If the disease recurs or the medication that caused the hirsutism is used again, the hirsutism may reappear.

If the cause is not clear or cannot be removed, hirsutism cannot be cured.

Hazards

Hirsutism can cause some psychological and social stress to the patient and may affect daily life.

If hirsutism is caused by a tumor, such as adrenal cancer, untimely treatment may affect life expectancy.

Polycystic ovary syndrome, if the condition is serious, may cause infertility.

Daily

Daily management

Hirsutism generally does not require special dietary or lifestyle management.

If physical therapy or cosmetic and other related treatments are performed the following needs to be taken care of.

Dietary management

It is recommended to focus on a diet high in protein, calories and vitamins, and eat more fish, shrimp, eggs, soy products and other high-quality protein foods.

Eat more fresh vegetables and fruits to supplement vitamins to enhance resistance.

Avoid spicy, fried and other stimulating foods.

Skin care

Do not apply drugs and cosmetics before physical therapy.

If itching or other discomfort occurs in the treatment area, consult your doctor to deal with it and do not scratch.

If there is wound after treatment, keep the wound clean to avoid infection.

After treatment, pay attention to sun protection, avoid direct sunlight, go out and take good protection, such as wearing sun hats, umbrellas, topical sunscreen products and so on.

Psychological support

Family and friends should sympathize with, care for and consider the patient, and create a kind, gentle and harmonious interpersonal environment.

Family members should help patients to build up confidence and courage to overcome the disease, so that they can take the initiative to cooperate with the treatment and care.

Prevention

There is no effective preventive measure for idiopathic hirsutism.

It is recommended to follow the doctor’s prescription and avoid self-medication to avoid the occurrence of drug-induced hirsutism.

Avoid consanguineous marriages to minimize the risk of idiopathic hirsutism and congenital adrenal hyperplasia.

Genetic and fertility counseling is recommended if there is a family history of hirsutism.

Aggressively treat primary causes such as acromegaly and Cushing’s syndrome.