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clinical practice
Hirsutism
Robert L. Rosenfield, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem.
Evidence supporting various strategies is then presented, followed by a review of formal guidelines,
when they exist. The article ends with the author’s clinical recommendations.
A 19-year-old woman seeks care for slowly progressive hair growth. Since high school,
she has shaved her upper lip weekly and waxed her abdomen and thighs monthly. Her
menstrual periods are regular. Physical examination is unremarkable except for a body-
mass index (the weight in kilograms divided by the square of the height in meters) of
31 and trace hair over the abdomen and thighs, with a moderate amount over her back.
There is no clitorimegaly. How should this patient be evaluated and treated?
pathogenesis
The growth of sexual hair is entirely dependent on the presence of androgen (Fig. 3).1,5
Before puberty, hair is vellus (small, straight, and fair), and the sebaceous glands in an-
drogen-sensitive follicles are small. In response to the increased levels of androgens at
puberty, vellus follicles in specific areas develop into terminal hairs (larger, curlier, and
darker, hence more visible), becoming sexual-hair follicles; higher androgen levels are
required for the growth of beard than for the growth of pubic and axillary hair. In other
areas (e.g., the forehead and cheeks), the increased androgen levels dramatically in-
crease the size of the sebaceous glands, but the hair remains vellus; the reason for this
differential response is unclear.
Hirsutism results from an interaction between the androgen level and the sensitivity
of the hair follicle to androgen. Most women with androgen levels that are twice the
upper limit of the normal range or higher have some degree of hirsutism.6 However,
the severity of hirsutism does not correlate well with the level of androgen, because the re-
sponse of the androgen-dependent follicle to androgen excess varies considerably
within and among persons. Some women with excess androgen have no skin manifes-
tations, or they may have seborrhea, acne, or alopecia without hirsutism. In other wom-
Each of the nine body areas most sensitive to androgen is assigned a score, from 0 (no hair) to 4 (frankly virile), and these are summed to provide a hormonal hirsutism score. (Adapted
4
4
4
3
3
3
2
2
2
1
1
1
4
4
3
2
1
Vellus hair
Sebaceous
gland
Sebaceous follicle
(adult sebaceous gland)
Androgen Arrector
pili muscle
Vellus-like follicle
Androgen
Balding scalp
quently. Nonclassic congenital adrenal hyperplasia tomatic, idiopathic hyperandrogenism.17 This con-
is present in only 1.5 to 2.5 percent of women with dition may be due to abnormal peripheral metabo-
hyperandrogenism.9,17 Androgen-secreting tumors lism of prohormones. Androgenic medications also
are present in about 0.2 percent of women with may cause hirsutism.
hyperandrogenism9; more than half of such tumors
are malignant.24 Cushing’s syndrome, hyperpro- diagnostic strategies
lactinemia, acromegaly, and thyroid dysfunction The medical history and physical examination
must be considered as causes of androgen excess, should address risk factors associated with viriliz-
but these conditions usually present because of ing disorders, polycystic ovary syndrome or other
symptoms other than hirsutism. About 8 percent endocrinopathies, and the use of androgenic med-
of women with hirsutism have mild, often asymp- ications. A rapid pace of development or progres-
Prescription or non- Mild hirsutism Moderate hirsutism Risk of neoplasm: Risk of polycystic ovary Risk of other endocri-
prescription drug use (score, 8–15) (score, >15) sudden onset of syndrome: menstrual nopathy: symptoms
hirsutism, rapid irregularity, seborrhea, or signs of cortisol
progression, viriliza- acne, balding, obesity, excess, congenital
tion, abdominal acanthosis nigricans adrenal hyperplasia,
Discontinue or pelvic mass hyperprolactinemia,
if possible excess growth
hormone, thyroid
dysfunction
Plasma testosterone
Work up accordingly
level
Recheck early-morning
Idiopathic hirsutism levels of total and Androgen excess
free testosterone
testosterone levels, so assay-specific results differ a normal free testosterone level is unlikely to be
widely. The most reliable assays for measuring clinically relevant aside from being associated with
free testosterone compute the level of free testos- acne.5,35,36 Very high levels of total testosterone
terone from the levels of total testosterone and sex (more than 200 ng per deciliter [6.94 nmol per liter])
hormone–binding globulin.34 Methods that purport or of dehydroepiandrosterone sulfate (more than
to assay free testosterone directly are particularly 700 µg per deciliter [19 µmol per liter]) heighten
suspect. the likelihood of an underlying neoplasm (with el-
Routine testing for other androgens is of little evated levels of dehydroepiandrosterone sulfate
use.6,8,9 The level of dehydroepiandrosterone sul- indicating an adrenal source)37; however, lesser ele-
fate is increased in approximately 15 percent of vations were present in several cases among 17
women who have normal levels of total and free women with androgenic tumors.24
testosterone. A mildly elevated level in a woman with A total testosterone level that is normal or mar-
ginally elevated (within about 20 ng per deciliter matologic side effects. Laser treatment covers a
[0.69 nmol per liter] of the upper limits of normal) somewhat wider surface area, with fewer side ef-
in the absence of other features of concern proba- fects and less pain, than electrolysis, temporarily
bly indicates idiopathic hirsutism or idiopathic hy- reduces by a factor of about four the need for sim-
perandrogenism. Further workup is generally not ple cosmetic measures for several months after a
necessary unless the hirsutism progresses despite single session, and permanently reduces hair den-
therapy or worrisome features, such as menstrual sity by 30 percent or more with three to four treat-
irregularity, obesity, or increasing masculinization, ments at a site. Electrolysis involves the insertion of
become apparent. An assessment of the free testos- an electrode to destroy individual follicles. Both
terone level is warranted in patients with features of laser therapy and electrolysis require delivery by
other disorders, even if the total testosterone level trained personnel, are repetitious, expensive, and
is not clearly elevated. painful, are practical only for the treatment of lim-
If androgen excess or features that suggest a sec- ited areas, and may result in local reactions, includ-
ondary cause of hirsutism are present, referral to an ing burns, dyspigmentation, and scarring.
endocrinologist is reasonable. Additional workup
is discussed in the legend for Figure 4.22,31,38 Hormonal Treatments
Hormonal therapies act by either suppressing an-
management drogen production or blocking the action of andro-
Hirsutism can be reduced with the use of cosmet- gens within the skin.1 The suppression or block-
ic and hormonal therapy for as long as treatment age of androgen causes hairs to revert toward the
is given. Moderate, permanent reduction of hirsut- prepubertal vellus type. The maximal effect requires
ism can often be achieved by physical means in op- 9 to 12 months of treatment because of the long
timal circumstances. Table 1 reviews medications duration of the hair-growth cycle. Assessments of
used for treatment. efficacy are limited by their subjective nature, the
dearth of randomized, controlled trials, and the fact
Cosmetic and Physical Measures that treatment of hirsutism is an off-label use of
Cosmetic measures are the cornerstone of care for these agents — in part because androgen blockades
hirsutism,39 although the costs are not covered by for this indication have been limited by liability con-
insurance. Bleaching and shaving suffice for many cerns related to the risk of pseudohermaphrodit-
patients. Depilating agents and waxing treatments ism in male fetuses.
are useful but tend to cause skin irritation. Eflorni-
thine hydrochloride cream (Vaniqa) was recently Estrogen–Progestin Oral Contraceptives
approved for the treatment of facial hirsutism.40 Oral contraceptives suppress plasma-testosterone
Data from randomized, double-blind, placebo-con- levels, particularly the level of free testosterone,
trolled trials show that there is a maximal effect by mainly by inhibiting ovarian function and raising
8 to 24 weeks, with marked improvement among the levels of sex-hormone–binding globulin levels.1
32 percent of patients (as compared with 8 percent This method of treatment can reduce by half the
of patients treated with placebo). need for shaving43 and can arrest the progression
The Food and Drug Administration has per- of hirsutism from various causes, but it will not re-
mitted the marketing of many laser devices, as well verse hirsutism2,44; cosmetic measures should also
as equivalent flashlamps, for permanent hair re- be used. Although any combination pill will suffice,
duction. There is a paucity of published clinical data contraceptives with nonandrogenic progestins (Ta-
with regard to these devices.41,42 Wavelengths of ble 1) are preferable because of their potentially fa-
between 694 and 1064 nm damage hair follicles vorable effects on lipid levels,45 acne,46 and, in the
through the combination of relatively selective heat case of drospirenone, salt retention.47 It is unclear
absorption by dark hairs and penetration of the whether the newer low-dose pills included in the ta-
wavelengths into the dermis. Light-skinned wom- ble carry a risk of venous thromboembolism.48
en are the best candidates, since they require lower
energy pulses than women with dark skin. Those Antiandrogens
with heavily tanned or darker skin require the use For the substantial reduction of hirsutism, anti-
of lasers with built-in cooling devices and adjust- androgens are required. Competitive inhibitors of
ment of energy levels to minimize the risk of der- androgen binding to the androgen receptor are su-
Drug Type Active Ingredient Example Major Mechanism Indication Contraindications Dose Major Side Effects
Cell-cycle Eflornithine hydro- Vaniqa Irreversible inhibitor Focal hirsutism Pregnancy, breast- Topical, twice daily Rash, potential systemic toxicity
inhibitor chloride, 13.9% of ornithine de- feeding with widespread application
carboxylase
Oral contra- Ethinyl estradiol Suppresses ovarian Generalized Breast cancer, smok- 1 tablet by mouth at bed- Irregular vaginal bleeding,
ceptives* 30 µg + drospirenone Yasmin function hirsutism ing (absolutely if time (the larger es- venous thrombosis
35 µg + norgestimate Ortho-Cyclen age >35 yr), cardio- trogen doses may be
50 µg + ethynodiol Demulen 1–50 vascular disease, necessary in heavier
diacetate uncontrolled hyper- women for menstru-
tension al regularity)
Antiandrogens Spironolactone Competitive inhibi- Moderate or Lack of contraception, 50–100 mg by mouth, Male pseudohermaphroditism
tor of androgen- severe kidney or liver twice daily in fetus, irregular menstrual
receptor binding hirsutism failure bleeding unless oral contra-
www.nejm.org
Maintenance: 5 mg by administered cyclically,
clinical practice
* The oral contraceptives included here are examples of preparations with low androgenic activity.
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2585
The new england journal of medicine
cystic ovary syndrome, and I would evaluate a ran- recommend oral contraceptives, which would be
dom plasma specimen for the level of free testos- expected to substantially reduce the need for cos-
terone (measurement of the total testosterone level metic treatments over a 9-to-12-month period.
would be reasonable if reliable assessment of free I would also discuss the potential permanent ben-
testosterone were not readily available, as shown in efit, risks, and costs of laser hair removal or elec-
Fig. 4). A trial of eflornithine chloride cream might trolysis. For more severe hirsutism, spironolactone
be tried initially for facial hirsutism, although cost could be added to oral-contraceptive therapy, which
is a consideration. I would also encourage weight would require closer monitoring for side effects
control. I would plan a follow-up visit to assess than would the other options.
the patient’s response and to reassess whether ev- Supported by grants (HD-39267, U54-041859, and RR-00055)
from the U.S. Public Health Service.
idence had emerged to suggest a secondary cause Dr. Rosenfield reports having received consulting fees from Val-
of hirsutism (if so, I would recheck early-morning era Pharmaceuticals.
levels of free testosterone to ensure that they were I am indebted to Drs. David A. Ehrmann and Sarah Stein for their
careful review of the manuscript and to Dr. David Whiting for advice
normal). If hirsutism remained inadequately con- about Figure 3.
trolled, since there are no contraindications, I would
references
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