What is Hirsutism?
Hirsutism refers to excessive or disproportionate hair growth in a male-like pattern in women.
Facial and body hair is normal for women; however, the texture of the hair is usually fine, and the color is typically light. Some people call this hair “peach fuzz”. With hirsutism, hair is thick, dark, and coarse, and presents in areas where men typically have hair and women do NOT. Affected areas may include:
- The face
- Above the upper lip (in the distribution of a mustache)
- On the chin and sideburns
- On the chest
- Around the nipples
- On the lower abdomen
- On the upper, inner thighs, and
- On the upper and lower back
How Common is Hirsutism?
Hirsutism affects roughly 5–15% of all women. It tends to run in families and is more common in women of Mediterranean, South Asian, and Middle Eastern descent. It is less common in Asian and Native-American women; however, it affects women of ALL ethnic backgrounds.
What Causes Hirsutism?
Hirsutism represents a change from vellus hair (or short, fine, light-colored hair that covers much of the body) to terminal hair (or coarser, darker, thicker hair) in areas where men typically have hair and women do not.
Excess male sex hormones or androgens, primarily testosterone, are the most common cause of excessive, unwanted, hair growth in women, as increased androgen levels cause this conversion from vellus to terminal hair. Any condition that increases your androgen or testosterone levels can cause hirsutism.
Once a hair follicle converts or turns from a vellus to terminal hair it will never convert back. It can only be removed long-term via laser treatments or electrolysis.
What is the difference between vellus and terminal hair? Tell me more about my hair and hair growth…
Our skin has 3 layers: the epidermis (or the outermost layer), the dermis (containing our connective tissues, hair follicles, blood vessels, and sweat glands), and a deeper, underlying subcutaneous fat layer.
Hair is made up of a protein called keratin. The hair follicle is the structure that actually anchors each of your hairs to your skin. It looks like a tunnel. Inside of the hair follicle are stem cells, blood vessels that provide nourishment and deliver hormones to modify hair growth and structure, sebaceous glands, and the hair itself. Sebaceous glands are tiny sebum-producing glands that keep our hair moist and oily. Our scalps have about 100,000 hair follicles, which is why it can sometimes seem like we lose a lot of hair each day.
Most of our body is covered in hair follicles. Exceptions include: the palms of the hands and soles of the feet, behind our ears, on the forehead, eyelids, nose, lips, belly button, and in any areas where you might have scar tissue.
Hair growth occurs in 3 phases:
1. Anagen, or the period of hair “growth”: Here, cells are dividing rapidly and new hair is growing. At any given time, most of our hairs are in this phase. Hair will actively grow for an average of 2-7 years before hair follicles become dormant. The length of this phase is dependent on your personal maximal hair length. Hair growth varies by person, averaging ½ inch per month but is very individualized, and based on genetics, your age, overall health, underlying medical conditions, and other factors.
2. Catagen or the “transitional phase”: This period is short, lasting only 2-3 weeks. Here, hair growth slows, the hair detaches itself from its blood supply, and the hair follicle shrinks. It’s in-between growth and shedding, if you will.
3. Telogen or the “resting phase”: Hairs that detached from the blood supply in the catagen phase rest in their roots while new hairs begin to grow underneath them. These new hairs push the old hairs out as they grow. This phase typically lasts around 3 months, and is usually when most shedding occurs and is noticed. Roughly 25-100 hairs will shed daily.
The majority of hair on our bodies is vellus hair.
Vellus hair helps us to regulate body temperature by creating insulation for warmth. It also acts as a wick for sweat to cool us off thru perspiration.
Vellus hairs provide sensation. They let us know when something is crawling on our skin and they’re what give us the sensation of goosebumps. Goosebumps are a reflex that appear when the arrector pili muscles, or tiny muscles that surround the roots of our hair follicles, contract and tighten up, pulling the hairs into an upright position, creating small “goosebumps” on our skin.
Goosebumps play an important role in temperature regulation. When the hair stands up, it offers more insulation, which is why goosebumps appear when you’re cold. Adrenaline, which is released as a part of the fight-or-flight response, can also trigger goosebumps. So when you’re scared or in an emotionally intense situation, you might notice goosebumps.
Hair growth is one of the many changes that occurs during puberty. Increased androgen levels (especially testosterone) cause vellus hairs to convert to terminal hair son certain parts of the body, like the armpits and in the pubic area. Elevated androgen levels also causes hairs to develop subcutaneous glands that lubricate the hair with oil. This attributes to increased acne during puberty and adolescence.
Females tend to retain more vellus hair than males due to lower androgen levels.
What Underlying Medical Conditions can cause Hirsutism?
Underlying conditions that can cause elevated androgen levels and secondary Hirsutism include:
- Polycystic ovary syndrome (PCOS). This is most common cause of hirsutism. Research suggests that 5-10% of women of childbearing age have PCOS, and 60-70% of these women have hirsutism. PCOS causes an imbalance of sex hormones resulting in not just hirsutism but also irregular periods, central obesity, infertility, polycystic ovaries, insulin resistance, metabolic syndrome, and other skin changes like Acanthosis nigricans or dark discoloration noticed in body folds and creases.
- Cushing syndrome occurs as a result of elevated cortisol levels. Cortisol is a hormone produced by the adrenal glands (endocrine glands that sit on top of the kidneys and produce a number of hormones including adrenaline, cortisol, and aldosterone). Cushing syndrome can occur secondary to your adrenal glands producing too much cortisol, or from you taking certain medications like prednisone for a prolonged period of time. Symptoms may include: central obesity, moon facies (or extra fat build-up on the sides of your face), purple skin striae (or stretch marks), muscle weakness, acne, high blood pressure, and problems with how your body regulates glucose and insulin levels.
- Congenital adrenal hyperplasia is an inherited condition where your body produces abnormal levels of steroid hormones, including cortisol and androgens (like testosterone).
- b>Thyroid dysfunction is a rare cause of isolated hirsutism. Typically patients will have other symptoms as well that will help to formulate a proper diagnosis.
- Symptoms of Hypothyroidism (or a low functioning thyroid gland) may include: fatigue, lack of energy, cold intolerance or the feeling that you can never get warm enough, dry skin, hair loss, unexplainable weight gain, difficulty concentrating, depression, and irregular menstrual cycles.
- Symptoms of Hyperthyroidism (or an overactive thyroid gland) may include: heat intolerance or the sensation that you’re always warm, moist skin, palpitations or irregular or fast heartbeat, changes in your menstrual cycle, goiter or mass in your neck in the area of your thyroid gland, and sometimes a condition known as exophthalmos where the eyeball actually protrudes out from the eye socket making the eye appear to bulge.
- Adrenal gland tumors and ovarian tumors are less common causes of hirsutism. Typically these conditions will have a rapid onset of unwanted hair growth that comes out of nowhere. The hirsutism will progress despite treatment, and there will often be other concerning symptoms associated with elevated androgen levels like enlargement of the clitoris, increased muscle mass, and changes in your natural body contour.
- Pituitary adenomas or tumors in the pituitary gland in the brain can sometimes cause hirsutism. Again, they will often be associated with other alarming symptoms like: headache, visual problems, elevated prolactin levels, or changes in other hormones produced by the pituitary gland.
- Pregnancy: Sometimes increased hormone levels during pregnancy can turn vellus hair into terminal hair. This hair usually sheds once the baby is born and female hormone levels return to normal.
- Menopause: The hormonal changes your body goes through during menopause can result in a number of physical changes to your body. For some women this may mean increased facial hair.
- Medications. Some medications can cause hirsutism.
- Sometimes the cause will be unknown.
When is Hirsutism Concerning?
Any unwanted hair growth can be cosmetically disturbing.
It may represent a more serious underlying condition if the onset of your hair growth is rapid, fails to respond to typical treatments, and/or is associated with other symptoms associated with elevated androgen levels such as:
- Changes in your voice, or deepening of your voice
- Increased muscle mass
- Changes in your natural body contour to resemble more masculine features
- Enlargement of the clitoris
- Male pattern balding
- As well, hirsutism prior to puberty and after menopause is much more uncommon and should be promptly evaluated.
- Hirsutism with new onset headache, visual changes, or other changes in your general health should always be evaluated by a professional to assess for underlying disease.
What are the Symptoms of Hirsutism?
Typically, women will notice stiff, coarse, thick, or dark hair in areas where women don't commonly have hair like on the face, above the lip, on the chin, on the sideburns, on the chest, lower abdomen, upper inner thighs, and/or back.
What are the Risk factors for Hirsutism?
Risk factors may include:
- A Personal History of an Underlying Medical Condition known to cause Hirsutism such as PCOS
- Family history: If you have a family history of certain conditions like Congenital Adrenal Hyperplasia, Polycystic Ovary Syndrome (or PCOS), or Metabolic Syndrome you may be at increased risk.
- Ethnicity: Hirsutism is more common in women of Mediterranean, South Asian, and Middle Eastern descent. As well, women of Mediterranean, Middle Eastern and South Asian ancestry are more likely to have excessive body hair with NOT identifiable cause compared with women of other ethnicities.
- Obesity. Obesity can cause increased androgen levels, which can worsen hirsutism.
What are the Complications of Hirsutism?
Hirsutism can be cosmetically disturbing and emotionally distressing. For some women, it might make you feel self-conscious. Hirsutism itself doesn't pose any immediate dangers or physical complications; however, the underlying hormonal imbalance causing the condition, and any associated underlying medical conditions, may have complications associated with them. Being properly diagnosed and treated for any underlying conditions is paramount, not just to treating your symptoms, but also to your overall long-term health. Proper diagnosis and treatment is essential to avoid delayed care, missed diagnosed, associated complications, and poor outcomes.
How can I Prevent Hirsutism?
Hirsutism generally isn't preventable. Often there is a genetic component or underlying disease contributing to the condition. Addressing any underlying medical conditions will help. Losing weight might help if you're overweight to reduce hirsutism, particularly if you have Polycystic Ovary Syndrome since obesity can increase androgen levels.
How is Hirsutism Diagnosed?
Diagnosis is often made based on physical exam and laboratory findings, like testosterone and other hormone levels. Sometimes ultrasound is used to rule out pelvic or abdominal masses as an underlying cause of symptoms. MRI may be necessary if a Pituitary Adenoma or other more alarming condition is suspected.
How is Hirsutism Treated?
First and foremost, the cause of your symptoms should be identified. Any underlying medical conditions contributing to your symptoms should always be treated first.
After that, treatment is guided by the severity of your symptoms and the amount of distress the hirsutism is causing you. Treatment is a very personal decision and not always necessary unless you choose to pursue it.
- Medications are sometimes used and may include oral contraceptives, anti-androgens to block the effects of androgens like testosterone, and insulin lowering agents. Medical management should be discussed with the provider who is managing your underlying condition (such as PCOS or Insulin resistance), as again, we are a GI practice and our focus is your GI health.
- Any therapy for hirsutism should be continued for at least six months (or the average life cycle of a hair follicle) before determining if its effective or not.
- If you are obese, weight loss is often encouraged because obesity can alter the way the body produces and processes androgens. Obesity can reduce the effectiveness of medical treatment. Embarking on a weight-loss program may be beneficial.
- If you want to get rid of existing terminal hairs, laser treatment or electrolysis is typically needed. Often, women will try plucking, waxing and shaving first but these techniques can often worsen hirsutism by irritating the skin.
- Shaving is fast, safe, and effective, but needs to be repeated often. Hair regrowth after shaving can appear coarser, because the tip of the hair becomes blunt rather than tapered.
- Hair removal creams can be used to dissolve hairs, but can cause a reactive dermatitis or inflammation and irritation to the skin.
- Waxing or plucking removes hair down to above the bulb; however, in addition to being uncomfortable, scarring, folliculitis, and hyperpigmentation (or darkening of the skin) may occur after waxing or plucking.
- Laser therapy involves passing a beam of highly concentrated light (or a laser) over your skin to damage hair follicles and prevent them from growing. Multiple treatments may be necessary.
- Hyperpigmentation or darkening of the skin is a common side effect.
- Electrolysis involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and destroys the hair follicle. Again, you might require multiple treatments.
- Electrolysis can be painful and time-consuming because each hair follicle needs to be individually targeted. For this reason, electrolysis is often used for treating smaller skin areas.
If you have any concerns regarding Hirsutism please be sure to discuss them with your Primary Care Provider, OBGYN, and/or our office staff. We’re here to help you identify a cause to your symptoms and find a treatment approach that is both affordable and effective for you.
Remember, first and foremost, the cause of your symptoms should be identified. Any underlying medical conditions contributing to your symptoms should always be treated first. Proper diagnosis and treatment of any underlying conditions is essential to avoid delayed care, missed diagnosed, associated complications, and poor outcomes.