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Hirsutism — Not Always Benign

Hirsutism, a woman who develops a male pattern of hair growth on her body and, is frequently linked to underlying endocrinologic disorders.

Hirsutism is a significant source of distress and loss of self-esteem for a woman who develops a male pattern of hair growth on her body and face during her reproductive years. But it is frequently linked to underlying endocrinologic disorders, such as Cushing’s Disease, hyperplasia, obesity, hyperinsulinemia, hyperprolactinemia, and hypothyroidism, where the consequences to lack of treatment can be serious.

More than 80% of cases of hirsutism are due to androgenic causes such as polycystic ovary syndrome (PCOS) in about 70-80%. Endocrine Society guidelines recommend measuring androgen levels in moderate to severe cases (particularly when the onset is sudden, rapidly progressive, or when it is associated with menstrual irregularity, central obesity, acanthosis nigricans, or clitoromegaly) as serum testosterone levels greater than 200 ng/dL suggest an adrenal or ovarian tumor. 

Hirsutism is not the same as hypertrichosis, a simple form of abnormal hair growth in women that may be hereditary or due to metabolic or other non-endocrine disorders or the use of many common medications, but unlike hirsutism, is not related to androgen levels.  

Determining the cause of excessive facial hair growth will point to the most effective therapy (usually some form of hormonal therapy). Most cases of hirsutism will be idiopathic, and the diagnosis for the cause becomes one of exclusion. Pregnancy should first be ruled out. Imaging can aid in detecting neoplasms, and CNS imaging can help identify pituitary causes. A pelvic exam should be done where amenorrhea is present, along with labs for prolactin levels and thyroid function. Cortisol levels measured by a 24-hour urine test can rule out Cushing syndrome.

Lifestyle modifications that target insulin resistance and androgen production, such as weight loss in overweight and particularly obese patients, as well as regular exercise, are likely to improve hirsutism and give patients a small sense of control over symptoms — although treatment of underlying causes will still be needed.

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