Hirsutism and virilisation: the mFG score, the androgen-excess differential, and the management ladder (Endocrine Society 2018)

A 24-year-old presents distressed by coarse hair on her chin, chest and lower abdomen that has worsened over three years. Her cycles are regular. She wants it gone — today. Your job is not to reach for the laser first: it is to score the hair objectively with the mFG, run a focused androgen panel, exclude the mimics (PCOS is commonest, but non-classic CAH and a tumour must be ruled out before labelling), and then walk the evidence-based ladder with a realistic 6-month timeline. The Endocrine Society 2018 guideline and the mFG score exist to stop doctors treating the symptom before they have characterised it.^[1][6]

Overview and definition

Hirsutism is the presence of excess terminal (coarse, pigmented, androgen-responsive) hair in women in areas where it is normally male-pattern — the face, chest, abdomen and back. It is the principal clinical sign of androgen excess, affecting 5 to 15% of reproductive-age women, and is distinct from hypertrichosis, a generalised, non-androgen-mediated increase in fine vellus hair that is not driven by androgens and does not respond to anti-androgen therapy.^[6][11]

The clinical distinction that changes the workup is hirsutism versus virilisation. Hirsutism reflects mild-to-moderate androgen excess (typical of PCOS and idiopathic hirsutism). Virilisation — clitoromegaly, voice deepening, frontal balding, increased muscle bulk, breast atrophy — reflects marked androgen excess and substantially raises the suspicion of an androgen-secreting tumour. A woman who is hirsute is one clinical problem; a woman who is virilised is another, and the tempo of her presentation matters.^[1][11]

^{[1] [3] [6]}

References13ShowHide

1. [1]Martin KA, Anderson RR, Chang RJ, Ehrmann DA, Lobo RA, Murad MH, Pugeat MM, Rosenfield RL. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2018.PMID 29522147
2. [2]Elliott J, Liu K, Motan T, et al. Guideline No. 444: Hirsutism: Evaluation and Treatment. J Obstet Gynaecol Can, 2023.PMID 38049282
3. [3]DeUgarte CM, Woods KS, Bartolucci AA, Azziz R. Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. J Clin Endocrinol Metab, 2006.PMID 16449347
4. [4]Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer ES, Yildiz BO. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab, 2004.PMID 15181052
5. [5]Hatch R, Rosenfield RL, Kim MH, Tredway D. Hirsutism: implications, etiology, and management. Am J Obstet Gynecol, 1981.PMID 7258262
6. [6]Yildiz BO, Bolour S, Woods K, Moore A, Azziz R. Visually scoring hirsutism. Hum Reprod Update, 2010.PMID 19567450
7. [7]Speiser PW, Azziz R, Baskin LS, et al. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab, 2010.PMID 20823466
8. [8]Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2008.PMID 18334580
9. [9]Hamzavi I, Tan E, Shapiro J, Lui H. A randomized bilateral vehicle-controlled study of eflornithine cream combined with laser treatment versus laser treatment alone for facial hirsutism in women. J Am Acad Dermatol, 2007.PMID 17270315
10. [10]Alesi S, Forslund M, Melin J, et al. Efficacy and safety of anti-androgens in the management of polycystic ovary syndrome: a systematic review and meta-analysis of randomised controlled trials. EClinicalMedicine, 2023.PMID 37583655
11. [11]Stener-Victorin E, Teede H, Norman RJ, et al. Polycystic ovary syndrome. Nat Rev Dis Primers, 2024.PMID 38637590
12. [12]Teede HJ, Tay CT, Laven JJE, Dokras A, Moran LJ, Piltonen TT, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Fertil Steril, 2023.PMID 37589624
13. [13]Costello M, Shrestha B, Eden J, Sjoblom P, Johnson N. Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome. Cochrane Database Syst Rev, 2007.PMID 17253562