The Association of Minimally Invasive Gynecologic Surgeons
…dedicated to safe, state-of-the-art surgery and health life-styles for women of all ages
R. Wayne Whitted MD, MPH
Paul A. Pietro MD
8740 N Kendall Dr. Suite 101
Miami, Florida 33176
Phone: 305-596-3744
www.floridaamigos.com
INTRODUCTION — Hirsutism refers to the growth of coarse, dark hair in areas where women typically
grow fine hair or no hair at all - above the lip, and on the chin, chest, abdomen, and back). This growth is
caused by an excess of any of the hormones called androgens (male hormones), which all women have in
them normally.
Hirsutism warrants medical attention, especially if it develops or worsens rapidly in a woman aged 20
years or older, or if her relatives have comparatively less hair growth. In the vast majority of cases,
hirsutism is not caused by serious or malignant medical conditions; however, the cause of hirsutism
should be established and underlying conditions that pose related health problems should be treated.
Sometimes, the decision to treat hirsutism is a matter of personal choice. When it comes to the amount of
body hair, there is a wide range of normal among women. Race and ethnicity play a major role in the
growth of body hair: for example, Asian and Native American women tend to have little body hair,
whereas Middle Eastern and Mediterranean women tend to have moderate to large amounts of body hair.
Our culture also determines how much hair is cosmetically acceptable and how important we feel it is to
treat hirsutism. The psychological impact of hirsutism can range from annoying to severely disabling.
Any woman who is troubled by hirsutism should not hesitate to ask her doctor about treatment options.
CAUSES OF HIRSUTISM — Hirsutism is caused by an excess production or action of androgens,
usually by the ovaries or adrenal glands. Several different conditions can lead to hirsutism. The two most
common causes of hirsutism are polycystic ovary syndrome (PCOS) and idiopathic hirsutism. Both are
diagnosed by physical examination, medical and family history, and, sometimes, blood tests that help
exclude the rare causes of hirsutism.
Polycystic ovary syndrome — Women with PCOS often have hirsutism in combination with acne,
balding near the front of their head, and menstrual irregularities. PCOS is a chronic condition, but several
treatments can alleviate the hirsutism. PCOS is also associated with other medical problems such as
infertility due to the irregular menstrual cycles, obesity, diabetes mellitus, high cholesterol levels, and
possibly heart disease. It is important to identify any or all of these problems because effective treatments
are available.
Idiopathic hirsutism — Idiopathic hirsutism refers to hirsutism that has no identifiable cause. Doctors
suspect that it may be a mild variation of PCOS and, like PCOS, idiopathic hirsutism is usually chronic. A
gradual, increased growth of coarse body hair is typically the only symptom in women with this
condition. Menstrual cycles are always normal in women with idiopathic hirsutism.
Rare causes of hirsutism — In rare cases, hirsutism can be caused by hormone-secreting tumors of the
ovary or adrenal gland, by an ovarian condition called hyperthecosis (which may be an extreme form of
PCOS), by certain medications that have androgen-like effects, and by an inherited condition called
congenital adrenal hyperplasia.
The hirsutism associated with these conditions often develops abruptly in women over age 20 (rather than
at the time of puberty) and progresses rapidly. The sudden growth of body hair may be accompanied by
other signs of marked androgen excess, such as deepening of the voice and increased muscle mass.
TREATMENT OF HIRSUTISM — The treatment of hirsutism will depend upon the underlying cause.
The goals of treatment are to:
• Address any serious underlying medical conditions
• Slow or stop new hair growth
• Remove or camouflage the existing hair
• Address any related health problems, such as menstrual irregularities
• Anticipate any associated long-term health conditions, such as cardiovascular disease
Before prescribing any treatment, your doctor will carefully assess your degree of hirsutism, so that the
effectiveness of treatment can be gauged over time.
TREATMENT OF THE HIRSUTISM OF PCOS AND IDIOPATHIC HIRSUTISM — The
hirsutism of PCOS and idiopathic hirsutism are treated in similar ways. The treatment of PCOS may
further involve treatment of infertility, diabetes, and risk factors for cardiovascular disease.
Hair removal and lightening — Several methods can be used to physically remove excess hair or to
lighten it and make it less noticeable. These methods can be used in conjunction with medication. Women
with hirsutism who are trying to conceive or are already pregnant cannot take medications used to treat
hirsutism, and should ask their doctors about the safety of the various mechanical and chemical treatment
methods during pregnancy.
Shaving — Shaving is a safe and effective method for hair removal, but may require daily sessions.
Chemical depilation, waxing, and bleaching — Depilatory agents and wax can be used to remove hair,
and bleaches can be used to lighten hair. Depilatories and bleaches may cause skin sensitivity in some
women, so be certain to follow the directions for patch testing.
Electrolysis — Electrolysis damages individual hair follicles with an electric current so they do not
grow back. This treatment is safe and effective, but expensive. Furthermore, large areas often require
long-term treatment. Ask your doctor about guidelines for selecting a qualified electrologist.
Laser hair removal — Laser hair removal is effective for many with hirsutism, particularly those who
are fair-skinned with dark hair. Studies of the effectiveness of laser removal are encouraging. Although
laser is more expensive than electrolysis, it appears to be faster and less painful.
Creams — Vaniqa (eflornithine hydrochloride cream 13.9 percent) is a skin cream that has been
approved by the U.S. Food and Drug Administration for the treatment of unwanted facial hair in women.
It does not remove hair permanently, but seems to slow its growth. It is not yet known how effective this
cream will be.
Weight loss — Weight loss in overweight women can decrease levels of androgens and lessen hirsutism.
Women with menstrual irregularities may also notice that their cycles become more regular after they lose
weight.
Medications — Several medications are available for the treatment of hirsutism. These medications can
decrease the distribution of body hair, halt the growth of new hair, and decrease the growth rate and
coarseness of existing hair. Most of these medications must be taken for at least six months before
improvement is detectable, and not all medications are equally effective in all women.
Oral contraceptives — Oral contraceptives alter levels of several hormones, including androgens. They
are usually the first choice for the treatment of hirsutism, and between 60 and 100 percent of women with
hirsutism will notice improvement when taking these medications. Oral contraceptives can also help
establish regular menstrual cycles in women with hirsutism who have irregular cycles or who do not
menstruate at all.
One new pill, Yasmin, has become popular with many women for the treatment of hirsutism. However, it
has not been shown that Yasmin is any more effective than other birth control pills.
Oral contraceptives can cause side effects, such as high blood pressure and high cholesterol levels.
Therefore, your doctor may order tests before prescribing oral contraceptives.
Antiandrogens — Antiandrogens directly decrease androgen production or block the action of
androgens on the hair follicle. Because these medications may cause birth defects, doctors usually also
prescribe oral contraceptives for sexually active women who take antiandrogens.
• Spironolactone is usually prescribed if a six-month trial of oral contraceptives does not reduce hirsutism.
Between 60 and 70 percent of women with hirsutism will notice improvement when taking
spironolactone. If the initial dose is not effective after several months of treatment, your doctor may
recommend a higher dose.
• Finasteride may be as effective as spironolactone in some women with hirsutism. It is not approved for
use in women in the United States, but is available as a medication for male pattern balding (Propecia)
or prostate cancer (Proscar) in men. However, many insurers will not cover the costs of finasteride for
cosmetic reasons in either women or men.
• Cyproterone acetate reduces hirsutism in about 70 percent of women, but is currently unavailable in the
United States. It is used commonly in Europe and Canada, where it is a component of a type of birth
control pill.
Metformin — Metformin is a medication that is commonly used for the treatment of type 2 diabetes
(adult-onset). However, it is also sometimes used for women with polycystic ovary syndrome (irregular
periods and hirsutism or acne) to help make periods more regular and possibly improve fertility. Some
women also note some improvement in their hirsutism with metformin, but it does not appear to be as
effective as the other medications mentioned above.
TREATMENT OF THE RARE CAUSES OF HIRSUTISM — The treatment of most of the rare
causes of hirsutism is targeted at the underlying condition; hirsutism may lessen or resolve with effective
treatment.
Hormone-secreting tumors — Hormone-secreting tumors can be surgically removed and may require
additional chemotherapy or other medications.
Medications — A careful review of medications can identify medications that may cause hirsutism, such
as danazol, a medication used to treat endometriosis, and certain oral contraceptives that have androgen-
like actions. Your doctor may prescribe a lower dose of the medication or alternative medications or
treatments.
Congenital adrenal hyperplasia — Congenital adrenal hyperplasia is a rare chronic condition that is
usually treated with corticosteroids.
Hyperthecosis — Hyperthecosis is often treated with antiandrogen medications. Your doctor may also
recommend surgical removal of the ovaries because of the associated risk of ovarian cancer.
EXPECTATIONS OF TREATMENT — The treatment of hirsutism requires patience because hair
follicles have a life cycle of about six months. Most medications must be taken for three to six months
before a noticeable improvement occurs. In the meantime, the existing hair can be mechanically removed
or bleached, and some women may continue to use these methods in combination with medication.
Your doctor will monitor the progress of treatment and may repeat any tests if he or she is concerned
about an underlying condition. If a medication is ineffective initially, your doctor may change the dose or
recommend a trial of a different medication. It is important to have realistic goals for the reduction of
body hair and to place these goals within the context of your racial and ethnic background.
DURATION OF TREATMENT — The treatment of hirsutism is usually continued indefinitely
because, in most cases, the body continues to produce excess androgens. However, women must
discontinue all medications currently used to treat hirsutism before becoming pregnant. Furthermore,
some women eventually decide that the results of treatment are not worth the time, effort, and cost, or
they grow more comfortable with their body and the presence of body hair.
WHERE TO GET MORE INFORMATION — Your doctor is the best resource for finding out
important information related to your particular case. Not all patients with hirsutism are alike, and it is
important that your situation is evaluated by someone who knows you as a whole person.
This discussion will be updated as needed every four months on our web site (www.uptodate.com).
Additional topics as well as selected discussions written for health care professionals are also available for
those who would like more detailed information.
Some of the most pertinent include:
Professional Level Information:
Clinical features and diagnosis of polycystic ovary syndrome in adolescents
Evaluation of women with hirsutism
Pathogenesis and causes of hirsutism
Treatment of hirsutism
Clinical manifestations of polycystic ovary syndrome in adults
Diagnosis and treatment of polycystic ovary syndrome in adults
Treatment of polycystic ovary syndrome in adolescents
Use of GnRH agonists in the treatment of hyperandrogenism and hirsutism
Adrenal hyperandrogenism
A number of other sites on the internet have information about hirsutism. Information provided by the
National Institutes of Health, national medical societies, and some other well-established organizations
are often reliable sources of information, although the frequency with which their information is updated
is variable.
• National Library of Medicine
(www.nlm.nih.gov/medlineplus/)
• National Institue of Diabetes and Digestive and Kidney Diseases
(www.niddk.nih.gov/)
• The Hormone Foundation
(www.hormone.org)