What is hirsutism, how it is caused, and how can it be treated

Hirsutism is defined as excessive and unwanted facial and/or body (say in the neck, chest and lower abdomen) hair in a male-like formulation. Estimates suggest that it affects between 5% and 15% of women, varying according to characteristics. At least 5% of women of reproductive age suffer from this ailment.

It is a common issue causing significant social and psychological distress mainly among women, but modern diagnosis and treatment can surely take care of the problem.

Hair development biology

Our hair follicles first form in the fetal stage. The amount is approximately 5 million (20% of which is in the scalp) is genetically predetermined. To understand hirsutism better one needs to know the three hair types in humans and their life cycle.

• Lanugo hair: This soft, downy hair is first formed in the human fetus and disappears in late gestation or early postpartum stage.
• Vellus hair: It is non-pigmented, soft and short and occurs in the seemingly hairless body parts.
• Terminal hair: This is pigmented, dense, coarse and longer than vellus hair and makes the eyebrows, eyelashes, scalp hair, the pubic hair and axillary hair, etc.

The permanent conversion and development of vellus to terminal hair is a normal biological process triggered by androgens, testosterone and dihydrotestosterone (DHT) in body parts that are androgen receptive. This cycle normally starts at puberty, goes on during adult life and gradually diminishes with age and reproductive capacity in both sexes.

The normal life span of hair is made up of three alternating stages:

• Anagen stage: Growth
• Catagen phase: Involution
• Telogen phase: Rest

Diagnosis of Hirsutism

Medical diagnosis should obviously be done by a medical expert. Though hirsutism can be identified by the evident display of unwanted hair growth, it must not be mixed up with another similar syndrome called, hypertrichosis. Hypertrichosis also results in excessive hair growth but is of the non-terminal (vellus) kind and generally in non-sexual body parts. Its causes and treatment are also different.

The most prevalent technique of assessing hirsutism is that established by Ferriman and Gallwey in 1961. Hirsutism can be mild, moderate or severe as suggested by a pathological test. Generally, the diagnosis of hirsutism must start with a clinical history and physical check up to trace the signs and symptoms of the causes of hirsutism.

Causes and associated disorders of Hirsutism

Hirsutism can be traced to three categories of causes:

1. Nonandrogenic factors are the one’s that are not related to disproportionate androgen activity.
2. Result of androgen excess.
3. Idiopathic hirsutism.

1. Nonandrogenic causes

This is less prevalent and can be divided in the following forms:

• Unnecessary hair growth of acromegalics.
• Coarsening of the hairs associated with chronic skin problems, since a major function of the hair is to protect the skin
• Non-androgenic anabolic drugs often cause a general increase of many tissues, particularly hair. This can also result in vellus hypertrichosis and not hirsutism.

2. Androgenic causes

This is the most common cause of hirsutism, accounting for around 75–85% cases. The various androgen dysfunction causes are listed below, with a percentage of their prevalence among hirsute patients (Please note that figures often vary in various surveys and reports):

• Polycystic Ovarian Syndrome (PCOS) - 70–80%
• Hyperandrogenism - 6.8%
• Hypothyroidism - 0.7%
• The hyperandrogenic insulin-resistant acanthosis nigricans syndrome (HAIR-AN) - 3 %
• 21-hydroxylase non-classic I adrenal hyperplasia (late-onset CAH) - 1.6%
• 21 -hydroxylase-deficient congenital adrenal hyperplasia - 0.7%
• Hyperprolactinemia - 0.3%
• Androgenic tumors - 0.2%
• Cushing’s syndrome - 0-1%

3. Idiopathic hirsutism

The idiopathic cause is traced in 4.7% patients and it’s associated symptoms are hirsutism and probable overactive 5 alpha-reductase action in skin and hair follicle. However, menses are regular.

Treatment of Hirsutism

The clinical treatment of hirsutism is a process to check or at least decelerate the formation of new terminal hair growth without harming the existing hair follicles. For effective results, the hirsute patient must first get rid of terminal hairs. The treatment time is dependent on how fast one can check hair growth according to the anagen, catagen and telogen phases of the life cycle of hair. Generally, you must undergo at least 6 months of therapy to see some results.

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

1. Androgen suppression.
2. Peripheral androgen blockade.
3. Mechanical/cosmetic removal and destruction of the unwanted hairs.

The various permutations and combinations that can result in this three-pronged treatment are as follows:

• Oral contraceptive pills (OCPs): The target is to reduce ovarian steroid production with the use of estrogen and progestins as in oral contraceptive pills (OCPs).
• Spironolactone and antiandrogen: The two are either recommended exclusively or combined with OCPs in order to prevent androgen activity at hair follicles.
• Flutamide and finasteride treatment have similar results as spironolactone.
• Metformin and pioglitazone are insulin-sensitizing agents that can also help in treating hirsutism and acne.
• Cosmetic and mechanical hair removal like bleaching or chemical depilation, plucking, waxing, shaving and more permanent procedures like laser therapy, electrolysis etc.

Combinations of the above medications are often recommended to reduce prescribed doses, side effects and to improve the cosmetic therapy results. This apart, a treatment of hirsutism must address associated ailments like endometrial cancer, infertility, coronary ailments, dysfunctional bleeding, type 2 diabetes mellitus and dyslipidemia etc. This can be achieved by implementing a combination of lifestyle changes (like weight reduction by keeping off certain food, daily physical activity etc), insulin sensitizers and the use of lipid-lowering agents.