Hirsutism (Unwanted Facial Hair In Women) Information
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Hirsutism is the
development of androgen-dependent terminal body hair (dark course pigmented
hair normally seen on the face, underarms, scalp, eyebrows and pubis) in a
woman and in other places where this type of hair is not normally found
in women.
Remember a woman's
definition of hirsutism may differ secondary to her ethnic background.
Any definition of normal body hair should consider both race and ethnicity.
For example, most Asian and/or Native American women have little body
hair, while most women from the Mediterranean have moderately heavy
body hair. However, the most important consideration in diagnosing hirsutism
is the extent to which a woman's normal pattern of hair growth has changed.
Although hirsutism can occur in both men and women, it is usually only
a problem for women.
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Causes of
Hirsuitism
The most common
causes of hirsuitism are idiopathic hirsutism and polycystic ovary syndrome:
Idiopathic hirsutism
is the diagnosis given to women with hirsutism and no other presenting
clinical abnormalities. Women with idiopathic hirsutism generally present
with normal levels of serum androgen concentrations.
Polycystic ovary
syndrome is the most common cause of androgen excess in women. Polycystic
ovary syndrome (PCOS) is a common disease affecting 3-5% of women of
reproductive age. PCOS usually presents with the following symptoms:
- Menstrual abnormalities
- PCOS is often diagnosed during puberty secondary to menstrual irregularities.
Infrequent, irregular or absent menstrual cycles are common. Once
the period does arrive they are often uncharacteristically heavy.
This abnormal menstrual cycle is an indication that there may be a
problem with ovulation. The use of oral contraceptives can often delay
the presentation of PCOS.
- Androgenic symptoms
- androgens are a group of hormones, such as testosterone, found predominantly
in men, however, they are also present in women in lower levels. Woman
with PCOS have considerably higher than normal levels of androgens
which causes the characteristic excessive hair growth. Some woman
also experience acne and male pattern hair loss.
- Infertility -
secondary to the disruption in the menstrual cycle many women are
infertile. However, some women with PCOS will ovulate normally, some
will ovulate less frequently and some will fail to ovulate.
- Obesity - some
40% of woman with PCOS are considered to be obese. Unfortunately,
the obesity will exacerbate the symptoms associated with PCOS. The
hormone changes associated with PCOS make weight loss difficult.
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Other less frequent
causes of hirsutism include the following:
- Medications - Danazol and the androgenic progestins present in some oral contraceptives
such as norgestrel can result in hirsutism.
- Hyperprolactinemia - should be ruled out in patients with hirsuitism, ameorrhea and a
breast discharge.
- Congenital adrenal
hyperplasia - affected girls will generally present around puberty
with hirsutism and menstrual irregularity or primary amenorrhea. Excess
androgen production is a key feature of most forms of congenital adrenal
hyperplasia. Congenital adrenal hyperplasia is usually recognized
at birth or early in infancy.
- Hyperthecosis
- is a nonmalignant ovarian condition resulting in increased serum
testosterone concentrations. Women with hyperthecosis are generally
obese and have a long history of sever hirsutism. Unlike PCOS, which
occurs only during the reproductive years, hyperthecosis of the ovaries
can occur in postmenopausal women.
- Ovarian tumors
- hirsutism caused by an androgen-secreting tumor generally occurs
later in life and progresses very rapidly.
- Adrenal tumors
- adrenal tumors are a rare cause of hirsutism.
- Severe insulin
resistance syndromes - hirsutism is also associated with women who
have a severe insulin resistance marked by hyperinsulinemia.
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You should
note there are two conditions characterized by generalized hair growth
that do not represent true hirsutism:
- Hypertrichosis - which refers to diffusely increased total body hair. This is a rare
condition that is usually caused by a systemic illnesses or a medication.
- Androgen-independent hair - which is the soft, vellus, unpigmented hair that covers the
entire body. In infants, this hair is called lanugo.
Symptoms of Hirsutism
Hirsutism can present
with a broad spectrum of symptoms including the following:
- Excessive hair
growth - individuals with hirsutism will often present with excess
hair on areas of the body where hair follicles are sensitive to androgens
including: face, chest, breast, lower back, midline region of the
lower abdomen, inner thigh, arms, legs, etc.
- Acne - excess
androgen associated with hirsutism can also contribute to the development
of acne, which may occur on the face, chest and/or upper-back.
- Irregular menstrual
cycle - increased androgen levels can also disrupt the normal menstrual
cycles. In severe cases may cause women to be anovulatory.
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Hirsutism
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Diagnosis
of Hirsutism
The diagnosis of
hirsutism is based on a family history of hirsutism, a personal history
of menstrual irregularities, and the presentation of masculine traits.
The patients medical history can often reveal enough information were
no other diagnostic testing is needed.
However, if a
physician deems that further testing is needed the following represent
the most common diagnostic procedures:
- Ovarian ultrasound
- represents most consistent investigation in PCOS is ovarian ultrasound,
although a skilled ultrasound technician is necessary. The typical
ultrasonic presentation are those of a thickened capsule, multiple
3-5mm cysts and hyperechogenic stroma. In addition, it should also
be noted that prolonged hyper androgenization from any cause may result
in polycystic changes in the ovary. The use of ultrasound may also
show virilization ovarian tumors.
- 17-x-Hydroxyprogesterone
- is elevated in classical congential adrenal hyperplasia (CAH), but
may be apparent in late-onset CAH only after stimulation.
- Gonadotrophin
levels - LH hypersecretion is a consistent feature of PCOS, but
the pulsatile nature of secretion of this hormone means that an increased
LH/FSH ratio is not always observed on a random sample.
Serum testosterone levels - may be elevated in PCOS and is invariably
substantially raised in virilization tumours. Patients with hisutism
and normal testosterone level frequently have low levels of sex hormone
binding globulin (SHBG), leading to high free androgen levels.
- Additional
androgens - androstenedione and DHEA sulphate are frequently elevated
in PCOS, and even more elevated in congenital adrenal hyperplasia
including virilizing tumours.
- Serum prolactin
- mild hyperprolactinaemia is common in PCOS.
In addition, If
a virilization tumor is suspected clinically or after investigation,
then more complex tests may include dexamethosone suppression tests,
MRI, CT, etc.
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Treatment
of
Hirsutism
There are various
treatment options which should be discussed with the patient:
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treatment of unwanted facial hair around the lips and under the chin.
The fragrance-free medication is applied similar to a moisturizing cream
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Vaniqa works by actively inhibiting an enzyme located in the root
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facial hair.
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Oral contraceptives
- combination (estrogen and progesterone) oral contraceptives are indicated
for women with idiopathic, familial hirsutism and PCOS. Women with hypertension,
bleeding or clotting disorders, migraines, smoker or a family history
of breast and/or uterine cancer, should not use oral contraceptives
to treat hirsutism.
Oral contraceptive
or Depo-Provera injections establish a regular menstrual cycle but do
not restore ovulation. Oral contraceptives also suppress the ovarian
production of androgens, which is why they are to improve the symptoms
of hirsutism and acne.
Diabetes medications
- glucophage an insulin sensitizer used primarily in the treatment of
diabetes, may decrease insulin resistance and promote ovulation in women
with PCOS. This oral medication is not approved by the U.S. Food and
Drug Administration (FDA) for this indication, nor is it appropriate
for those who have kidney or liver disease.
Blood pressure
medication - spironolactone is prescribed primarily as an oral blood
pressure medication. However, the medication is also a synthetic steroid
with an aldosterone-like structure that acts as a competitive antagonist
at aldosterone receptors. Thus, the medication blocks androgens from
binding to their receptor reducing the effects of hirsutism. Spironolactone
is not FDA approved for the treatment of hirsutism (may cause birth
defects).
Male pattern
baldness medication - the commonly used medication for male pattern
baldness, finasteride brand name Propecia has been shown to improve
the effects of hirsutism. Once again, this medication is not FDA approved
for the treatment of hirsutism (may cause birth defects).
Mechanical hair
removal -remains one of the most popular treatment options for the
treatment of hirsutism. Mechanical treatment involves bleaching or physically
removing unwanted hair: Shaving, plucking, waxing, electrolysis, laser
hair removal, bleaching, depilatories, etc.
Hirsutism
vs. Virilization
Virilization is
esentailly hirsutism with signs of masculinization in a woman. Virilization
may include an increase in body hair, facial hair, deepening of the
voice, male pattern baldness, clitoral enlargement and the cessation
of the menstrual cycle. Virilization is not as common as hirsutism,
the physical changes associated with virilization is indicative of androgen
levels that are extremely high. Virilization may be caused by either
an adrenal or ovarian tumor which may be malignant. Individuals who
suspect virilization should urgently visit an endocrinologist to undergo
a thorough workup.
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