Hirsutism

Hirsutism is a condition in which stiff or dark body hair appears on areas of the body where women typically do not have hair. These areas include:

• Face
• Chest
• Lower abdomen
• Inner thighs
• Back

Hirsutism is caused by high levels of androgens, or male sex hormones. It can be accompanied by various other symptoms, including:

• Decreased breast size
• Enlarged ovaries
• Enlarged shoulder muscles
• Acne
• Oily skin
• Enlarged clitoris
• Irregular periods
• Deepening of voice

Increased levels of androgens (male sex hormones such as testosterone) or oversensitivity of the hair follicles to androgens can cause hirsutism. The conditions that can cause hirsutism include:

• Polycystic ovarian disorder (PCOS): A common hormonal condition that causes excessive production of androgens. Some women with this disorder do not have cysts, while some women without the disorder can develop cysts. Other than hirsutism, PCOS can also cause:
  • Thinning hair on the head
  • Infertility
  • Acne
  • Mood changes
  • Pelvic pain
  • Headaches
  • Sleep problems
  • Weight gain/obesity
• Genetic disorder: A group of genetic disorders that affect the adrenal glands (a pair of walnut-sized organs above the kidneys), such as congenital adrenal hyperplasia, can cause hirsutism.
• Adrenal and ovarian tumor: Tumors of the adrenal glands, pituitary glands, and ovaries can sometimes lead to hirsutism. In rare cases of ovarian and adrenal tumors, female sex hormone levels are often suppressed to or below the lower limit of normal, while the levels of androgens in circulation are twice the upper limit of normal or higher.
• Idiopathic hirsutism: Hirsutism with normal androgen levels is referred to as idiopathic hirsutism. It may be due to increased sensitivity to androgens. A typical example is familial hirsutism, characterized by gradually increased growth of rough facial hair.
• Cushing’s syndrome: Cushing syndrome is a result of prolonged exposure to cortisol, a steroid hormone. Its levels increase in response to high stress and low blood glucose concentration. Along with excessive hair growth, visible signs include a large abdomen with thin arms and legs, as well as potential muscle weakness, weak bones, breakouts, and sensitive skin.
• Increased sensitivity to androgens: Under a quarter of premenopausal women with hirsutism have normal androgen levels, which may be due to increased sensitivity to androgens.
• Certain medications: The following medications can lead to excessive hair growth or hirsutism:
  • Anabolic steroids
  • Testosterone
  • Glucocorticoids
  • Minoxidil
  • Cyclosporine
  • Phenytoin
  • Diazoxide
  • Progestin-containing medications

Several factors can influence your likelihood of developing hirsutism, including:

• Family history: Several conditions that cause hirsutism, including congenital adrenal hyperplasia and polycystic ovary syndrome, run in families. Up to 50% of women with hirsutism have a family history of the disorder.
• Regional differences: Women of Mediterranean, Middle Eastern, and South Asian ancestry are more likely to have increased body hair with no identifiable cause than women of other ancestries.
• Obesity: Obesity or being overweight can lead to increased androgen production, which may result in hirsutism.

Medical History

• Age of onset of hirsutism (puberty, middle age, menopause)
• Rate of onset of symptoms (gradual or sudden)
• Other signs or symptoms (acne, deepening of voice, infrequent menstruation, loss of breast tissue, increased muscle mass as in shoulder girdle, malodorous perspiration, etc.)

Physical Examination

Lab Tests

• Testosterone: Serum testosterone may be normal or elevated in cases of polycystic ovarian syndrome (PCOS) and congenital adrenal hyperplasia (CAH), but is significantly raised (>200 ng/ml) in cases of malignant tumors of the adrenal or ovary.
• Dehydroepiandrosterone sulfate (DHEAS): DHEA is a hormone produced by the adrenal glands. A raised DHEAS (>700 μg/dl) indicates an adrenal cause, whether benign or malignant.
• 17 Hydroxy progesterone: This serum marker is unique for congenital adrenal hyperplasia.
• Cortisol: Cortisol is measured for those exhibiting signs and symptoms of Cushing's syndrome, which occurs when the body produces excessive cortisol.
• Serum Thyroid-stimulating hormone (TSH): Serum TSH is a marker of thyroid function. Hypophyseal hypothyroidism can act as a cofactor in hirsutism, causing raised TSH levels.
• Prolactin: A prolactin (PRL) test measures the level of prolactin in the blood. High levels of prolactin may induce hirsutism through various mechanisms.
• LH/FSH (Luteinising hormone to follicular stimulating hormone): The change in the LH to FSH ratio can disrupt ovulation and is a useful indicator in diagnosing PCOS.

Imaging Tests

• Pelvic Ultrasonography: A pelvic ultrasound uses sound waves to create images of the organs inside your pelvis. It is a noninvasive diagnostic exam useful in detecting ovarian neoplasms or polycystic ovaries.
• Computed Tomography (CT) / Magnetic Resonance Imaging (MRI) of Abdomen or Pelvis: These imaging technologies create detailed three-dimensional images of the organs and tissues in the abdomen or pelvis.

Though hirsutism cannot always be prevented, the following measures can control the causative factors of excessive hair growth like PCOS:

• Maintaining a healthy weight: PCOS can be managed by losing weight. It can also improve reproductive health, lower the risk of heart disease, and make it easier to manage diabetes.
• Exercising regularly: Burning more calories while reducing the number of calories you consume creates a calorie deficit. Exercise can help prevent excess weight gain and maintain a healthy weight, which in turn helps in maintaining hormonal balance in the body.
• Eating a well-balanced diet: A well-balanced diet should include high-fiber foods, lean proteins (skinless chicken and fish), and healthy fats (coconut, olive, and fish oils). Dairy, sugar, processed, baked, and junk foods should be avoided. Foods like wheatgrass, barley grass, and spirulina can help manage PCOS and thus prevent hirsutism.
• Managing stress: Excessive stress can lead to weight gain, difficulty losing weight, and elevated levels of cortisol, all of which predispose individuals to excessive hair growth. Consider engaging in activities that relieve stress, such as chatting with friends, pursuing a hobby, practicing yoga, listening to music, or journaling.
• Getting regular and adequate sleep: Sufficient sleep can help manage stress and anxiety levels. Activities like long walks in nature, yoga, or meditation, as well as switching off electronic devices at least two hours before sleeping, can promote restful sleep.

Lifestyle modifications are first-line treatments for women with polycystic ovary syndrome (PCOS), particularly if they are overweight. Studies have shown that obese women with PCOS who manage to lose more than five percent of their initial body weight experience significant improvements in their biochemical profile, including:

• Reduction of testosterone
• Increase in sex hormone-binding globulin (SHBG)
• Improvement in Ferriman-Gallway scores

All medical therapies require a minimum of 8 weeks before noticeable results appear.

Cosmetic Therapies (Temporary Solution)

Most women adapt to hair removal through various epilation methods, such as:

• Plucking
• Shaving
• Waxing

While these methods are simple and inexpensive, they are temporary and may cause side effects including:

• Physical discomfort
• Scarring
• Irritant dermatitis
• Discoloration

Electrolysis (50% Efficacy)

Electrolysis involves damaging hair follicles by inserting a needle that emits a pulse of electrical current into each follicle. With repeated treatments, the efficacy ranges from 15% to 50% permanent hair loss. However, it is challenging to treat large areas, such as the chest or upper back, with electrolysis, and it can be time-consuming.

Laser Hair Treatment (80% Reduction)

Lasers have gained popularity in the past two decades and can achieve permanent reduction of hair (not complete removal). Laser therapy operates on the principle of selective photothermolysis, where the laser energy targets melanin and acts specifically on anagen hair follicles. Therefore, multiple treatments are required to achieve a significant reduction of approximately 80%. Ideal candidates for laser hair removal have light skin and dark hair. Possible side effects include:

• Skin irritation
• Swelling
• Redness

The most commonly used lasers are:

• 755-nm alexandrite laser
• 800-nm diode laser
• 1064-nm Nd:YAG laser
• Pulsed light sources

Medications

Before starting any medications, a proper diet and exercise regimen are advised for all women with PCOS. For obese women, weight loss should be recommended as a therapeutic approach. The drugs commonly used in the treatment of hirsutism include:

1. Oral Contraceptive Pills (OCP): OCP is the first-line treatment for hirsutism, particularly in women desiring contraception. These estrogen/progesterone combinations act by:
• Reducing gonadotropin secretion and thereby decreasing ovarian androgen production
• Inhibiting adrenal androgen production
• Increasing levels of SHBG, resulting in lower levels of free testosterone

Various drugs used as OCPs include:

• Ethinyl estradiol
• Norgestimate
• Desogestrel
• Norethindrone
• Ethynodiol diacetate
• Drospirenone
2. Anti-Androgen Therapy
• Spironolactone (SPA): An androgen blocker that competes with Dihydrotestosterone (DHT) for binding to the androgen receptor. It is more effective in treating hirsutism when combined with Oral Contraceptives due to their complementary anti-androgenic actions.
• Cyproterone Acetate (CPA): It possesses strong progestogenic and anti-androgen properties, decreasing circulating androstenedione levels and effectively treating hirsutism. However, CPA can cause steroidal side effects and abnormalities in liver function and menstrual irregularities.
• Flutamide: Primarily used for managing prostate cancer, it has also been used off-label for hirsutism.

Note: Although anti-androgens are effective for hirsutism, their use is not recommended due to potential adverse effects on a developing male fetus. However, in women who cannot conceive or are using reliable contraceptive methods, anti-androgens may be considered for monotherapy.

3. 5-alpha-Reductase Inhibitors (5-RA Inhibitors)

Finasteride, a 5-alpha reductase inhibitor, is effective in treating Idiopathic Hirsutism (IH).

4. Gonadotropin-Releasing Hormone (GnRH Agonists)

This therapy is reserved for women with severe hirsutism who do not respond to oral contraceptives and anti-androgens. GnRH analogs reduce ovarian stimulation, estrogen production, and thus testosterone levels. This therapy is used in combination with an oral contraceptive pill containing estrogen and progestin. An example of this drug class is leuprolide acetate.

5. Corticosteroids

Glucocorticoids, such as dexamethasone and prednisone, are primarily used to treat hirsutism associated with congenital adrenal hyperplasia.

6. Biological Modifiers
• Topical Eflornithine Hydrochloride: A new agent used as a topical cream to decrease or arrest facial hair growth in women. It is thought to inhibit hair growth by blocking an enzyme involved in keratin synthesis. Gradual improvement is typically observed in six to eight weeks and can be combined with laser treatments for enhanced effects.
• Insulin Lowering Agents: Insulin-sensitizing agents may improve hirsutism by reducing insulin levels and, therefore, circulating free and biologically active androgens. An example of this drug is metformin.

• Spearmint tea (pudina): This tea is one of the best natural remedies for hirsutism. Drinking spearmint tea regularly has shown strong anti-androgenic activity, which can help manage hirsutism.
• Zinc: Zinc works by blocking an enzyme involved in testosterone metabolism that causes excessive and unwanted hair growth. Sources of zinc include chickpeas, pumpkin seeds, yogurt, beans, beef, chicken, and oysters.
• Cinnamon (dalchini): This is one of the best natural remedies for hirsutism. In women with PCOS, it is known to improve insulin sensitivity and lipid profile.
• Folic acid: Folic acid helps balance the levels of homocysteine, a common amino acid found in the blood, and is also beneficial for improving reproductive health.
• Licorice (mulethi) tea: One of the main compounds in this tea, glycyrrhizic acid, has proven effective in halting hair growth in individuals suffering from unwanted hair growth.
• Flax seeds (alsi): Flax seeds can lead to a reduction in Body Mass Index (BMI), total serum testosterone, and free serum testosterone levels, resulting in decreased excessive hair growth.
• Astragalus polysaccharide: Astragalus polysaccharides can be effective in improving insulin resistance, high androgen hormone status, and lipid metabolism in patients with PCOS.

Diet

• Reduce calorie intake, especially during the evening. Distribute calorie intake into 5 to 6 meals per day to maintain weight and reduce the chances of obesity and hirsutism.
• Consume foods with a low glycemic index (GI) that do not cause sharp increases in blood glucose levels, such as non-starchy vegetables and legumes. Include at least 20g of protein with every meal, such as eggs, chicken, fish, shellfish, and turkey.
• Drink plenty of fresh, filtered water between meals, aiming for about half your body weight in ounces per day.
• Increase your intake of vitamin B, particularly B2, B3, B5, and B6.
• Avoid trans fats, which contribute to hormonal imbalances and symptoms like hirsutism. Trans fats are found in packaged processed foods such as cookies, cakes, unhealthy vegetable oils, pastries, and crackers. Replace these with healthy fats like avocado oil, nuts, and seeds.

Acupuncture

Acupuncture is a traditional Chinese medicine technique that involves inserting finely pointed needles into specific areas of the body known as acupuncture points. It has shown promise in the management of excessive hair growth.

Yoga and Exercise

Regular yoga and exercise can improve blood circulation, enhance overall well-being, and prevent fatigue. These practices are effective in reducing stress, managing anxiety, and aiding in pain management.

Hot Water Bath

A hot water bath possesses muscle relaxant properties; the heat can improve blood circulation and alleviate muscle tension.

Self-management can help in taking care of yourself.

• Know about your condition: Hirsutism can sometimes affect a person's mental health, leading to anxiety and depression. Talking to loved ones can help alleviate emotional distress and contribute to an effective treatment plan.
• Exercising daily: Regular exercise increases blood circulation and helps relieve tension and stress.
• Take your medicine on time: If prescribed, medications should be taken regularly under medical supervision.
• Talk with a doctor openly: Feel free to ask as many questions as needed regarding any issues faced.
• Lower stress levels: Practicing meditation and yoga can help reduce stress and promote happiness.
• Take adequate sleep: Sufficient sleep calms the body and mind, reducing feelings of fatigue.