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Hirsutism

What Is It, Causes, Treatment, and More

Author:Anna Hernández, MD

Editors:Alyssa Haag,Emily Miao, PharmD

Illustrator:Jessica Reynolds, MS

Copyeditor:David G. Walker


What is hirsutism?

Hirsutism is a condition in those assigned female at birth, that results in excess hair growth in androgen-dependent areas of the body, including the chin, upper lip, chest, and back. Although hirsutism is often the result of a benign process, it is important to identify the underlying cause as it can be the first sign of a more serious medical condition. Hirsutism should be also distinguished from hypertrichosis, which is defined as generalized hair growth that is independent of androgen production. 

What causes hirsutism?

The causes of hirsutism can be divided into androgenic, non-androgenic, and idiopathic (i.e., the underlying cause is unknown). Androgens, including testosterone, dihydrotestosterone, and their prohormones, act on the hair follicles of sex-related areas of the body to convert fair, vellus hair to larger, coarser, and darker terminal hair. 

The majority of cases of hirsutism are caused by polycystic ovary syndrome (PCOS), which is characterized by excess androgen levels, menstrual irregularities, and ovarian cysts on an ultrasound. Other causes of increased androgen levels include non-classic congenital adrenal hyperplasia; androgen secreting tumors of the ovary or the adrenal gland; and ovarian hyperthecosis, which is when the ovarian follicles secrete increased amounts of testosterone due to hyperplasia of the theca layer. 

On the other hand, non-androgenic causes of hirsutism include medication-related side effects, which can be caused by corticosteroids; exogenous androgens, like danazol; and certain immune modulating agents, like cyclosporine. It can also be caused by endocrine disorders, like acromegaly, Cushing syndrome, hyperprolactinemia, and thyroid dysfunction. 

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What other signs and symptoms are associated with hirsutism?

Hirsutism typically presents as excess terminal hair growth in androgen-dependent areas of the body, including the chin, upper lip, sideburns, chest, back, and abdomen. In some cases, hirsutism can present alongside other signs of virilization, including weight gain, acne, deepening voice, and male-pattern balding. Although hirsutism is often a benign process, the presence of rapid onset hirsutism, obvious signs of virilization, or a palpable abdominal or pelvic mass could be warning signs of a more serious condition, such as an androgen secreting tumor.  

How is hirsutism diagnosed?

The diagnosis of hirsutism begins with a thorough medical history and physical exam. Medical history should focus on assessing any body changes, as well as inquiring about the individual’s menstrual history and current medications. Regarding the physical exam, excess hair growth can be quantified using the Ferriman-Gallwey score, which assesses the amount of hair present in different parts of the body. However, since the natural amount of body hair can vary between ethnic groups, the most important consideration is not necessarily the amount of body hair, but rather if the pattern of hair growth has changed or if the rate of growth has increased over time. 

After the initial evaluation, individuals with mild hirsutism and no other symptoms may not require any further testing. On the other hand, individuals with moderate to severe hirsutism may require additional testing to identify any underlying causes. Further testing may involve obtaining serum androgen levels and undergoing a gynecological exam with a pelvic ultrasound in order to diagnose polycystic ovarian syndrome. If an androgen-secreting tumor is suspected, diagnosis may involve additional imaging techniques, such as an abdominal or pelvic ultrasound or a CT scan. Finally, diagnosis of endocrine disorders may involve assessing other hormone levels, including steroid hormones, growth hormone, and thyroid function. If hirsutism is present without elevated serum testosterone levels, menstrual irregularities, or any other identifiable cause, the diagnosis is idiopathic hirsutism.

How is hirsutism treated?

Treatment for hirsutism is based on the severity of the condition and the presence of an underlying disorder. If hirsutism is caused by an underlying medical condition, treatment involves addressing the cause when possible. 

In individuals with PCOS, treatment depends on whether they have insulin resistance or desire a pregnancy. In individuals with insulin resistance who desire a pregnancy, metformin therapy and weight loss are typically recommended, as they can decrease serum testosterone levels and improve ovulation rates. Conversely, individuals without insulin resistance who do not wish to become pregnant can be treated with combined oral contraceptives (i.e., birth control pills). If oral contraceptives are contraindicated or if they are unable to treat the hirsutism, spironolactone, an aldosterone receptor antagonist which has antiandrogen effects, can be used instead. 

Finally, hirsutism can be treated with several methods to remove unwanted hair, including shaving or waxing as well as more definitive hair removal methods, like laser hair removal. 

What are the most important facts to know about hirsutism?

Hirsutism refers to excess hair growth in androgen-dependent areas of the body, including the chin, upper lip, chest, back, and abdomen. Although hirsutism is most often a benign condition, it can be caused by underlying medical conditions, including polycystic ovary syndrome, androgen secreting tumors, or endocrine disorders. Diagnosis of hirsutism is based on a thorough medical history and physical exam, and may involve additional laboratory or imaging tests to identify the underlying cause. Treatment for hirsutism involves several methods to remove unwanted hair as well as treatment of the underlying cause when possible.

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Related links

Androgens and antiandrogens
Virilization: Clinical practice
Polycystic ovary syndrome
Amenorrhea
Contraception: Clinical practice

Resources for research and reference

Escobar-Morreale, H. F., Carmina, E., Dewailly, D., Gambineri, A., Kelestimur, F., Moghetti, P., & Norman, R. J. (2011). Epidemiology, diagnosis and management of hirsutism: A consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society. Human Reproduction Update, 18(2), 146–170. DOI: 10.1093/humupd/dmr042 

Martin, K. A., Anderson, R. R., Chang, R. J., Ehrmann, D. A., Lobo, R. A., Murad, M. H., & Rosenfield, R. L. (2018). Evaluation and treatment of hirsutism in premenopausal women: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 103(4), 1233–1257. DOI: 10.1210/jc.2018-00241 

Matheson, E., & Bain, J. (2019). Hirsutism in women. American Family Physician, 100(3), 168–175.