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Hirsutism Workup

  • Author: George T Griffing, MD; Chief Editor: Michel E Rivlin, MD  more...
Updated: Jul 14, 2016

Laboratory Studies

Approximately 50% of women with even minimal hirsutism have excessive androgen. Laboratory studies in hirsutism serve both to confirm the clinical impression of hyperandrogenism and to identify the source of excess androgens, either adrenal or ovarian. The workup described in the image below recommends 2 visits, a baseline evaluation followed by a 2-week dexamethasone treatment period. Specific discussion of the testing is below.

Etiologic diagnosis of hirsutism. Etiologic diagnosis of hirsutism.

See the list below:

  • Testosterone: The most important assay is the level of serum testosterone, the major circulating androgen. If the total serum testosterone level is normal, measure the free serum level because hyperandrogenism (and insulin resistance, if present) decreases sex steroid-binding globulin, such that the unbound, biologically active testosterone moiety may be elevated even if the total level is unremarkable. Extremely high testosterone levels are likely to be associated with adrenal or ovarian tumors, whereas idiopathic and benign etiologies result in very mild elevations. Indeed, in idiopathic hirsutism, the results from testing androgen levels are often normal. In some of these women, hirsutism is thought to be caused by increased skin sensitivity to androgen or by increased skin 5-alpha-reductase activity. This enzyme is located in the skin near the hair follicle, and it converts plasma testosterone to the androgen metabolite dihydrotestosterone.
  • Dehydroepiandrosterone sulfate (DHEAS): Because testosterone can originate in either the adrenal cortex or the ovary, an elevated testosterone level does not indicate the gland of origin. Accordingly, measurement of elevated plasma levels of DHEAS, an androgen synthesized almost exclusively by the adrenal cortex, can indicate excess adrenal function. Elevations in both testosterone and DHEAS suggest an adrenal origin, whereas an isolated testosterone elevation indicates an ovarian source.
  • Dexamethasone suppression (see the image above): Laboratory testing of testosterone (free or total) and DHEAS can be performed on the initial visit. At the same time, a diagnostic trial of dexamethasone therapy for 7-14 days can be initiated to help exclude adrenocorticotropin hormone (ACTH)–dependent hirsutism. When the patient returns, free testosterone, DHEAS, and plasma cortisol levels are measured. Dexamethasone-mediated suppression of androgens is observed in healthy women who do not have hirsutism and in those with congenital adrenal hyperplasia (CAH) and idiopathic hirsutism.
  • Adrenocorticotropin stimulation: An ACTH-stimulation test (250 mcg for 30 min) can help differentiate between CAH and idiopathic hirsutism because CAH produces abnormal findings (elevations in metabolic precursors of cortisol).
    • Hirsutism caused by CAH is due to 1 of 3 cortisol biosynthetic defects, ie, 21-hydroxylase deficiency, 3 3 β -hydroxysteroid dehydrogenase, or 11-β -hydroxylase deficiency.
    • Because 21-hydroxylase deficiency accounts for the vast majority of cases of CAH (approximately 90%), the discussion is focused on this diagnosis. Investigate possible 21-hydroxylase deficiency by measuring plasma 17-hydroxyprogesterone levels obtained between 0700 and 0900 hours. Values of less than 7 nmol/L exclude the diagnosis, and values of greater than 45 nmol/L (in women who are nongestational) confirm 21-hydroxylase deficiency. When basal values of 17-hydroxyprogesterone are between 7 and 45 nmol/L, an ACTH-stimulated concentration of greater than 45 nmol/L is also diagnostic.
    • Although elevated basal plasma 17-hydroxyprogesterone levels (as high as 17 nmol/L) may be present during the luteal phase of the menstrual cycle and in PCOS, ACTH-stimulated increments are blunted.
  • Cortisol suppression: Investigation of subnormal dexamethasone suppression of androgens can be guided by the patient’s cortisol level, without the need for an ACTH-stimulation test. PCOS and adrenal and ovarian tumors are associated with normal suppression of cortisol by dexamethasone, whereas cortisol levels in patients with Cushing syndrome are not suppressed.

Other laboratory tests include the following:

  • Serum prolactin or FSH: Women with hirsutism and amenorrhea of unknown cause should have a serum prolactin or FSH test to evaluate for either a prolactinoma or ovarian failure.
  • Diabetes screening: Women with hirsutism, PCOS, obesity, or acanthosis nigricans may have insulin resistance, and screening for diabetes and hyperlipidemia is warranted. Approximately 50% of these women have increased insulin levels and 5% have undiagnosed diabetes mellitus.
  • Prostate-specific antigen (PSA): Ultrasensitive assays can detect PSA in women and is a potential marker for androgen excess. Studies thus far, however, have not shown a good correlation with the change in androgen levels after treatment. Therefore, further studies are needed.[8]

Imaging Studies

If indicated based on the findings from the clinical evaluation and laboratory testing, perform ovarian ultrasonography and adrenal computed tomography scanning or magnetic resonance imaging to evaluate for either ovarian or adrenal sources of androgen production.

Contributor Information and Disclosures

George T Griffing, MD Professor Emeritus 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, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

Michel E Rivlin, MD Former Professor, 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, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

  1. Ekback M, Wijma K, Benzein E. "It is always on my mind": women's experiences of their bodies when living with hirsutism. Health Care Women Int. 2009 May. 30(5):358-72. [Medline].

  2. Shah D, Patel S. Hirsutism. Gynecol Endocrinol. 2009 Mar. 25(3):140-8. [Medline].

  3. Hawryluk EB, English JC 3rd. Female adolescent hair disorders. J Pediatr Adolesc Gynecol. 2009 Aug. 22(4):271-81. [Medline].

  4. Comim FV, Marchesan LQ, Copes RM, et al. Increased risk of humerus and lower leg fractures in postmenopausal women with self-reported premenopausal hirsutism and/or oligomenorrhea. Eur J Obstet Gynecol Reprod Biol. 2016 Jun 10. 203:162-166. [Medline].

  5. Yildiz BO, Bolour S, Woods K, Moore A, Azziz R. Visually scoring hirsutism. Hum Reprod Update. 2009 Jun 30. [Medline]. [Full Text].

  6. Costello MF, Shrestha B, Eden J, Johnson NP, Sjoblom P. Metformin versus oral contraceptive pill in polycystic ovary syndrome: a Cochrane review. Hum Reprod. 2007 May. 22(5):1200-9. Epub 2007 Jan 29. [Medline].

  7. Villarroel C, Lopez P, Merino PM, Iniguez G, Sir-Petermann T, Codner E. Hirsutism and oligomenorrhea are appropriate screening criteria for polycystic ovary syndrome in adolescents. Gynecol Endocrinol. 2015. 31 (8):625-9. [Medline].

  8. Mueller A, Cupisti S, Binder H, Hoffmann I, Kiesewetter F, Beckmann MW, et al. Endocrinological markers for assessment of hyperandrogenemia in hirsute women. Horm Res. 2007. 67(1):35-41. [Medline].

  9. Unluhizarci K, Ozel D, Tanriverdi F, Karaca Z, Kelestimur F. A comparison between finasteride, flutamide, and finasteride plus flutamide combination in the treatment of hirsutism. J Endocrinol Invest. 2009 Jan. 32(1):37-40. [Medline].

  10. FDA News Release. Abbott Laboratories agrees to withdraw its obesity drug Meridia. Available at Accessed: October 8, 2010.

  11. Ajossa S, Guerriero S, Paoletti AM, Orrù M, Melis GB. The treatment of polycystic ovary syndrome. Minerva Ginecol. 2004 Feb. 56(1):15-26. [Medline].

  12. Ali I, Dawber R. Hirsutism: diagnosis and management. Hosp Med. 2004 May. 65(5):293-7. [Medline].

  13. Amato MC, Galluzzo A, Merlino S, Mattina A, Richiusa P, Criscimanna A, et al. Lower insulin sensitivity differentiates hirsute from non-hirsute Sicilian women with polycystic ovary syndrome. Eur J Endocrinol. 2006 Dec. 155(6):859-65. [Medline].

  14. Archer JS, Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2004 Oct. 18(5):737-54. [Medline].

  15. Barbieri RL, Gargiulo AR. Metformin for the treatment of the polycystic ovary syndrome. Minerva Ginecol. 2004 Feb. 56(1):63-79. [Medline].

  16. Beigi A, Sobhi A, Zarrinkoub F. Finasteride versus cyproterone acetate-estrogen regimens in the treatment of hirsutism. Int J Gynaecol Obstet. 2004 Oct. 87(1):29-33. [Medline].

  17. Boronat M, Carrillo A, Ojeda A, et al. Clinical manifestations and hormonal profile of two women with Cushing's disease and mild deficiency of 21-hydroxylase. J Endocrinol Invest. 2004 Jun. 27 (6):583-90. [Medline].

  18. Carmina E. Mild androgen phenotypes. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):207-20. [Medline].

  19. Carmina E, Rosato F, Jannì A, Rizzo M, Longo RA. Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab. 2006 Jan. 91(1):2-6. [Medline].

  20. Cheewadhanaraks S, Peeyananjarassri K, Choksuchat C. Clinical diagnosis of hirsutism in Thai women. J Med Assoc Thai. 2004 May. 87(5):459-63. [Medline].

  21. Christy NA, Franks AS, Cross LB. Spironolactone for hirsutism in polycystic ovary syndrome. Ann Pharmacother. 2005 Sep. 39(9):1517-21. [Medline].

  22. Clayton WJ, Lipton M, Elford J, Rustin M, Sherr L. A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome. Br J Dermatol. 2005 May. 152 (5):986-92. [Medline].

  23. Curran DR, Moore C, Huber T. Clinical inquiries. What is the best approach to the evaluation of hirsutism?. J Fam Pract. 2005 May. 54(5):465-7. [Medline].

  24. Dawber RP. Guidance for the management of hirsutism. Curr Med Res Opin. 2005 Aug. 21(8):1227-34. [Medline].

  25. Dereli D, Dereli T, Bayraktar F, Ozgen AG, Yilmaz C. Endocrine and metabolic effects of rosiglitazone in non-obese women with polycystic ovary disease. Endocr J. 2005 Jun. 52(3):299-308. [Medline].

  26. DeUgarte CM, Woods KS, Bartolucci AA, Azziz R. Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. J Clin Endocrinol Metab. 2006 Apr. 91(4):1345-50. [Medline].

  27. Eberting CL, Javor E, Gorden P, Turner ML, Cowen EW. Insulin resistance, acanthosis nigricans, and hypertriglyceridemia. J Am Acad Dermatol. 2005 Feb. 52(2):341-4. [Medline].

  28. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med. 2005 Mar 24. 352(12):1223-36. [Medline].

  29. Glintborg D, Andersen M, Hagen C, Hermann AP. Higher bone mineral density in Caucasian, hirsute patients of reproductive age. Positive correlation of testosterone levels with bone mineral density in hirsutism. Clin Endocrinol (Oxf). 2005 Jun. 62(6):683-91. [Medline].

  30. Glintborg D, Henriksen JE, Andersen M, Hagen C, Hangaard J, Rasmussen PE, et al. Prevalence of endocrine diseases and abnormal glucose tolerance tests in 340 Caucasian premenopausal women with hirsutism as the referral diagnosis. Fertil Steril. 2004 Dec. 82(6):1570-9. [Medline].

  31. Glintborg D, Henriksen JE, Andersen M, Hagen C, Hangaard J, Rasmussen PE, et al. Prevalence of endocrine diseases and abnormal glucose tolerance tests in 340 Caucasian premenopausal women with hirsutism as the referral diagnosis. Fertil Steril. 2004 Dec. 82(6):1570-9. [Medline].

  32. Glintborg D, Hermann AP, Brusgaard K, Hangaard J, Hagen C, Andersen M. Significantly higher adrenocorticotropin-stimulated cortisol and 17-hydroxyprogesterone levels in 337 consecutive, premenopausal, Caucasian, hirsute patients compared with healthy controls. J Clin Endocrinol Metab. 2005 Mar. 90(3):1347-53. [Medline].

  33. Goodarzi MO, Shah NA, Antoine HJ, Pall M, Guo X, Azziz R. Variants in the 5alpha-reductase type 1 and type 2 genes are associated with polycystic ovary syndrome and the severity of hirsutism in affected women. J Clin Endocrinol Metab. 2006 Oct. 91(10):4085-91. [Medline].

  34. Guzelmeric K, Seker N, Unal O, Turan C. High serum prostate-specific antigen concentrations in hirsute women do not decrease with treatment by the combination of spironolactone and the contraceptive pill. Gynecol Endocrinol. 2004 Oct. 19(4):190-5. [Medline].

  35. Hahn S, Fingerhut A, Khomtsiv U, Khomtsiv L, Tan S, Quadbeck B, et al. The peroxisome proliferator activated receptor gamma Pro12Ala polymorphism is associated with a lower hirsutism score and increased insulin sensitivity in women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2005 May. 62(5):573-9. [Medline].

  36. Harper JC. Antiandrogen therapy for skin and hair disease. Dermatol Clin. 2006 Apr. 24(2):137-43, v. [Medline].

  37. Hart R, Hickey M, Franks S. Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2004 Oct. 18(5):671-83. [Medline].

  38. Hassa H, Tanir HM, Yildirim A, Senses T, Eskalen M, Mutlu FS. The hirsutism scoring system should be population specific. Fertil Steril. 2005 Sep. 84(3):778-80. [Medline].

  39. Hassa H, Tanir HM, Yildiz Z. Comparison of clinical and laboratory characteristics of cases with polycystic ovarian syndrome based on Rotterdam's criteria and women whose only clinical signs are oligo/anovulation or hirsutism. Arch Gynecol Obstet. 2006 Jul. 274(4):227-32. [Medline].

  40. Hoyt KL, Schmidt MC. Polycystic ovary (Stein-Leventhal) syndrome: etiology, complications, and treatment. Clin Lab Sci. 2004. 17(3):155-63. [Medline].

  41. Kazerooni T, Dehghan-Kooshkghazi M. Effects of metformin therapy on hyperandrogenism in women with polycystic ovarian syndrome. Gynecol Endocrinol. 2003 Feb. 17(1):51-6. [Medline].

  42. Kelestimur F, Everest H, Unluhizarci K, Bayram F, Sahin Y. A comparison between spironolactone and spironolactone plus finasteride in the treatment of hirsutism. Eur J Endocrinol. 2004 Mar. 150(3):351-4. [Medline].

  43. Keller J, Subramanyam L, Simha V, Gustofson R, Minjarez D, Garg A. Lipodystrophy: an unusual diagnosis in a case of oligomenorrhea and hirsutism. Obstet Gynecol. 2009 Aug. 114(2 Pt 2):427-31. [Medline]. [Full Text].

  44. Lipton MG, Sherr L, Elford J, Rustin MH, Clayton WJ. Women living with facial hair: the psychological and behavioral burden. J Psychosom Res. 2006 Aug. 61(2):161-8. [Medline].

  45. Mermejo LM, Elias LL, Marui S, Moreira AC, Mendonca BB, de Castro M. Refining hormonal diagnosis of type II 3beta-hydroxysteroid dehydrogenase deficiency in patients with premature pubarche and hirsutism based on HSD3B2 genotyping. J Clin Endocrinol Metab. 2005 Mar. 90(3):1287-93. [Medline].

  46. Moghetti P, Toscano V. Treatment of hirsutism and acne in hyperandrogenism. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):221-34. [Medline].

  47. Raja A, Hashmi SN, Sultana N, Rashid H. Presentation of polycystic ovary syndrome and its management with clomiphene alone and in combination with metformin. J Ayub Med Coll Abbottabad. 2005 Apr-Jun. 17(2):50-3. [Medline].

  48. Randall VA, Lanigan S, Hamzavi I, et al. New dimensions in Hirsutism. Lasers Med Sci. 2006 Sep. 21(3):126-33. [Medline].

  49. Sagsoz N, Kamaci M, Orbak Z. Body hair scores and total hair diameters in healthy women in the Kirikkale Region of Turkey. Yonsei Med J. 2004 Jun 30. 45(3):483-91. [Medline].

  50. Sahin Y, Kelestimur F. Medical treatment regimens of hirsutism. Reprod Biomed Online. 2004 May. 8(5):538-46. [Medline].

  51. Scheinfeld N. Impact of phenytoin therapy on the skin and skin disease. Expert Opin Drug Saf. 2004 Nov. 3(6):655-65. [Medline].

  52. Souter I, Sanchez LA, Perez M, Bartolucci AA, Azziz R. The prevalence of androgen excess among patients with minimal unwanted hair growth. Am J Obstet Gynecol. 2004 Dec. 191(6):1914-20. [Medline].

  53. Souter I, Sanchez LA, Perez M, Bartolucci AA, Azziz R. The prevalence of androgen excess among patients with minimal unwanted hair growth. Am J Obstet Gynecol. 2004 Dec. 191(6):1914-20. [Medline].

  54. Stanczyk FZ. Diagnosis of hyperandrogenism: biochemical criteria. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):177-91. [Medline].

  55. Taponen S, Ahonkallio S, Martikainen H, Koivunen R, Ruokonen A, Sovio U, et al. Prevalence of polycystic ovaries in women with self-reported symptoms of oligomenorrhoea and/or hirsutism: Northern Finland Birth Cohort 1966 Study. Hum Reprod. 2004 May. 19(5):1083-8. [Medline].

  56. Tekin O, Avci Z, Isik B, Ozkara A, Uraldi C, Catal F, et al. Hirsutism: common clinical problem or index of serious disease?. MedGenMed. 2004 Oct 15. 6(4):56. [Medline].

  57. Tok EC, Ertunc D, Evruke C, Dilek S. The androgenic profile of women with non-insulin-dependent diabetes mellitus. J Reprod Med. 2004 Sep. 49(9):746-52. [Medline].

  58. Townsend KA, Marlowe KF. Relative safety and efficacy of finasteride for treatment of hirsutism. Ann Pharmacother. 2004 Jun. 38(6):1070-3. [Medline].

  59. Vergoulas G, Eleftheriadis T, Avdelidou A, Ioannou K, Miserlis G, Solonaki F, et al. Body dysmorphic disorder due to hirsutism in a patient treated with cyclosporin. Nephrol Dial Transplant. 2005 Feb. 20(2):473. [Medline].

  60. Watts J. Understanding the causes and management of hirsutism. Nurs Times. 2006 Feb 21-27. 102(8):26-8. [Medline].

  61. Wild RA, Vesely S, Beebe L, Whitsett T, Owen W. Ferriman Gallwey self-scoring I: performance assessment in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2005 Jul. 90(7):4112-4. [Medline].

  62. Yildiz BO. Diagnosis of hyperandrogenism: clinical criteria. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):167-76. [Medline].

  63. Zawar V, Sankalecha C. Facial hirsutism following danazol therapy. Cutis. 2004 Nov. 74(5):301-3. [Medline].

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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