Dig deeper when diagnosing hirsutism

The first update to hirsutism guidelines for premenopausal women in over a decade calls on doctors to investigate androgen levels in all women with the condition

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The first update to hirsutism guidelines for premenopausal women in over a decade calls on doctors to investigate androgen levels in all women with the condition. 

The guidelines, recently published by the Endocrine Society in the US, warn that elevated androgen levels in women with hirsutism could indicate significant underlying pathology.

“Run a few tests and find out what is going on with their hormones,” Professor Robert Norman, a specialist in reproductive medicine and endocrine biochemistry at The University of Adelaide, recommended.

If a test indicates elevated androgen levels in women with hirsutism, it is worth assessing for conditions such as polycystic ovary syndrome (PCOS), or nonclassical congenital adrenal hyperplasia (NCCAH).

If there was an underlying condition causing the hirsutism that could be the focus of treatment, Professor Norman said. “If you find nothing wrong then you just have to give symptomatic treatment.”

The majority of women with hirsutism have high levels of male hormones, and around 70 to 80% of women with hirsutism will have PCOS.

PCOS affects around 12 to 21% of Australian women of reproductive age, but most women with the condition have not been diagnosed. 

While women with excess hair growth generally need further investigation, the new guidelines warn against testing women whose hirsutism is localised to a single area. 

“I don’t think it’s worth testing if it’s just local,” Professor Norman said. “If somebody comes in and says, ‘look, I’ve got a couple of hairs on my chin but I haven’t got hairs on my cheek or upper lip, there’s nothing on my tummy’, then your chance of finding something hormonal is remote.”

Oral contraceptives are the first-line treatment for most women with hirsutism who do not have an underlying endocrine disorder and have already tried cosmetic hair removal. 

Women who are at higher risk of venous thromboembolism, such as those over the age of 39, the guidelines recommend oral contraceptives containing the lowest effective dose of ethinyl oestradiol (usually 20mcg) and a low-risk progestin.

Due to the long hair growth cycle, the guidelines recommend waiting around six months before changing the dose or switching medication. 

It was also important to take into account the effect hirsutism can have on women’s mental well-being. Women with hirsutism often suffer profound psychological distress.

“People can actually retreat from life and get very withdrawn and very depressed,”  Professor Norman said. “Handling the psychological side is really important as well.”

Patients with severe hirsutism causing emotional distress, or women who have tried an oral contraceptive and have not seen any improvement, should be treated with combination therapy of an oral contraceptive and an antiandrogen. 

“However, we suggest against combination therapy as a standard first-line approach,” the guidelines state.