Hirsutism is a condition in which women develop excessive, thick, dark, coarse hair in a male-like (androgenic) distribution – that is, on areas of the body where men typically grow hair and women usually have fine, light, or no hair at all. These areas include the upper lip, chin, chest, upper abdomen, lower back, buttocks, and inner thighs.
It is important to distinguish hirsutism from hypertrichosis – which is a general increase in fine, light hair anywhere on the body and is not hormone-related. Hirsutism specifically refers to terminal hair (coarse, pigmented, thick hair) that grows in response to androgens (male-type hormones) such as testosterone.
Hirsutism affects approximately 5–10% of women of reproductive age worldwide. It is more prevalent in certain ethnic groups – women of Mediterranean, Middle Eastern, and South Asian descent may have higher baseline hair growth and lower thresholds for being diagnosed.
Causes
Hirsutism is caused by excess production or increased sensitivity to androgens (male hormones) in the body, commonly caused by:
- PCOS (around 70–80%) causes the ovaries to produce higher-than-normal levels of androgens, leading to hirsutism, acne, irregular periods, and often polycystic ovaries on ultrasound.
- Idiopathic (unexplained) hirsutism – around 5–20% of cases where androgen levels are within the normal range on blood tests, but the hair follicles are genetically more sensitive to normal levels of androgens. There is no underlying disease.
- Menopause – as oestrogen levels decline around and after menopause, the relative proportion of androgens increases, which can cause new or worsening hirsutism.
- Certain medications including:
- Anabolic steroids
- Minoxidil (used for hair loss)
- Cyclosporine (immunosuppressant)
- High-dose progestogens (in some hormonal contraceptives)
- Hormonal disorders (rare but serious), including:
- Cushing’s syndrome – excess cortisol production
- Congenital adrenal hyperplasia (CAH) – a genetic condition affecting adrenal hormone production
- Androgen-secreting tumours of the ovary or adrenal gland (less than 1% of cases)
Symptoms
The main symptom is the presence of coarse, dark hair in areas such as:
- Face – upper lip, chin, sideburns
- Chest and nipples
- Abdomen – especially a central line of hair from the pubic area up towards the belly button
- Lower back and buttocks
- Inner thighs
Associated signs (androgen excess):
- Acne – often persistent or severe
- Scalp hair thinning – male-pattern balding
- Oily skin
- Irregular or absent periods – often associated with PCOS
- Deepening of the voice – a sign of significant androgen excess
- Decreased breast size
- Clitoromegaly (enlargement of the clitoris) – a sign of very high androgen levels
Diagnosis
- History and physical examination
- Menstrual history – regularity, frequency, last period
- Medication history
- Family history – PCOS or hirsutism in relatives
- Ferriman-Gallwey scoring – a standardised visual scoring system to grade hair growth in 9 body areas. A score of 8 or more is considered hirsutism.
Blood tests may include:
- Total testosterone – to check for elevated androgens
- Free androgen index (FAI) – a more accurate measure of active testosterone
- Sex hormone-binding globulin (SHBG) – low levels can indicate androgen excess
- DHEAS – a marker of adrenal androgen production
- 17-hydroxyprogesterone (17-OHP) – to screen for congenital adrenal hyperplasia
- Thyroid function tests – to rule out thyroid disorders
- Prolactin – if periods are absent
- Pelvic ultrasound – to check for polycystic ovaries and look for ovarian masses
- Further imaging (CT or MRI) of the adrenal glands or ovaries to rule out tumours
Treatment Options
A. Lifestyle Measures
- Weight loss – if you are overweight, losing even 5–10% of your body weight can significantly reduce androgen levels and improve hirsutism, especially in PCOS.
- Diet and exercise – improving insulin sensitivity can help.
B. Medical Therapies (To Reduce New Hair Growth)
- Combined Oral Contraceptive Pill (COCP) – first-line medical treatment. It reduces ovarian androgen production and increases SHBG, lowering free testosterone. It also regulates periods and protects the uterine lining.
- Anti-androgens
- Spironolactone – the most commonly used anti-androgen in the UK. Results take at least 6 months.
- Cyproterone acetate – often combined with ethinylestradiol in the COCP (e.g., Dianette). Effective but usually used for up to 6 months.
- Finasteride – less commonly used but an option.
- Insulin-sensitising drugs – Metformin is often used in PCOS to improve insulin resistance, which can lower androgen levels, though its effect on hirsutism is modest.
C. Cosmetic Hair Removal Methods (For Existing Hair)
- Shaving – quick and safe. Regrowth may feel stiffer, but shaving does not stimulate more hair growth.
- Waxing – effective but can irritate sensitive skin. Avoid on the face if you have acne-prone skin.
- Depilatory creams – chemically dissolve hair. Always perform a patch test first.
- Bleaching creams – make dark hair lighter but can cause irritation.
- Electrolysis – permanent hair removal by destroying individual hair follicles with an electric current.
- Laser hair removal.
- Eflornithine cream (Vaniqa) – a prescription cream that slows facial hair growth. Applied twice daily; results take 4–8 weeks and stop if treatment is discontinued.
eGynaecologist Advice
- Do not dismiss hirsutism as "just cosmetic" – it is a medical sign that deserves investigation, as it may reveal an underlying hormonal condition like PMOS that has important health implications for your future (diabetes, heart disease, endometrial health).
- If you have irregular periods, acne, or hair loss alongside hirsutism, you should be assessed by gynaecologist. Do not try to self-diagnose with supplements from the internet.
- Monitor for red flags – if your hirsutism suddenly worsens, or you develop voice deepening, significant weight loss, or pelvic pain, you must see your gynaecologist urgently. These are signs that warrant rapid investigation.
Frequently Asked Questions
Does shaving make the hair grow back thicker or darker?
No – this is a common myth. Shaving cuts the hair at the skin surface, removing the tapered tip, so the regrowth may feel blunt and coarser, but it does not change the hair follicle or the actual rate or thickness of growth.
Will losing weight help my hirsutism?
Yes, if you are overweight. In PCOS, weight loss improves insulin sensitivity, which lowers androgen levels. Even a 5–10% weight reduction can improve hirsutism, regulate periods, and reduce acne.
How long do medical treatments take to work?
At least 6 months. Hair follicles have a long growth cycle, and it takes several cycles for anti-androgen treatments to have a noticeable effect.
Does hirsutism mean I have a tumour?
Tumours are extremely rare – accounting for less than 1% of all hirsutism cases. However, if your hirsutism developed rapidly, is severe, or is accompanied by voice deepening or clitoral enlargement, you must see your gynaecologist urgently for a thorough evaluation.
Can I take anti-androgens if I am trying to get pregnant?
No. Anti-androgens like spironolactone and cyproterone can affect a male fetus. You must use reliable contraception while taking them. If you wish to conceive, you should stop these medications and discuss alternative options with your doctor.
