While hirsutism is often dismissed as a minor cosmetic issue, it can be a sign of abnormal androgen activity in the body, stemming from underlying endocrine disorders such as polycystic ovary syndrome (PCOS) or, in rare cases, more serious medical conditions. Beyond the physical symptoms, the emotional toll it can have on a person can be profound—impacting a woman's self-esteem, relationships, and mental health.

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Hirsutism Is More Than Just Abundant Hair Growth

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Hirsutism is characterized by excessive hair growth on certain parts of the body, especially in areas where men typically grow hair, such as the chin, upper lip, chest, back, and abdomen. This hair is usually coarse, curly, and pigmented (terminal hair) rather than the fine, soft, and lightly pigmented hair (peach fuzz) commonly present on a woman’s body.

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While the primary symptom of hirsutism is the excessive growth of dark hair, women with more body hair than what’s considered normal shouldn’t assume they have the condition. A physician or healthcare professional will be able to provide an accurate diagnosis after assessing the symptoms and extent of hair growth.

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What Causes Hirsutism In Women?

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Hirsutism is often a symptom of other conditions and typically results from hormonal imbalances or disorders that increase the level of androgens in the body. [2]

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Androgens are a group of hormones that are present in all people. However, men and people assigned male at birth naturally produce more of these androgen hormones than do females. When an adult woman has high androgen levels, it triggers a pattern of physical and sexual development that’s typical of males, including overstimulation of hair follicles, leading to excessive hair growth. This process is called virilization. [3]

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Apart from hirsutism, other signs of virilization include:

• Acne

• Oily skin

• A deep or masculine voice

• Balding (temporal hair recession)

• Increased musculature

• Decreased breast size

• Irregular menstruation

• Enlarged clitoris

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Other conditions that can cause hirsutism include:

• Polycystic Ovarian Syndrome (PCOS) – The leading cause of hirsutism, where nearly 70-80% of all people diagnosed with PCOS develop hirsutism. Those with PCOS have an imbalance of sex hormones. Over time, it leads to excess hair growth, abnormal menstruation, weight gain, and challenges with fertility. [4]

• Cushing’s Syndrome – Cortisol is a hormone that can affect various organs controlling the integumentary system–hair, skin, nails, glands, and nerves. In people with Cushing's syndrome, there is a high level of cortisol. Prolonged exposure to high cortisol levels can disrupt androgen production. [5]

• Congenital Adrenal Hyperplasia (CAH) – A genetic condition where the adrenal glands produce abnormal amounts of steroid hormones, including androgens and cortisol. [6]

• Androgen-Secreting Tumors – Rare ovarian or adrenal tumors can lead to high levels of male hormones, leading to rapid-onset hirsutism. [7]

• Medications – Some drugs, like anabolic steroids, testosterone, minoxidil, cyclosporine, danazol, and phenytoin, can cause hirsutism. [8]

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Sometimes, hirsutism can be familial, meaning it is inherited and isn’t associated with any underlying medical condition. You might be more susceptible to developing hirsutism if you have a family history of conditions that cause it. In addition, the chances of developing hirsutism increases with age, especially after menopause, due to hormonal imbalances. [1]

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Lastly, genetics significantly influences hair color, thickness, and density or distribution of hair follicles. For instance, women from regions like the Middle East, the Mediterranean, and the Indian subcontinent often naturally have darker and thicker body or facial hair. So, in these populations, more hair on the face and body is typically considered normal and may not be a sign of hirsutism.

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Diagnosing Hirsutism

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A physician would initially conduct a physical examination to determine the extent of uncommon hair growth, which is assessed using the Ferriman-Gallwey scale. [9]

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The Ferriman-Gallwey scale examines nine areas of your body where male-pattern hair is likely to develop due to high androgen influence–the upper lip, chin, chest, upper abdomen, lower abdomen, upper arms, thighs, upper back, and lower back/buttocks. Each area is scored on a scale from 0-4 based on the density and thickness of terminal hair. Low numbers indicate mild hirsutism and higher numbers indicate severe male-pattern hair growth.

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The scores from all nine areas are added to determine a total score between 0 and 36. Typically, the scores are interpreted as follows:

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• ≤8: Normal (no significant hirsutism)

• 8-15: Mild hirsutism

• >15: Moderate to severe hirsutism

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While the Ferriman-Gallwey score is a helpful diagnostic tool, it has some limitations. For instance, due to how genetics influence hair growth patterns, the threshold for what constitutes "normal" may vary slightly depending on factors like ethnicity. Here are the scores that are considered normal based on ethnicity.

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• Black or white (Caucasian) people – 8

• Mediterranean, Hispanic, and Middle Eastern people – 9 or 10

• Asians – less than 2

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So, in clinical practice, this scoring system is often combined with blood tests (which help measure androgen levels) and diagnostic imaging tests (CT, ultrasound, and X-ray) if an underlying cause is suspected.

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Managing Hirsutism: Treatment Options

Managing hirsutism typically involves addressing its underlying cause. Generally, weight loss is the first step in treatment. According to studies, obesity can increase androgen production, worsening hirsutism. [10] [11] Hence, losing even 5% of the body weight can lower androgen levels and prevent excessive hair growth. [12]

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In some cases, especially if the patient has mild hirsutism that is spontaneous or that happens without a known cause, cosmetic measures may be sufficient to manage it, such as shaving, bleaching, waxing, or plucking. Hair removal options like electrolysis (to destroy hair roots one by one) and laser (to destroy hair cells with a lot of pigment) can also be administered.

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In other cases, a topical or systemic therapy might be necessary to treat hirsutism. [13] These options may include:

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• Birth control pills / oral contraceptives – The first-line treatment for hirsutism, they lower androgen levels by suppressing ovarian activity.

• Androgen-suppressing medications – Medications like spironolactone, finasteride, and flutamide block androgens from binding to hair follicles, reducing hair thickness and growth rate.

• Low-dose steroid medications – Used if overactive adrenal glands are causing hirsutism. Adrenal glands produce sex hormones, including cortisol.

• Insulin-lowering medications – High insulin levels trigger ovaries to produce androgens. Metformin and pioglitazone improve insulin sensitivity, thereby indirectly lowering androgen production. However, they aren’t used as a first-line treatment due to their significant side effects.

• Gonadotropin-releasing hormone (GnRH) agonists – Rarely used, they suppress ovarian androgen production. Since they require injections, they can be expensive.

• Eflornithine skin cream – A topical product that slows down hair growth. It takes 6 to 8 weeks to see noticeable results.

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The proper treatment option for hirsutism will depend on its severity. Medications for treating hirsutism often take weeks or months to show any noticeable results; lifestyle modifications through weight management are also beneficial and can give more impactful results that endure over your life.

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Always consult with your family physician or nurse practitioners for any serious and persistent concerns about your medical condition, diagnosis, and treatment, or to seek personalized medical care. Join the Healthyher.Life as a community member and connect with others in our Community Forum who have had similar experiences with managing hirsutism.

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References:

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[1] Sachdeva S. Hirsutism: evaluation and treatment. Indian J Dermatol. 2010;55(1):3-7. doi: 10.4103/0019-5154.60342. PMID: 20418968; PMCID: PMC2856356. [PubMed]

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[2] Rosenfield, R. L. (2005). Hirsutism. New England Journal of Medicine, 353(24), 2578-2588. [The New England Journal of Medicine]

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[3] Spritzer PM, Marchesan LB, Santos BR, Fighera TM. Hirsutism, Normal Androgens and Diagnosis of PCOS. Diagnostics (Basel). 2022 Aug 9;12(8):1922. doi: 10.3390/diagnostics12081922. PMID: 36010272; PMCID: PMC9406611. [PubMed]

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[4] Spritzer PM, Barone CR, Oliveira FB. Hirsutism in Polycystic Ovary Syndrome: Pathophysiology and Management. Curr Pharm Des. 2016;22(36):5603-5613. doi: 10.2174/1381612822666160720151243. PMID: 27510481. [ResearchGate]

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[5] Haouat, E., Ben, S. L., Kamoun, I., Zrig, N., Turki, Z., & Ben, S. C. (2012, May 1). Androgens profile in Cushing. https://www.endocrine-abstracts.org/ea/0029/ea0029p953 [Endocrine Abstracts]

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[6] Baskin HJ. Screening for Late-Onset Congenital Adrenal Hyperplasia in Hirsutism or Amenorrhea. Arch Intern Med. 1987;147(5):847–848. doi:10.1001/archinte.1987.00370050043007 [JAMA Network]

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[7] Varma T, Panchani R, Goyal A, Maskey R. A case of androgen-secreting adrenal carcinoma with non-classical congenital adrenal hyperplasia. Indian J Endocrinol Metab. 2013 Oct;17(Suppl 1):S243-5. doi: 10.4103/2230-8210.119585. PMID: 24251173; PMCID: PMC3830319. [PubMed]

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[8] Patel A, Malek N, Haq F, Turnbow L, Raza S. Hirsutism in a female adolescent induced by long-acting injectable risperidone: a case report. Prim Care Companion CNS Disord. 2013;15(3):PCC.12l01454. doi: 10.4088/PCC.12l01454. PMID: 24171143; PMCID: PMC3795580. [PubMed]

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[9] Bhns. (n.d.-a). https://bhns.org.uk/ccs_files/web_data/Resources/Diseases%20(severity%20scoring)/Hirsuitism.pdf [British Hair and Nail Society]

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[10] Mazza, E., Troiano, E., Ferro, Y., Lisso, F., Tosi, M., Turco, E., Pujia, R., & Montalcini, T. (2024). Obesity, Dietary Patterns, and Hormonal Balance Modulation: Gender-Specific Impacts. Nutrients, 16(11), 1629. https://doi.org/10.3390/nu16111629 [MDPI]

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[11] Pasquali R. Obesity and androgens: facts and perspectives. Fertil Steril. 2006 May;85(5):1319-40. doi: 10.1016/j.fertnstert.2005.10.054. PMID: 16647374.[PubMed]

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[12] Zapała B, Marszalec P, Piwowar M, Chmura O, Milewicz T. Reduction in the Free Androgen Index in Overweight Women After Sixty Days of a Low Glycemic Diet. Exp Clin Endocrinol Diabetes. 2024 Jan;132(1):6-14. doi: 10.1055/a-2201-8618. Epub 2024 Jan 18. PMID: 38237611; PMCID: PMC10796197. [PubMed]

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[13] Hunter MH, Carek PJ. Evaluation and treatment of women with hirsutism. Am Fam Physician. 2003 Jun 15;67(12):2565-72. PMID: 12825846. [PubMed]