Hirsutism 

  • Author: George T Griffing, MD; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Oct 8, 2010
 

Background

Although hirsutism is broadly defined as excessive hairiness, the common clinical use of the term refers to women with excess growth of terminal hair in a male pattern. In this sense, hirsutism is one of the most common endocrine disorders, affecting approximately 10% of women in the United States. In these women, the hairiness implies the presence of abnormal androgen action, which may represent a serious or, more likely, a nonserious medical problem. Regardless of the etiology, hirsutism can produce mental trauma and emotional anguish.[1] Even mild cases of hirsutism may be viewed by the patient and others as a presumptive loss of femininity. In more severe cases, hirsutism can be a serious cosmetic problem. The major objectives in the management of hirsutism are to rule out a serious underlying medical condition and to devise a plan of treatment.[2]

Idiopathic hirsutism in an elderly woman is shown in the photo below.

Idiopathic hirsutism in an elderly woman. Idiopathic hirsutism in an elderly woman.
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Pathophysiology

Hormones and the intrinsic characteristics of the hair follicle determine the quality of hair growth. Vellus hairs are fine, unpigmented hairs that cover most of the body before puberty. Pubertal androgens promote the conversion of these vellus hairs to coarser, pigmented terminal hairs. The level and duration of exposure to androgens, the local 5-alpha-reductase activity, and the intrinsic sensitivity of the hair follicle to androgen action determine the extent of conversion from vellus to terminal hair. However, some terminal hair growth is androgen-independent (eg, scalp, eyebrows, lashes).[3]

The development of terminal hair or reversion back to a vellus pattern may not be immediately evident because of the characteristics of the hair cycle. This cycle has 2 phases that include active hair growth (anagen phase) and a resting period (telogen phase), which follows the anagen phase. During the resting period, the hair shaft separates from the dermal papillae at the follicle base, and no further growth takes place. Eventually, growth restarts and the new hair shaft formed by the reactivated papillae pushes the old hair out. The cycle may take months to complete, and this causes a delay in hair growth response to changes in the androgen milieu.

Dihydrotestosterone is the androgen that acts on the hair follicle to produce terminal hair. This hormone is derived from both the bloodstream and local conversion of a precursor, testosterone. The local production of dihydrotestosterone is determined by 5-alpha-reductase activity in the skin. Differences in the activity of this enzyme may explain why women with the same plasma levels of testosterone can have different degrees of hirsutism.

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Epidemiology

Frequency

United States

Hirsutism affects approximately 10% of women in the United States.

International

The prevalence rates of hirsutism in northern Europe are similar to those in the United States; in other places, rates are not known with certainty.

Mortality/Morbidity

The mortality and morbidity of hirsutism are determined by the underlying cause.

  • Most women with idiopathic hirsutism have no associated mortality or morbidity.
  • On the other extreme, a small number of women may have malignant disease with a grave prognosis.

Race

Ethnic origin significantly affects terminal hair growth in healthy women.

  • Northern, fair-skinned Europeans have the least amount of terminal hair, whereas southern European, dark-skinned Mediterranean women have the greatest amount of terminal hair.
  • The difference in the racial patterns of normal terminal hair growth may be related to genetic differences of 5-alpha-reductase activity in the skin.
  • With the exception of congenital adrenal hyperplasia (CAH), the prevalence of diseases that cause hyperandrogenism and hirsutism has not been shown to differ among persons of different races.

Sex

As a medical problem, hirsutism predominates in women.

  • Although hirsutism can occur in men, it is more difficult to recognize because of the wide variability of healthy male terminal hair growth.
  • Hirsutism in prepubertal children occurs equally between sexes, is usually a sign of precocious puberty, and may signify a serious underlying disease.

This discussion focuses on adult women.

Age

The age of onset of hirsutism depends on the etiology. Most forms of nonneoplastic hirsutism become evident around puberty. This includes polycystic ovary syndrome (PCOS), CAH, and idiopathic hirsutism.

Hirsutism and acne are shown in the image below.

The photograph depicts hirsutism in a young woman The photograph depicts hirsutism in a young woman with polycystic ovary syndrome. Note the acne lesions and excessive hair on her face and neck.

Hirsutism may also develop after weight gain and cessation of the use of oral contraceptives (OCs) in young women. Normally, terminal hair growth becomes apparent after adrenarche and accelerates after puberty. Terminal hair continues to develop gradually in healthy women until after menopause, when loss of ovarian androgen leads to a loss of hair. Rapidly worsening hirsutism, especially in older women, should raise the suspicion of an androgen-secreting tumor.

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Contributor Information and Disclosures
Author

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Specialty Editor Board

Stanley Wallach, MD  Executive Director, American College of Nutrition; Clinical Professor, Department of Medicine, New York University School of Medicine

Stanley Wallach, MD is a member of the following medical societies: American Society for Bone and Mineral Research, American Society for Clinical Investigation, American Society for Clinical Nutrition, American Society for Nutritional Sciences, Association of American Physicians, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Don S Schalch, MD  Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Mark Cooper, MBBS, PhD, FRACP  Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD  Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

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Idiopathic hirsutism in an elderly woman.
The photograph depicts hirsutism in a young woman with polycystic ovary syndrome. Note the acne lesions and excessive hair on her face and neck.
The photograph depicts familial hirsutism in a Pakistani woman.
Etiologic diagnosis of hirsutism.
 
 
 
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