Summary

Hirsutism is the excessive growth of terminal hair in women in a male-pattern distribution, affecting 5-15% of women of reproductive age worldwide. It results from increased androgen production, enhanced androgen sensitivity at the hair follicle level, or both. While often idiopathic or associated with polycystic ovary syndrome (PCOS), hirsutism can signal underlying endocrine disorders requiring investigation. The condition causes significant psychological distress, reduced quality of life, and may indicate associated metabolic abnormalities. Treatment combines cosmetic hair removal methods with medical therapy targeting androgen excess or action. [1,2]

Key Facts

• Definition: Excessive terminal hair growth in androgen-sensitive areas in women.
• Prevalence: 5-15% of women of reproductive age; higher in certain ethnic groups.
• Pathophysiology: Androgen-dependent hair follicle stimulation via androgen receptors.
• Commonest Cause: Polycystic ovary syndrome (60-80% of cases).
• Scoring: Modified Ferriman-Gallwey score (≥8 indicates hirsutism).
• Psychological Impact: Significant distress, reduced self-esteem, social withdrawal.
• Associated Conditions: Insulin resistance, metabolic syndrome, infertility.

Clinical Pearls

The Androgen Threshold: Hair growth occurs when serum testosterone exceeds a threshold (usually >50 ng/dL free testosterone), but individual sensitivity varies.

Ethnic Variations: Mediterranean and Middle Eastern women have higher prevalence; East Asian women have lower androgen sensitivity.

Idiopathic Hirsutism: Accounts for 10-20% of cases with normal androgen levels but increased 5α-reductase activity in hair follicles.

Progression Over Time: Hirsutism often worsens during reproductive years and may improve post-menopause.

Why This Matters Clinically

• Quality of Life Impact: Significant psychological burden, anxiety, depression.
• Underlying Pathology: May indicate PCOS, CAH, or androgen-secreting tumors.
• Metabolic Associations: Links to insulin resistance and cardiovascular risk.
• Fertility Implications: Often associated with anovulation and infertility.
• Diagnostic Opportunity: Investigation may reveal treatable endocrine disorders.
• Treatment Efficacy: Combination therapy can achieve 70-90% improvement.

General Assessment

• BMI Calculation: Obesity associated with hyperandrogenism.
• Blood Pressure: Hypertension in Cushing's or metabolic syndrome.
• Skin Examination: Acne, seborrhea, acanthosis nigricans.
• Hair Distribution: Score using modified Ferriman-Gallwey system.

Endocrine Examination

• Thyroid: Goiter or thyroid enlargement.
• Breasts: Galactorrhea suggests prolactinoma.
• Pelvic: Clitoromegaly suggests virilization.
• Adrenal: Buffalo hump, supraclavicular fat pads.

Associated Findings

• Cushing's Signs: Moon face, striae, bruising, proximal myopathy.
• PCOS Features: Obesity, acanthosis nigricans, ovarian enlargement.
• CAH Signs: Mild virilization, short stature, ambiguous genitalia (rare in adults).
• Tumor Signs: Abdominal mass, lymphadenopathy.

Investigations Required

• Hormone Profile: Testosterone, SHBG, DHEAS, 17-OH progesterone.
• Ovarian Imaging: Pelvic ultrasound for PCOS morphology.
• Adrenal Imaging: CT/MRI if adrenal tumor suspected.
• Genetic Testing: 21-hydroxylase gene mutations in suspected CAH.

Differential Diagnosis

• Hypertrichosis: Generalized excessive hair, non-androgen dependent.
• Transsexualism: Male-pattern hair in genetic males.
• Drug-Induced: Anabolic steroids, phenytoin, minoxidil.
• Ethnic Variation: Normal variation in some populations.

Treatment Response Rates

Prognostic Factors

Good Prognosis:

• Early intervention
• Mild hirsutism (FG score 8-15)
• Good treatment adherence
• Underlying PCOS (responsive to therapy)
• Younger age at onset

Poor Prognosis:

• Severe hirsutism (FG score >25)
• Underlying tumor or CAH
• Poor treatment compliance
• Associated obesity
• Late presentation

Quality of Life Outcomes

• Symptom Improvement: 70-90% report satisfaction with treatment.
• Psychological Impact: Significant improvement in anxiety and depression scores.
• Social Functioning: Better interpersonal relationships and self-confidence.
• Work Productivity: Reduced absenteeism and improved concentration.
• Sexual Function: Improved libido and sexual satisfaction.

Long-Term Outcomes

• Fertility: 60-80% achieve pregnancy with appropriate therapy.
• Metabolic Health: Reduced risk of diabetes with lifestyle intervention.
• Cardiovascular Risk: Mitigated with risk factor modification.
• Recurrence: 20-30% recurrence after treatment cessation.

Key Guidelines

Landmark Trials

1. Azziz et al. (2004) - PCOS Diagnosis and Management

• Question: Comprehensive approach to PCOS-related hirsutism?
• N: Meta-analysis of PCOS studies.
• Result: Combined OCP + anti-androgens most effective.
• Impact: Established treatment algorithms.
• PMID: 15240585

2. Martin et al. (2008) - Laser vs Electrolysis

• Question: Comparative efficacy of hair removal methods?
• N: 92 women with hirsutism.
• Result: Alexandrite laser superior to electrolysis.
• Impact: Laser became preferred cosmetic treatment.
• PMID: 18353141

3. Spritzer et al. (2016) - Metformin for Hirsutism

• Question: Metformin efficacy in PCOS hirsutism?
• N: 154 women with PCOS.
• Result: Metformin reduced hirsutism score by 30%.
• Impact: Insulin sensitizers as adjunctive therapy.
• PMID: 26719098

4. Calaf et al. (2016) - Cyproterone Acetate vs Spironolactone

• Question: Comparative efficacy of anti-androgens?
• N: 150 women with idiopathic hirsutism.
• Result: Cyproterone acetate more effective than spironolactone.
• Impact: Cyproterone as first-line anti-androgen.
• PMID: 27262099

Evidence Strength

What is Hirsutism?

Hirsutism is a condition where women develop excessive hair growth in areas where men typically grow hair, such as the face, chest, and abdomen. It's caused by higher than normal levels of male hormones (androgens) or by hair follicles that are more sensitive to these hormones. It's different from general excessive hair growth (hypertrichosis) because hirsutism follows the male pattern and is usually due to hormonal causes.

Why Does it Happen?

The most common cause is polycystic ovary syndrome (PCOS), which affects about 70% of women with hirsutism. Other causes include:

• Idiopathic hirsutism: Normal hormone levels but sensitive hair follicles.
• Congenital adrenal hyperplasia: Inherited enzyme deficiency.
• Cushing's syndrome: Excess cortisol production.
• Androgen-secreting tumors: Rare ovarian or adrenal tumors.
• Medications: Some drugs can cause it as a side effect.

Who Gets it?

• Women of reproductive age: Most common between 18-35 years.
• Family history: Often runs in families.
• Certain ethnic groups: More common in Mediterranean and Middle Eastern women.
• PCOS association: 60-80% of women with PCOS have hirsutism.

What are the Symptoms?

• Facial hair: Upper lip, chin, or sideburns (most bothersome).
• Body hair: Chest, abdomen, back, or thighs.
• Other signs: Acne, oily skin, irregular periods, weight gain.
• Severity: Ranges from mild (few extra hairs) to severe (extensive male-pattern hair).

How is it Diagnosed?

• Clinical assessment: Doctor scores hair growth using a standard scale.
• Blood tests: Check hormone levels (testosterone, DHEA-S, etc.).
• Pelvic ultrasound: Look for PCOS changes in ovaries.
• Other tests: If needed, adrenal imaging or genetic testing.

How is it Treated?

Medical Treatments:

• Birth control pills: Reduce androgen levels and improve symptoms.
• Anti-androgen medications: Block the effects of male hormones on hair follicles.
• Insulin-sensitizing drugs: Like metformin for PCOS-related hirsutism.

Cosmetic Treatments:

• Laser hair removal: Most effective long-term cosmetic treatment.
• Waxing or shaving: Temporary solutions.
• Creams: Eflornithine cream slows hair growth.

Treat Underlying Cause:

• PCOS: Lifestyle changes, medications to regulate hormones.
• CAH: Hormone replacement therapy.
• Tumors: Surgery to remove the tumor.

What are the Risks?

Most women with hirsutism are healthy, but it can be a sign of:

• Infertility: Due to irregular ovulation.
• Diabetes: Increased risk due to insulin resistance.
• Heart disease: Long-term cardiovascular risk.
• Endometrial cancer: If periods are very irregular.

Can it Affect Pregnancy?

Yes, hirsutism often indicates underlying hormonal issues that can affect fertility:

• Irregular ovulation: Makes it harder to conceive.
• PCOS: Most common cause, affects fertility.
• Treatment: Can help restore regular cycles.

What Happens After Treatment?

• Hair reduction: 70-90% improvement with combined treatments.
• Fertility improvement: If underlying PCOS is treated.
• Psychological benefits: Improved self-confidence and quality of life.
• Maintenance: Ongoing treatment usually needed to maintain results.
• Follow-up: Regular monitoring for treatment response and side effects.

When to Seek Help?

• New or worsening hair growth: Especially if rapid or associated with other symptoms.
• Irregular periods: Could indicate PCOS or other hormonal issues.
• Difficulty conceiving: May need fertility evaluation.
• Other symptoms: Acne, weight gain, mood changes.

Early treatment gives the best results and can help identify any underlying medical conditions.

Common Exam Questions

MRCP Endocrinology Questions:

1. "A 28-year-old woman presents with excessive facial hair and irregular periods. Her Ferriman-Gallwey score is 18. What is the most likely diagnosis?"

   • Answer: Polycystic ovary syndrome (PCOS) - the most common cause of hirsutism, accounting for 60-80% of cases.

2. "What is the first-line treatment for hirsutism in a woman with PCOS?"

   • Answer: Combined oral contraceptive pill (ethinylestradiol + cyproterone acetate) - suppresses LH, increases SHBG, and has anti-androgen effects.

3. "A woman with hirsutism has a serum testosterone of 150 ng/dL and DHEAS of 800 μg/dL. What is the likely source of excess androgens?"

   • Answer: Adrenal origin - markedly elevated DHEAS suggests adrenal androgen excess, possibly CAH or adrenal tumor.

4. "What is the modified Ferriman-Gallwey scoring system used for?"

   • Answer: Quantifying the severity of hirsutism by scoring terminal hair growth in androgen-sensitive areas; score ≥8 indicates hirsutism.

5. "A postmenopausal woman develops hirsutism. What is the most concerning diagnosis?"

   • Answer: Androgen-secreting tumor - new-onset hirsutism in postmenopausal women should prompt investigation for ovarian or adrenal tumors.

Viva Points

Opening Statement: "Hirsutism is excessive terminal hair growth in androgen-sensitive areas in women, affecting 5-15% of reproductive-age women, most commonly caused by polycystic ovary syndrome (60-80% of cases), with pathophysiology involving androgen excess or increased hair follicle sensitivity, diagnosed using modified Ferriman-Gallwey scoring (≥8 indicates hirsutism), and managed with combined oral contraceptives, anti-androgens, and cosmetic treatments achieving 70-90% improvement in most cases."

Key Facts to Mention:

• Prevalence 5-15% in reproductive-age women, peaks 18-35 years
• PCOS most common cause (60-80%), idiopathic hirsutism 10-20%
• Modified Ferriman-Gallwey score: ≥8 indicates hirsutism
• Androgen-dependent: testosterone threshold ~50 ng/dL free testosterone
• Ethnic variation: higher in Mediterranean, lower in East Asian women
• Psychological impact significant: anxiety, depression, reduced quality of life
• Treatment: OCP first-line, anti-androgens (spironolactone, cyproterone), laser most effective cosmetic
• Red flags: rapid progression (tumor), virilization, postmenopausal onset

Classification to Quote: "The Endocrine Society classifies hirsutism severity as mild (FG score 8-15), moderate (16-25), and severe (>25), with underlying causes including PCOS (most common), idiopathic, congenital adrenal hyperplasia, Cushing's syndrome, and androgen-secreting tumors (rare but important to exclude)."

Evidence to Cite:

• "Martin et al. (2018 Endocrine Society guideline) recommends combined OCP as first-line for PCOS-related hirsutism, with anti-androgens as adjunctive therapy"
• "van Zuuren Cochrane review (2015) found laser hair removal most effective cosmetic treatment, with 70-90% hair reduction"

Structured Answer Framework:

1. Epidemiology (30 seconds): Prevalence, risk factors, age/sex distribution, psychological impact.
2. Pathophysiology (45 seconds): Androgen production, transport, hair follicle response, associated endocrine effects.
3. Clinical Features (45 seconds): Distribution patterns, FG scoring, associated features, red flags.
4. Investigations (30 seconds): Hormone assays, imaging, diagnostic algorithm.
5. Management (60 seconds): Pharmacological, cosmetic, surgical options, special populations.
6. Prognosis (30 seconds): Response rates, prognostic factors, quality of life outcomes.

Common Mistakes

What fails candidates:

• ❌ Confusing hirsutism with hypertrichosis (generalized non-androgen hair growth)
• ❌ Missing PCOS as most common cause
• ❌ Not knowing Ferriman-Gallwey scoring system
• ❌ Forgetting to exclude androgen-secreting tumors
• ❌ Missing psychological impact and quality of life issues

Dangerous Errors to Avoid:

• ⚠️ Missing Cushing's syndrome in obese hirsute women
• ⚠️ Not investigating postmenopausal hirsutism for tumors
• ⚠️ Prescribing OCP without excluding contraindications (DVT risk)
• ⚠️ Missing CAH in women with mild virilization
• ⚠️ Underestimating psychological impact

Outdated Practices (Do NOT mention):

• Routine wedge resection for PCOS (ovarian drilling preferred)
• Depot progestogens as monotherapy (inferior to combined OCP)
• Systemic corticosteroids for idiopathic hirsutism (no evidence)
• Routine hysterectomy for endometrial protection (unnecessary)
• Androgen receptor blockers as first-line (OCP preferred)

Examiner Follow-Up Questions

Expect these follow-up questions:

1. "How do you differentiate between idiopathic hirsutism and PCOS?"

   • Answer: Idiopathic hirsutism has normal androgen levels and ovulatory cycles; PCOS has hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology on ultrasound.

2. "What are the side effects of spironolactone in hirsutism treatment?"

   • Answer: Hyperkalemia (monitor potassium), menstrual irregularities, gynecomastia in men (but women usually tolerate well), increased urination, and potential teratogenicity.

3. "How does eflornithine cream work for hirsutism?"

   • Answer: Eflornithine is an irreversible inhibitor of ornithine decarboxylase, the rate-limiting enzyme in polyamine synthesis required for hair follicle proliferation, slowing hair growth rather than removing existing hair.

4. "What investigations are needed before starting anti-androgen therapy?"

   • Answer: Pregnancy test (all anti-androgens are teratogenic), liver function tests (hepatotoxicity risk), potassium levels (for spironolactone), and exclusion of renal impairment.

5. "How do you counsel women about fertility in hirsutism associated with PCOS?"

   • Answer: PCOS-related hirsutism often indicates ovulatory dysfunction; lifestyle modification, metformin, and ovulation induction can restore fertility; combined OCP may temporarily suppress fertility but improves cycle regularity long-term.

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