Hirsutism in Women

 

Am Fam Physician. 2019 Aug 1;100(3):168-175.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/hirsutism.

Author disclosure: No relevant financial affiliations.

Hirsutism is the excessive growth of terminal hair in a typical male pattern in a female. It is often a sign of excessive androgen levels. Although many conditions can lead to hirsutism, polycystic ovary syndrome and idiopathic hyperandrogenism account for more than 85% of cases. Less common causes include idiopathic hirsutism, nonclassic congenital adrenal hyperplasia, androgen-secreting tumors, medications, hyperprolactinemia, thyroid disorders, and Cushing syndrome. Women with an abnormal hirsutism score based on the Ferriman-Gallwey scoring system should be evaluated for elevated androgen levels. Women with rapid onset of hirsutism over a few months or signs of virilization are at high risk of having an androgen-secreting tumor. Hirsutism may be treated with pharmacologic agents and/or hair removal. Recommended pharmacologic therapies include combined oral contraceptives, finasteride, spironolactone, and topical eflornithine. Because of the length of the hair growth cycle, therapies should be tried for at least six months before switching treatments. Hair removal methods such as shaving, waxing, and plucking may be effective, but their effects are temporary. Photoepilation and electrolysis are somewhat effective for long-term hair removal but are expensive.

Hirsutism is excessive growth of terminal hair in a typical male pattern in a female. It is typically a sign of excessive androgen levels. Hirsutism has been reported in 5% to 15% of women and is often associated with decreased quality of life and significant psychological stress.15 Hirsutism should be differentiated from hypertrichosis, which is increased growth—typically of vellus hair—in a generalized nonsexual distribution that is independent of androgens, although hyperandrogenism can exacerbate the condition.6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Women with an abnormal Ferriman-Gallwey score should be tested for elevated androgen levels.6,14,22

C

Based on expert opinion and consensus guidelines in the absence of clinical trials

Combined oral contraceptives are first-line therapy for women with hirsutism who are not trying to conceive and in whom cosmetic measures are ineffective.6,22,25,26,32

B

Based on inconsistent or limited-quality evidence from RCTs showing improvement in patient-reported hirsutism

If patient-important hirsutism persists after six months of therapy with combined oral contraceptives, the addition of an antiandrogen should be considered.6,22,25,27,28,33

A

Based on consistent evidence from RCTs showing improvement in patient-reported hirsutism

Gonadotropin-releasing hormone agonists should be avoided for the treatment of hirsutism except in patients with severe hyperandrogenism, in whom combined oral contraceptives and antiandrogens are ineffective.6,34

C

Based on expert opinion and consensus guidelines in the absence of clinical trials

Insulin-lowering drugs are not recommended to treat hirsutism.6,25,30

B

Based on limited-quality patient-oriented evidence from RCTs showing no improvement in patient-reported hirsutism

Photoepilation is the preferred treatment for most patients who desire permanent hair removal. Those with blonde or white hair should use electrolysis.6,36

B

Based on limited-quality patient-oriented evidence from RCTs showing improvement in patient-reported hirsutism


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Women with an abnormal Ferriman-Gallwey score should be tested for elevated androgen levels.6,14,22

C

Based on expert opinion and consensus guidelines in the absence of clinical trials

Combined oral contraceptives are first-line therapy for women with hirsutism who are not trying to conceive and in whom cosmetic measures are ineffective.6,22,25,26,32

B

Based on inconsistent or limited-quality evidence from RCTs showing improvement in patient-reported hirsutism

If patient-important hirsutism persists after six months of therapy with combined oral contraceptives, the addition of an antiandrogen should be considered.6,22,25,27,28,33

A

Based on consistent evidence from RCTs showing improvement in patient-reported hirsutism

Gonadotropin-releasing hormone agonists should be avoided for the treatment of hirsutism except in patients with severe hyperandrogenism, in whom combined oral contraceptives and antiandrogens are ineffective.6,34

C

Based on expert opinion and consensus guidelines in the absence of clinical trials

Insulin-lowering drugs are not recommended to treat hirsutism.6,25,30

B

Based on limited-quality pati

The Authors

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ERIC MATHESON, MD, MS, is a transitional year residency director and associate professor of family medicine at the Medical University of South Carolina, Charleston....

JENNIFER BAIN, MD, is a women's health education director, clinical services director, and clinical associate professor of family medicine at the Medical University of South Carolina.

Address correspondence to Eric Matheson, MD, MS, 9228 Medical Plaza Dr., Charleston, SC 29406 (email: matheson@musc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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