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Hirsutism

 

What are the aims of this leaflet?

This leaflet has been written to help you understand more about hirsutism. It tells you what it is, what causes it, what can be done about it, and provides sources of additional information.

What is hirsutism?

Hirsutism essentially means that an individual, usually female, grows too much body or facial hair in a male pattern. Although hirsutism sometimes occurs in males,it is more difficult to detect because of the wide range of normal hair growth in men. Hirsutism affects approximately 10% of women in Western societies and is commoner in those of Mediterranean or Middle-Eastern descent.
Another term is used if the excessive hair is generalised and not in a gender specific pattern. This term is ‘hypertrichosis’, which means increased (‘hyper’) hair (‘trichosis’). In this leaflet we will discuss only hirsutism.

Is hirsutism hereditary?

No, although some cases can run in families.

What causes hirsutism?

Androgens are often thought of as exclusively ‘male hormones’ but, in fact both men and women produce them; men usually in greater amounts than women. Circulating testosterone hormone is converted in the skin by the actions of an enzyme called 5-alpha-reductase to dihydrotestosterone. Dihydrotestosterone is the androgen that acts on immature body and facial hair to produce a mature hair. Variation in the levels of activity of 5-alpha-reductase could be the explanation as to why females with identical serum levels of testosterone could have clinically different levels of severity of hirsutism.

In the majority of cases, hirsutism is not associated with any significant medical abnormality. The exception to this rule is if hirsutism develops before puberty in either sex. Most women develop more facial or body hair gradually as they get older, especially after the menopause; however, it is a cause of much psychological distress to a high proportion of those affected. With the exception of polycystic ovarian syndrome (PCOS), underlying medical causes are very rare, but your dermatologist may request some hormone tests, possibly an ultrasound of the pelvis (to look for PCOS) and may occasionally refer you to an endocrinologist (specialist in hormonal disorders). Most of these conditions will have excess androgens as part of the abnormality. Extremely rarely, hirsutism can be caused by tumours that secrete androgens. In such cases the hirsutism will be severe and appear in a very short period.

It is important to see your doctor if your hirsutism is associated with any of the following:

  • Developing quickly (over 1-2 years), or before puberty.
  • Accompanied by menstrual problems.
  • Associated with features suggesting an increase in androgens such as thinning of the scalp hair, baldness, or deepening of the voice.
  • Accompanied by obesity or diabetes.

How can hirsutism be treated?

In the rare cases where there is an underlying hormonal disorder, the treatment is of the underlying disease.

What can I do?

  • Shaving. Some people think that shaving encourages more hair growth, but this is not true. However, the stubble that follows regrowth may be undesirable. Frequent shaving can irritate your skin.
  • Waxing is effective for some people, but can irritate the skin and should be used with caution on the face. Scarring occasionally follows. Folliculitis (inflammation of the hair follicles) can occur with shaving, and waxing.
  • Depilatories (creams that remove hair) chemically dissolve hair shafts thereby leaving no stubble, but may also irritate your skin. Before using them you should first test your skin to see how sensitive it is. Always follow the manufacturer’s instructions for testing and product applications.
  • Bleaching creams are designed to make the dark hairs pale. They can irritate the skin and may be unsuitable for brown and black skins.

Physical treatments

  • Electrolysis. An electrical current is passed into a hair follicle through a needle. The aim is to destroy the hair root permanently. Electrolysis is relatively expensive and time-consuming. Before you have electrolysis, check that the operator is properly qualified, and registered with the Institute of Electrolysis. Check that the practitioner uses new, disposable (not simply re-sterilised) needles. Equipment designed for electrolysis at home are not recommended. Scarring is a potential side effect of this treatment. It is not always available on the NHS.
  • Laser and intense pulsed light (IPL) treatments also aim to destroy the hair root permanently. They are not always available on the NHS. Laser treatment and IPL are expensive and several treatments are given over a period of months. This form of hair reduction must be done at a special clinic by an operator who is properly qualified. Check that they are registered with the Healthcare Commission or British Medical Laser Association. It is better to take the route of a referral from your medical practitioner to a specialist. Possible side effects include redness, darkening or lightening of the skin, and scarring. Total compliance during the treatment plan is required; this will include no sun bathing (or fake tanning) and cessation of all forms of hair removal, with the exception of shaving.

Medical treatments

  • Eflornithine cream. This cream works by slowing hair growth. It is not a depilatory cream. It has recently been accepted for use in women for whom other medical treatments cannot be used or have been ineffective. It can be applied after any regular hair removal techniques, such as the self-care or physical methods described in the preceding paragraphs. It is left on the skin to inhibit hair growth. The cream takes two to three months of regular use to have an effect. Side effects are usually mild and include burning or stinging of the skin and acne.
  • Anti-androgens. Your doctor may prescribe these to block the action of the androgens that can cause hirsutism. Anti-androgens usually take 4-6 months to have an effect. Hair growth will then slow, and the hairs will gradually become thinner and less noticeable; the problem, however, tends to return when medication is stopped.

Anti-androgens include:

  • Oral contraceptives. Some low-dose combined pills may help, and one has been designed specifically to have an anti-androgenic activity. Side effects include spotting (bleeding between periods), tender breasts, nausea and headaches, especially in the first few months. The oral contraceptive pill is not suitable for Cyproterone. Combined with an oral contraceptive this can help women with hirsutism. Larger doses of cyproterone (i.e. 50 to 200 mg for 10 days each cycle) can be used for more severe hirsutism. Side effects include weight gain, depression, blood clotting in veins of legs and loss of libido.
  • Spironolactone. This is used more commonly in the USA than in the UK. It works as an anti-androgen but also increases the amount of urine that is passed – in other words it is also a water tablet (diuretic). Spironolactone (50 to 200 mg daily) can slowly reduce excessive hair growth. Side effects include tender breasts, irregular menstruation and liver damage.
  • Finasteride. Used at the dose to treat benign prostatic hyperplasia (5mg), rather than male-pattern baldness (1mg). This drug blocks the enzyme that makes testosterone into the active androgen dihydrotestosterone. It appears to be as effective as spironolactone, but is not licensed for treating hirsutism in the UK. Its usage should be restricted to postmenopausal women.

N.B. An important side effect of all anti-androgen drugs is that they can harm an unborn male baby if you take them while you are pregnant. For this reason, they must not be taken unless you are using effective contraception.

Where can I get more information about hirsutism?
Web links to detailed leaflets:
http://www.uptodate.com/contents/patient-information-hirsutism-excess-hair-growth-in-women?source=search_result&selectedTitle=1~110
http://www.dermnetnz.org/hair-nails-sweat/hirsutism.html
http://www.dermnetnz.org/hair-nails-sweat/hypertrichosis.html