Hirsutism and excess hair growth has a complex biology

Hirsutism is a human hair production disorder that affects approximately 5% to 10% women. Its primary symptom is dense, coarse and unwanted hair growth like in their male counterparts, in various body parts like the face, neck, chest, lower abdomen etc.

Hirsutism often leads to social and psychological agony in patients, apart from related clinical disorders and risks. However, the good news for hirsute patients is that there are a number of modern and effective treatments for hirsute patients.

To understand the biology of this physiological phenomenon, one needs to get to the root of the matter. First, you should know what causes this problem. Though primarily caused by endocrine disorder, hirsutism can also be the result of many other factors.

Endocrine related causes

In simple terms, this is marked by follicular or endocrine malfunction, which results in excess androgen activity, excess testosterone secretion and reaction of hair follicles to androgens. All these genetically predetermined factors lead to unwanted hair growth. The most prevalent cause of this phenomenon is polycystic ovary syndrome (PCOS), seen in 70% to 80 % of all hirsute patients.

Medically, PCOS is marked by follicular cystic formations in the ovary and is detected by an ultrasound and medical tests for biochemical irregularities like increased LH:FSH hormone ratio, serum LH more than 10 IU/L, reduced SHBG and a disproportionate serum testosterone level. Other than hirsutism, PCOS also shows associated symptoms like amenorrhea or dysfunctional uterine bleeding, obesity, infertility, irregular menstrual cycle and acne.

Other less prevalent endocrine-triggered causes of hirsutism include hyperandrogenism, hypothyroidism, hyperandrogenic insulin-resistant acanthosis nigricans syndrome (HAIR-AN), 21-hydroxylase non-classic I adrenal hyperplasia (late-onset CAH), 21-hydroxylase-deficient congenital adrenal hyperplasia, hyperprolactinemia, androgenic tumors and Cushing’s syndrome.

Non-endocrine causes

Causes of hirsutism not traced to a central endocrine abnormality also means that they are not related to the excess androgen syndrome. They are of the three following kinds:

1. Unwanted hair growth of acromegalics.
2. Hair coarseness and denseness because of chronic skin sensitivity, since a major activity of hair is to protect the skin.
3. Use of non-androgenic anabolic drugs also results in the overall increase of many tissues, which also includes hair. This can also result in a hirsutism like symptom called vellus hypertrichosis. Hypertrichosis is also marked by unwanted hair growth but of the non-terminal (vellus) kind, particularly in non-sexual body parts.

Idiopathic causes of hirsutism

The idiopathic factor is the second most common cause of hirsutism after PCOS and is traced in 6% to 17% cases. Though the detailed biology of this cause is still being researched, patients with this kind of hirsutism have a probable excess peripheral 5 alpha-reductase action in skin and hair follicle, other variations in androgen metabolism or greater sensitivity of the androgen receptor.

Its primary symptoms are also excess terminal hair growth in androgen-receptive body parts. However, menses (i.e. ovulation) and serum androgen levels remain unaffected.

Idiopathic hirsute patients must be evaluated with the following medical tests:

• A daily basal body temperature charting.
• Luteal phase progesterone, DHEAS, testosterone.
• Either follicular phase basal 17-OH progesterone levels or a Cortrosyn stimulation III test.

Studies about this kind of hirsutism found that in the peripheral blood lymphocytes of certain patients the longer of the two-androgen receptor alleles was “preferentially methylated” (and hence dysfunctional). Hence, experts suggest that it is probable that genetic modifications of the androgen receptor function and possibly 5-reductase function can alter the manifestation of hirsutism.

Treatment of hirsutism

The clinical treatment of hirsutism must check or at least slow down the formation of new terminal hair without harming the existing hair follicles. Treatment of endocrine-triggered hirsutism can be done by androgen suppression, peripheral androgen blockade combined with mechanical/cosmetic or topical removal and destruction of the unwanted hairs. It is also essential for obese hirsute patients to lose weight not only to get rid of the unwanted hair faster but also to prevent their propensity to diabetes. In such patients, weight control helps by increasing the SHBG and hence lessening free androgen levels.

Broadly, the treatment process should involve a combination of the following steps:

1. Androgen control.
2. Peripheral androgen check.
3. Mechanical/cosmetic elimination and destruction of the unwanted hairs.
4. Topical therapy.

You can avail of a combination of these methods (following the four strategies given above) for effective treatment:

• Oral contraceptive pills (OCPs).
• Spironolactone and antiandrogen.
• Flutamide and finasteride treatment.
• Metformin and pioglitazone insulin-sensitizing agents.
• Cosmetic and mechanical hair removal like bleaching or chemical depilation, plucking, waxing, shaving and more permanent procedures like laser therapy, electrolysis etc.
• Topical methods like with Eflornithine 11.5% cream.

However, one must be aware that most treatments have some side effects and you should know about them before you choose a therapy.