Hirsutism is the development of androgen-dependent terminal body hair (dark course pigmented hair normally seen on the face, underarms, scalp, eyebrows and pubis) in a woman and in other places where this type of hair is not normally found in women.

Remember a woman's definition of hirsutism may differ secondary to her ethnic background. Any definition of normal body hair should consider both race and ethnicity. For example, most Asian and/or Native American women have little body hair, while most women from the Mediterranean have moderately heavy body hair. However, the most important consideration in diagnosing hirsutism is the extent to which a woman's normal pattern of hair growth has changed. Although hirsutism can occur in both men and women, it is usually only a problem for women.

Causes of Hirsuitism

The most common causes of hirsuitism are idiopathic hirsutism and polycystic ovary syndrome:

Idiopathic hirsutism is the diagnosis given to women with hirsutism and no other presenting clinical abnormalities. Women with idiopathic hirsutism generally present with normal levels of serum androgen concentrations.

Polycystic ovary syndrome is the most common cause of androgen excess in women. Polycystic ovary syndrome (PCOS) is a common disease affecting 3-5% of women of reproductive age.

PCOS usually presents with the following symptoms:

Menstrual abnormalities - PCOS is often diagnosed during puberty secondary to menstrual irregularities. Infrequent, irregular or absent menstrual cycles are common. Once the period does arrive they are often uncharacteristically heavy. This abnormal menstrual cycle is an indication that there may be a problem with ovulation. The use of oral contraceptives can often delay the presentation of PCOS.

Androgenic symptoms - androgens are a group of hormones, such as testosterone, found predominantly in men, however, they are also present in women in lower levels. Woman with PCOS have considerably higher than normal levels of androgens which causes the characteristic excessive hair growth. Some woman also experience acne and male pattern hair loss.

Infertility - secondary to the disruption in the menstrual cycle many women are infertile. However, some women with PCOS will ovulate normally, some will ovulate less frequently and some will fail to ovulate.

Obesity - some 40% of woman with PCOS are considered to be obese. Unfortunately, the obesity will exacerbate the symptoms associated with PCOS. The hormone changes associated with PCOS make weight loss difficult.

Other less frequent causes of hirsutism include the following:

Medications - Danazol and the androgenic progestins present in some oral contraceptives such as norgestrel can result in hirsutism.

Hyperprolactinemia - should be ruled out in patients with hirsuitism, ameorrhea and a breast discharge.

Congenital adrenal hyperplasia - affected girls will generally present around puberty with hirsutism and menstrual irregularity or primary amenorrhea. Excess androgen production is a key feature of most forms of congenital adrenal hyperplasia. Congenital adrenal hyperplasia is usually recognized at birth or early in infancy.

Hyperthecosis - is a nonmalignant ovarian condition resulting in increased serum testosterone concentrations. Women with hyperthecosis are generally obese and have a long history of sever hirsutism. Unlike PCOS, which occurs only during the reproductive years, hyperthecosis of the ovaries can occur in postmenopausal women.

Ovarian tumors - hirsutism caused by an androgen-secreting tumor generally occurs later in life and progresses very rapidly.

Adrenal tumors - adrenal tumors are a rare cause of hirsutism.

Severe insulin resistance syndromes - hirsutism is also associated with women who have a severe insulin resistance marked by hyperinsulinemia.

Individuals should note there are two conditions characterized by generalized hair growth that do not represent true hirsutism:

Hypertrichosis - which refers to diffusely increased total body hair. This is a rare condition that is usually caused by a systemic illnesses or a medication.

Androgen-independent hair - which is the soft, vellus, unpigmented hair that covers the entire body. In infants, this hair is called lanugo.

Symptoms of Hirsutism

Hirsutism can present with a broad spectrum of symptoms including the following:

Excessive hair growth - individuals with hirsutism will often present with excess hair on areas of the body where hair follicles are sensitive to androgens including: face, chest, breast, lower back, midline region of the lower abdomen, inner thigh, arms, legs, etc.

Acne - excess androgen associated with hirsutism can also contribute to the development of acne, which may occur on the face, chest and/or upper-back.

Irregular menstrual cycle - increased androgen levels can also disrupt the normal menstrual cycles. In severe cases may cause women to be anovulatory.

Diagnosis of Hirsutism

The diagnosis of hirsutism is based on a family history of hirsutism, a personal history of menstrual irregularities, and the presentation of masculine traits. The patients medical history can often reveal enough information were no other diagnostic testing is needed.

However, if a physician deems that further testing is needed the following represent the most common diagnostic procedures:

Ovarian ultrasound - represents most consistent investigation in PCOS is ovarian ultrasound, although a skilled ultrasound technician is necessary. The typical ultrasonic presentation are those of a thickened capsule, multiple 3-5mm cysts and hyperechogenic stroma. In addition, it should also be noted that prolonged hyper androgenization from any cause may result in polycystic changes in the ovary. The use of ultrasound may also show virilization ovarian tumors.

17-x-Hydroxyprogesterone - is elevated in classical congential adrenal hyperplasia (CAH), but may be apparent in late-onset CAH only after stimulation.

Gonadotrophin levels - LH hypersecretion is a consistent feature of PCOS, but the pulsatile nature of secretion of this hormone means that an increased LH/FSH ratio is not always observed on a random sample.

Serum testosterone levels - may be elevated in PCOS and is invariably substantially raised in virilization tumours. Patients with hisutism and normal testosterone level frequently have low levels of sex hormone binding globulin (SHBG), leading to high free androgen.

Additional androgens - androstenedione and DHEA sulphate are frequently elevated in PCOS, and even more elevated in congenital adrenal hyperplasia including virilizing tumours.

Serum prolactin - mild hyperprolactinaemia is common in PCOS.

In addition, If a virilization tumor is suspected clinically or after investigation, then more complex tests may include dexamethosone suppression tests, MRI, CT, etc.

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