Unwanted Hair Growth (Hirsutism)

Hirsutism vs other unwanted hair

Not all extra hair is hirsutism:

Doctors grade hirsutism with the modified Ferriman-Gallwey score, rating hair in 9 body areas from 0 to 4. A total of 8 or more is often used as the threshold in the US, though lower cut-offs apply in some ethnic groups such as East Asian women, who tend to have less body hair.

Causes of unwanted hair

Polycystic ovary syndrome

PCOS accounts for roughly 70 to 80 percent of hirsutism. The ovaries make extra androgens, often driven by insulin resistance. Other features are irregular or missing periods, acne, weight gain, scalp hair thinning and difficulty getting pregnant. Hirsutism usually starts around or after puberty and progresses slowly.

Idiopathic hirsutism

Some women have hirsutism with normal periods and normal androgen levels. The hair follicles are thought to be more sensitive to normal androgen levels. It often runs in families.

Congenital adrenal hyperplasia

An inherited enzyme deficiency makes the adrenal glands produce extra androgens. The mild, non-classic form may first appear in adolescence or adulthood and looks very like PCOS. See congenital adrenal hyperplasia.

Cushing syndrome

Excess cortisol causes hirsutism along with central weight gain, a rounded face, purple stretch marks, thin skin, muscle weakness and high blood pressure. See Cushing syndrome.

Androgen-secreting tumors

Rare tumors of the ovary or adrenal gland produce large amounts of testosterone. They cause rapid hair growth and virilization: a deeper voice, balding, increased muscle mass and clitoral enlargement. See adrenal tumors and ovarian tumors.

Medicines and other causes

• Testosterone or DHEA supplements, anabolic steroids
• Some progestins, danazol, valproate
• Hyperprolactinemia and thyroid disorders (less common causes)
• After menopause, the balance shifts toward androgens and a few coarse chin hairs are common; marked new hirsutism after menopause needs testing

How the cause is found

A doctor will ask when the hair growth started and how fast it is progressing, about periods, fertility, acne, weight, medicines and family history, and will examine hair pattern, skin, blood pressure and signs of virilization. Tests usually include:

• Total testosterone (ideally measured in the morning, in the first part of the menstrual cycle)
• 17-hydroxyprogesterone for non-classic congenital adrenal hyperplasia
• Prolactin, thyroid function and pregnancy test
• DHEA-S if an adrenal source is suspected
• Glucose and cholesterol if PCOS is likely
• Pelvic ultrasound to look at the ovaries
• Cortisol testing if Cushing syndrome is suspected
• CT or MRI if testosterone is very high or virilization is present

Treatment

Most women benefit from combining a medicine that reduces new hair growth with a method that removes existing hair. Medicines take at least 6 months to show their full effect, because that is the length of a hair growth cycle.

Hair removal

• Shaving, plucking, waxing, threading and depilatory creams: quick and cheap. Shaving does not make hair grow back thicker.
• Laser hair removal: reduces hair long term; works best on dark hair and lighter skin, with specific lasers for darker skin. Several sessions are needed.
• Electrolysis: permanently destroys individual follicles; suits small areas and all hair colors.
• Eflornithine cream: a prescription cream that slows facial hair growth while used.

Medicines

• Combined oral contraceptive pills: first-line for most premenopausal women. They lower ovarian androgen production and increase a protein that binds testosterone.
• Anti-androgens such as spironolactone, added if the pill alone is not enough after 6 months. They must be used with reliable contraception because they can affect a male fetus.
• Treatment of the cause: for example glucocorticoids in congenital adrenal hyperplasia, surgery for tumors or Cushing syndrome, stopping a causative medicine.

Lifestyle

In women with PCOS and excess weight, losing 5 to 10 percent of body weight can lower androgen levels, improve periods and reduce hair growth.

Emotional impact

Unwanted hair can cause significant distress, self-consciousness and avoidance of social situations. This is a valid reason to seek treatment, even if the medical cause is benign. Support from a doctor, dermatologist or counselor can help.

Frequently asked questions

What causes unwanted hair growth in women?

Most often, polycystic ovary syndrome, which raises androgen levels. Other causes include sensitivity of hair follicles to normal hormone levels, congenital adrenal hyperplasia, Cushing syndrome, some medicines and, rarely, ovarian or adrenal tumors. Family background also influences how much hair is normal.

Is hirsutism a sign of PCOS?

Often, yes. PCOS causes most cases of hirsutism. Other signs of PCOS include irregular or absent periods, acne, weight gain and difficulty getting pregnant. A doctor can confirm PCOS with your history, blood tests and sometimes an ultrasound.

When is excess hair growth serious?

It is more concerning when hair appears rapidly over months, starts after menopause, or comes with a deeper voice, balding, increased muscle or clitoral enlargement. These suggest very high androgen levels, possibly from a tumor, and need prompt testing.

What is the best treatment for unwanted facial hair?

For lasting results, combine hair removal, such as laser or electrolysis, with a medicine that slows regrowth, like a combined birth control pill or an anti-androgen. Eflornithine cream slows facial hair growth. Results from medicines take about 6 months.

Does shaving make hair grow back thicker?

No. Shaving cuts hair at the surface, leaving a blunt tip that may feel coarser as it grows, but it does not change the thickness, color or rate of growth. Shaving is a safe and simple way to remove unwanted hair.