Hirsutism

Several factors can increase the likelihood of developing hirsutism, including:

• Family History: Certain conditions, such as congenital adrenal hyperplasia and polycystic ovary syndrome (PCOS), are hereditary. Around 50% of women with hirsutism have a family history of the condition.
• Regional Differences: Women from Mediterranean, Middle Eastern, and South Asian backgrounds tend to have more body hair without any apparent cause compared to other women.
• Obesity: Being overweight or obese can elevate androgen production, leading to hirsutism.

Medical History:

The physician will review the patient’s medical history, focusing on the menstrual cycle. Important details such as the age at which hirsutism started (puberty, middle age, menopause), the speed of symptom onset (gradual or sudden), and any other associated symptoms (like acne, deepening voice, irregular periods, loss of breast tissue, or increased muscle mass) will be noted. Additionally, any history of weight gain or diabetes, as well as medications taken before the condition started, will be discussed.

Physical Examination:

A comprehensive physical exam will be conducted, including palpation of the abdomen for ovarian masses. The Ferriman-Gallwey score is used to assess the severity of hirsutism by grading the amount and location of hair growth in nine body areas. A score of 8-15 is considered mild, while a score above 15 is moderate to severe. This score helps in evaluating the response to treatment.

Lab Tests:

• Testosterone: Elevated levels may indicate conditions like PCOS or congenital adrenal hyperplasia (CAH), while extremely high levels (>200 ng/ml) suggest a malignant tumor of the adrenal or ovary.
• Dehydroepiandrosterone sulfate (DHEAS): Elevated DHEAS levels (>700 μg/dl) indicate an adrenal cause.
• 17 Hydroxy progesterone: This test is specific for diagnosing congenital adrenal hyperplasia.
• Cortisol: Cortisol levels are tested in suspected cases of Cushing's syndrome, which can lead to excessive hair growth.
• Serum Thyroid-stimulating hormone (TSH): High TSH levels may indicate hypothyroidism, which can be a contributing factor to hirsutism.
• Prolactin: Elevated prolactin levels may contribute to hirsutism through various mechanisms.
• LH/FSH (Luteinizing hormone to Follicular Stimulating Hormone): A change in the LH to FSH ratio can disrupt ovulation and may be a helpful marker in diagnosing PCOS.

Imaging Tests:

• Pelvic Ultrasonography: A non-invasive test using sound waves to visualize the pelvic organs, helpful in detecting ovarian neoplasms or polycystic ovaries.
• CT/MRI: These imaging techniques provide detailed, three-dimensional images of the abdominal and pelvic organs.

While hirsutism cannot always be prevented, certain measures can help manage underlying conditions like PCOS and reduce excessive hair growth:

• Maintaining a Healthy Weight: Weight loss can help manage PCOS and improve reproductive health, lower the risk of heart disease, and make diabetes easier to control.
• Regular Exercise: Regular physical activity helps maintain a healthy weight, which can assist in balancing hormones and preventing excessive hair growth.
• Balanced Diet: A nutritious diet rich in high-fiber foods, lean proteins (such as skinless chicken and fish), and healthy fats (like coconut, olive, and fish oils) is recommended. Avoid processed, sugary, and junk foods. Foods like wheatgrass, barley grass, and spirulina can also aid in managing PCOS.
• Stress Management: High stress levels can lead to weight gain, difficulties in losing weight, and increased cortisol, all of which contribute to hirsutism. Engage in stress-reducing activities such as talking with friends, practicing yoga, or listening to music.
• Adequate Sleep: Sufficient rest can help manage stress and anxiety. Activities like long walks, yoga, or meditation, along with turning off electronic devices at least two hours before bedtime, can promote better sleep.

Specialists to Visit

When diagnosing the cause of hirsutism is challenging, a general practitioner (GP) may be the first point of contact. The GP can refer the patient to other specialists as needed:

• Endocrinologists: These specialists focus on the endocrine system and conditions like congenital adrenal hyperplasia. They can help manage related disorders, such as diabetes, and once the underlying cause is treated, hirsutism may subside.
• Dermatologists: If hirsutism runs in the family (familial hirsutism), a dermatologist can provide care for this condition.
• Psychologists: If hirsutism causes anxiety or depression, a psychologist may help address mental health concerns.
• Dietitians: If obesity is an issue, a dietitian can assist with maintaining a healthy weight and creating a balanced nutrition plan.

For women with polycystic ovary syndrome (PCOS), lifestyle changes are typically the first course of treatment, especially if they are overweight. Studies show that women with PCOS who lose more than five percent of their body weight experience significant improvements in their hormone levels. This includes lower testosterone, higher sex hormone-binding globulin (SHBG), and a reduction in Ferriman-Gallwey scores.

Medical treatments typically take a minimum of 8 weeks before visible improvements are noticed.

Cosmetic Treatments (Temporary Solutions)

Many women choose hair removal techniques such as plucking, shaving, or waxing as a quick and inexpensive solution, though these methods are temporary and come with side effects like discomfort, scarring, skin irritation, and discoloration.

Electrolysis (50% effectiveness)

This method involves inserting a needle that sends electrical pulses into individual hair follicles. With multiple treatments, electrolysis can lead to 15-50% permanent hair loss. However, it is not ideal for large areas, such as the chest or upper back, and can be time-consuming.

Laser Hair Removal (80% reduction)

Laser treatments have gained popularity for achieving long-term reduction (not complete removal) of hair. The laser works by specifically targeting melanin in the hair follicles and is most effective on light-skinned individuals with dark hair. Multiple sessions are needed to achieve about 80% hair reduction. Side effects may include skin irritation, swelling, or redness.

Commonly used lasers include the 755-nm alexandrite, 800-nm diode, and 1064-nm Nd:YAG lasers, along with pulsed light sources.

Medications

For women with PCOS, a combination of proper diet, exercise, and weight management is recommended before considering medications. Medications used to treat hirsutism include:

Oral Contraceptive Pills (OCP)

OCPs are a first-line treatment for hirsutism, especially for women seeking contraception. These pills work by reducing gonadotropin secretion, lowering ovarian androgen production, inhibiting adrenal androgen production, and increasing SHBG, which results in lower free testosterone levels. Commonly used OCPs include:

• Ethinyl estradiol
• Norgestimate
• Desogestrel
• Norethindrone
• Ethynodiol diacetate
• Drospirenone

Anti-Androgen Therapy

• Spironolactone (SPA): This androgen blocker competes with dihydrotestosterone (DHT) for binding to androgen receptors. It is more effective when combined with OCPs, as they have complementary anti-androgenic effects.
• Cyproterone Acetate (CPA): A potent anti-androgen with progestogenic properties, it reduces circulating androstenedione levels. However, CPA may have steroidal side effects and cause liver function abnormalities and menstrual irregularities.
• Flutamide: Primarily used for prostate cancer, flutamide has also been used off-label to treat hirsutism.

Note: Anti-androgens can be effective but are not recommended for women who are pregnant or may become pregnant due to the risk of harm to a male fetus. They may be considered in women using reliable contraception.

5-Alpha-Reductase Inhibitors

• Finasteride: A 5-alpha reductase inhibitor effective for idiopathic hirsutism (IH).

Gonadotropin-Releasing Hormone (GnRH) Agonists

These are used for severe hirsutism cases unresponsive to OCPs and anti-androgens. GnRH agonists reduce ovarian stimulation, estrogen production, and testosterone levels. Leuprolide acetate is an example of this drug.

Corticosteroids

• Glucocorticoids: Used primarily to treat hirsutism caused by congenital adrenal hyperplasia (CAH), dexamethasone, and prednisone are commonly prescribed.

Biological Modifiers

• Topical Eflornithine Hydrochloride: This topical cream reduces facial hair growth by inhibiting an enzyme involved in keratin synthesis. Gradual improvement is typically seen within 6-8 weeks, and it can be used alongside laser treatments.
• Insulin-Lowering Agents: Drugs like metformin may help reduce insulin levels, thus lowering free androgens, which can improve hirsutism.

Diet

• Limit calorie intake, especially in the evening, and divide meals into 5-6 smaller meals throughout the day.
• Choose low glycemic index (GI) foods that help avoid sharp blood sugar spikes, like non-starchy vegetables and legumes. Include at least 20g of protein with each meal (e.g., eggs, chicken, fish).
• Stay hydrated by drinking plenty of fresh, filtered water.
• Boost your intake of vitamin B, especially B2, B3, B5, and B6.
• Avoid trans fats, found in processed foods like cookies and cakes, and opt for healthier fats such as those from avocado oil, nuts, and seeds.

Acupuncture

This traditional Chinese medicine technique, involving the insertion of fine needles at specific body points, has shown promise in managing excessive hair growth.

Yoga and Exercise

Regular yoga and physical activity improve blood circulation, reduce fatigue, and help manage stress, anxiety, and pain.

Hot Water Bath

Hot water baths can relax muscles, improve blood circulation, and relieve tension in the body, offering comfort to those with hirsutism.

Home Remedies

• Spearmint Tea: Regular consumption has shown strong anti-androgenic effects that may help manage hirsutism.
• Zinc: Zinc blocks an enzyme involved in testosterone metabolism, which can reduce unwanted hair growth. Sources include chickpeas, pumpkin seeds, yogurt, beans, beef, chicken, and oysters.
• Cinnamon (Dalchini): Known for improving insulin sensitivity and lipid profiles in women with PCOS.
• Folic Acid: Balances homocysteine levels, contributing to better reproductive health.
• Licorice (Mulethi) Tea: Glycyrrhizic acid, a compound in licorice, has proven effective in halting hair growth.
• Flax Seeds (Alsi): Flax seeds reduce BMI and serum testosterone levels, leading to decreased hair growth.
• Astragalus Polysaccharide: Improves insulin resistance and androgen levels in patients with PCOS.

Managing hirsutism effectively can involve a combination of self-care strategies.

Understanding Your Condition:

Hirsutism can have an emotional impact, potentially leading to anxiety and depression. Talking with loved ones can help alleviate emotional stress, making it easier to follow an effective treatment plan.

Daily Exercise:

Regular physical activity improves blood circulation and helps reduce tension, stress, and anxiety.

Stick to Your Medication Routine:

If prescribed, medications should be taken consistently as directed by your healthcare provider.

Communicate with Your Doctor:

Don't hesitate to ask your doctor any questions regarding your condition or treatment. Open dialogue can help address any concerns you may have.

Reduce Stress:

Practicing meditation and yoga can significantly lower stress levels and contribute to overall happiness and well-being.

Ensure Sufficient Sleep:

Adequate rest is crucial as it helps the body and mind to relax, leaving you feeling more refreshed and less fatigued.