Update on the management of hirsutism
ABSTRACTHirsutism is a source of significant anxiety in women. While polycystic ovary syndrome or other endocrine conditions are responsible for excess androgen in many patients, other patients have normal menses and normal androgen levels (“idiopathic” hirsutism). The goal of the evaluation is to rule out any underlying pathology. The goals of therapy are to treat any underlying condition and to remove the excess hair. Current options for hair removal are discussed. Educating patients so they have reasonable treatment expectations is essential, as significant improvement may take weeks or months, and treatment may need to be repeated on an ongoing basis.
KEY POINTS
- The finding of polycystic ovaries is not required for the diagnosis of polycystic ovary syndrome, nor does their presence prove the diagnosis. Gonadotropin-dependent functional ovarian hyperandrogenism is believed to cause this syndrome; however, mild adrenocorticotropic-dependent functional adrenal hyperandrogenism also is a feature in many cases.
- Even women with mild hirsutism with subtle symptoms and signs of hyperandrogenism can have elevated androgen levels, and thus, they deserve a laboratory evaluation.
- Laser treatment does not result in complete, permanent hair reduction, but it is more effective than shaving, waxing, and electrolysis, producing partial hair reduction for up to 6 months.
CURRENT USE OF DIAGNOSTIC IMAGING
When malignancy is suspected
A testosterone level above 200 ng/dL suggests an ovarian tumor, and a DHEAS level above 700 μg/dL suggests an adrenal tumor.26 However, not all tumors present with such high androgen levels, and sudden onset of hirsutism, rapid progression of hirsutism, or signs of virilization suggest a tumor.15 In such cases, transvaginal ultrasonography, computed tomography, or magnetic resonance imaging (MRI) of the abdomen can exclude an ovarian or adrenal tumor.
When polycystic ovary syndrome is suspected
The diagnosis of polycystic ovary syndrome is confirmed by two out of three criteria:
- Oligo-ovulation or anovulation
- Clinical or laboratory signs of hyperandrogenism
- Ultrasonographic evidence of polycystic ovaries, with exclusion of other causes of hyperandrogenism.
ADDITIONAL LABORATORY TESTING
Tests for polycystic ovary syndrome
Assessment of polycystic ovary syndrome involves transvaginal ultrasonography, but ultrasonographic evidence of a polycystic ovary is not necessary for the diagnosis.16 A fasting lipid profile and fasting serum glucose are recommended, and if the fasting serum glucose is normal, an oral glucose tolerance test is recommended. 17
Some have reported measuring the ratio of luteinizing hormone to follicle-stimulating hormone in the workup of polycystic ovary syndrome, and a ratio greater than 2 has been considered indicative but not diagnostic.16,25 The individual levels of luteinizing hormone, follicle-stimulating hormone, and estradiol are more important in the evaluation of infertility and ovulatory dysfunction. In patients with elevations of these hormones or with these symptoms, referral for infertility screening with an endocrinologist or gynecologist is recommended. 25
Additional testing and referral for Cushing syndrome, other conditions
Cushing syndrome can be tested for with a 24-hour urine cortisol, overnight low-dose dexamethasone suppression test, and late-night salivary cortisol.27,28 Referral to an endocrinologist for further testing can differentiate between corticotropin-dependent or corticotropin-independent Cushing syndrome.25 Cushing syndrome is often associated with hyperandrogenism, particularly in those cases caused by adrenal tumors.29
The prolactin level and the level of somatomedin C (insulin-like growth factor 1) can be used to rule out hyperprolactinemia and acromegaly, respectively.12 If Cushing syndrome, hyperprolactinemia, or acromegaly is diagnosed by endocrinologic testing, pituitary MRI should be performed.12,25
Referral to specialist centers with experience with these conditions is essential. Nonclassical congenital adrenal hyperplasia can be screened for by a serum 17-hydroxyprogesterone level measured in the follicular phase.12 Measurement of thyroid-stimulating hormone, free thyroxine, and thyroid peroxidase antibodies screens for thyroid disease.12 Hirsutism has been reported with the commencement of L-thyroxine therapy.30
THE PRINCIPLES OF TREATMENT
Patient education regarding the cause of hirsutism and reasonable treatment expectations and emotional support are important in the management of hirsutism. Also important is regular follow-up to measure and document the response to treatment; this can include repeating Ferriman-Gallwey scoring, taking photographs of affected areas, and retesting androgen levels after 3 to 6 months.12
Treatment must be continued for an ongoing effect, and most pharmacologic treatments can take up to 3 to 6 months to produce significant improvement.1
When an underlying condition is diagnosed, treatment of the condition is essential. Androgen-secreting tumors require surgical management.12 Cushing disease, hyperprolactinemia, and acromegaly should be clinically apparent from examination and testing, and appropriate referral and standard management should be instigated. Exogenous sources of androgen such as androgenic progestins or anabolic steroids should be discontinued. Lifestyle management is important, and weight loss in obese patients with polycystic ovary syndrome can improve hirsutism as well as mitigate cardiovascular risk factors.31
In classic congenital adrenal hyperplasia, glucocorticoid therapy manages both ovulation induction and hirsutism.20 However, in nonclassical congenital adrenal hyperplasia, glucocorticoid therapy supports ovulation induction, but hirsutism usually requires both systemic antiandrogen and hair removal.20
CURRENT OPTIONS FOR HAIR REMOVAL
The choice of method depends on patient preference, adverse effects, the degree of hirsutism, the level of distress, previous treatments, and cost.1,15,32
Self-care methods
Self-care methods offer only temporary reduction of excess hairs.
Plucking removes the entire hair, including the root, but it is painful and time-consuming, and it is only practical for areas where few hairs exist, such as on the face.1
Shaving is an easy, inexpensive, and painless choice for hair removal. Although a common belief is that shaving causes faster or thicker hair regrowth, shaving affects neither the diameter nor the rate of growth of the hair.32 Given its masculine association, shaving is not acceptable to most women except perhaps for use on the legs and axillae.1,32 Shaving can cause irritation, folliculitis, pseudofolliculitis, and infection.1
Waxing removes the entire hair. While it is more expensive than plucking, regrowth is slower, occurring over weeks. It is painful and can cause thermal burns, irritation, folliculitis, scarring, and postinflammatory dyspigmentation.1
Chemical depilatories, usually thioglycollic acid preparations, are inexpensive, painless, and easy to use. However, the resulting hair reduction is of short duration because the hair shafts are only removed at the level of the skin surface.1 They can also cause irritant dermatitis. 1
Bleaching with hydrogen peroxide is inexpensive and can camouflage dark facial hair, but it can also cause skin discoloration and irritation. 1
