Hirsutism refers to excessive growth of dark, thick and coarse hair in an individual (usually female) in a male pattern. Commonly affected areas are upper lips, chin, central chest, midline of the stomach, lower back, buttocks and front of thighs. Hirsutism affects approximately 10% of women in western societies and is more common in those of Mediterranean or middle-eastern descent¹.

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Hirsutism can be caused by:

• increased androgen production
• increased skin sensitivity to androgens
• both of the above
• or no apparent underlying cause

Androgens are often thought of as exclusively 'male hormones' but, in fact both men and women produce them; men usually in greater amounts than women.

In premenopausal women, the most common cause of hirsutism is due to polycystic ovary syndrome (PCOS) which is associated with increased androgen production².

Most women develop more facial or body hair gradually as they get older, especially after the menopause. This is because in menopausal women, reduction in oestrogen and progesterone production can result in hair and skin disorders. The reduction in progesterone can increase the influence of androgens on the sebaceous glands and hair follicles, thus causing hirsutism³.

Rarely, hirsutism can be caused by medications such as steroids, and other hormonal disorders.

However, no apparent underlying cause is found in about half of women with mild hirsutism³.

Management options in primary care for women include:

• Weight loss (if obese or overweight), as this can help to restore normal hormone levels, in particular lowering androgen levels.
• Hair reduction and removal treatments (such as shaving, waxing, electrolysis, or laser treatment).
• Eflornithine cream which slows hair growth on the face.
• A combined oral contraceptive (COC) in premenopausal women

Referral to a specialist is recommended if:

• An underlying endocrine condition is suspected that requires secondary care diagnosis and/or management, e.g. Cushing’s syndrome.
• Treatment has not been effective after at least 6 months' trial.
• Clinical features suggestive of an underlying adrenal or ovarian tumour (urgent referral).
  • Features of androgen-secreting tumours include sudden onset and rapid progression of hair growth, signs of virilisation, or an abdominal or pelvic mass.

Treatments that may be offered by specialists include:

• Anti-androgens, e.g cyproterone acetate, finasteride, spironolactone, and flutamide
• Insulin-sensitising drugs, e.g. metformin, pioglitazone.
• Gonadotrophin-releasing hormone analogues, e.g. goserelin.

More information on these treatments can be found at: https://cks.nice.org.uk/hirsutism.