Evaluation and Treatment of Women with Hirsutism - American Family Physician

www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2565 growth varies widely among women, and distinguishing normal variations of hair growth from hypertrichosis and true hirsutism is important. With hirsutism, terminal hair grows from androgen-sensitive pilosebaceous units. While 60 to 80 percent of women with hirsutism have increased levels of circulating androgens, degrees of hirsutism correlate poorly with androgen levels. The ovary is the major source of increased levels of testosterone in women who have hirsutism. Dehydroepiandrosterone sulfate (DHEAS) is an androgen that arises almost exclusively from the adrenal gland but is an uncommon cause of hirsutism. Nearly all circulating testosterone is bound to sex hormone binding globulin (SHBG) and albumin, with free testosterone being the most biologically active form. When elevated insulin levels are present, SHBG levels decrease while free testosterone levels increase. Hypertrichosis is defined as a diffuse increase in vellus hair growth and is not androgen dependent. Hypertrichosis may be congenital (e.g., Hurler’s syndrome, trisomy 18 syndrome, or fetal alcohol syndrome) or associated with hypothyroidism, porphyrias, epidermolysis bullosa, anorexia nervosa, malnutrition, or dermatomyositis. It also may occur H irsutism is a common disorder affecting up to 8 percent of women. It often results from conditions that are not life-threatening, such as chronic anovulation. Hirsutism is defined as the presence of excessive terminal hair in androgen-dependent areas of a woman’s body. The disorder is a sign of increased androgen action on hair follicles, from increased circulating levels of androgens (endogenous or exogenous) or increased sensitivity of hair follicles to normal levels of circulating androgens. Infrequently, hirsutism may signal more serious pathology, and clinical evaluation should differentiate benign causes from tumors or other conditions that require specific treatment. Most women who seek treatment for hirsutism do so for cosmetic reasons, because excess body hair outside of cultural norms can be very distressing. Hair Hirsutism is a common disorder, often resulting from conditions that are not lifethreatening. It may signal more serious clinical pathology, and clinical evaluation should differentiate benign causes from tumors or other conditions such as polycystic ovary syndrome, late-onset adrenal hyperplasia, and Cushing’s syndrome. Laboratory testing should be based on the patient’s history and physical findings, but screening for levels of serum testosterone and 17 -hydroxyprogesterone is sufficient in most cases. Women with irregular menses and hirsutism should be screened for thyroid dysfunction and prolactin disorders. Pharmacologic and/or nonpharmacologic treatments may be used. Advances in laser hair removal methods and topical hair growth retardants offer new options. The use of insulin-sensitizing agents may be useful in women with polycystic ovary syndrome. (Am Fam Physician 2003;67:2565-72. Copyright© 2003 American Academy of Family Physicians.)