Hirsutism - What Is It?

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Hirsutism - What Is It?

Hirsutism : the excessive conversion of vellus hair into terminal hair in women. This is found in the androgen to testosterone dependent sites such as the beard area, neck, chest, abdomen and inner thighs.

Hypertrichosis : a term used to describe excessive hair growth in non androgen dependent areas.

Hirsutism is related to hormonal factors normally related to increased androgen levels. Androgens such as testosterone are usually produced in the adrenal gland and in the ovaries. Many cases of familial or constitutional hirsutism have no such abnormalities. In hirsutism it is important to rule out underlying abnormalities. The treatment will be based on the administration of anti-androgens as well as newer topical medications and physical treatments.

Hirsutism is not observed before puberty. At puberty, the secondary sexual characteristics develop in men leading to increased hair in the beard and moustache areas, the chest, shoulders, back, arms, thighs, pubic skin and on the lower abdomen and buttocks. In women, if these changes are present it means an increased secretion of androgens from the ovaries or the adrenal gland to an increase in sensitivity of the hairs that are present to the testosterone. At the time of menopause the androgen oestrogen ratio changes with relatively more androgens available. 70% of post menopausal women will develop hirsutism.

Hirsutism is common. A study from the UK suggested that at one point 2% of women in London have a problem with hirsutism.

Excessive hair growth is really determined by the woman herself. If it is thought to be a problem then it is. It is self defining. There is often a feeling of embarrassment, self-consciousness, obsession with removal, unfeminity, inhibition, etc.

Classification of Severity of Hirsutism

In 1961 Ferriman-Galwey published studies on 430 Caucasian women between the ages of 15-74 years based on patients seen in a hospital clinic. The system is based on 11 body sites with a severity score of 0 to 5 for the upper lip, chin, lower back, upper abdomen, arms, forearms, thigh and leg.

Score for the upper lip and chin

Grade 1 - a few hairs at the outer part of the upper lip/few scattered hairs on the chin
Grade 2 - small moustache at the outer margins of the upper lip/scattered hair with a small concentration on the chin
Grade 3 -moustache extending halfway from the outer margin of the upper lip/light complete coverage of the chin
Grade 4 -moustache on the entire upper lip/heavy growth on the entire chin

Hirsutism - Classification of Causes

There are a number of ways to classify the causes of hirsutism:

Constitutional or familial - there may be a slight increase in androgens from the adrenal gland. In familial hirsutism no hormone abnormalities are found.

Hirsutism may be seen from abnormalities in the pituitary gland. There is an increase in ACTH causing secondary increases in cortisone and prolactin. Prolactin secreting tumours as well as some psychogenic drugs and the contraceptive pill can encourage prolactin secretion.

Abnormalities in the adrenal gland will produce increased DHEAS.

Certain ovarian tumours may produce progesterone, testosterone, and androstenedione.

A decrease in the sex hormone-binding globulins as is sometimes produced by liver abnormalities may enable more free testosterone to be available. This is converted into the hair top DHT (dehydrotesterone).

Certain drugs such as anabolic steroids may increase hirsutism.

Clinical Features of Hirsutism

The most common cause is probably related to polycystic ovarian syndrome (PCOS). This is characterized by:

·	Infertility

·	Menstrual abnormalities or amenorrhea

Obesity

·	Polycystic ovaries

It is thought that the fundamental problem may be an increase in resistance to insulin which in turn derives the ovaries to produce testosterone. This in turn will have secondary effects on hair growth. It will also be associated with an increase in acne. Hirsutism usually is present on the sides of the breasts, the sides of the face and neck as well as on the abdomen. About half the individuals affected by this will be obese and have some brown discolouration called acanthosis nigricans on the sides of the neck and in the arm pits.