Hirsutism: Symptoms, Types, Causes and Treatment

Hirsutism is a condition that can deeply impact the lives of many women, not just physically but emotionally and socially. Defined by excessive, male-pattern hair growth in women, it is both a cosmetic and a medical issue—sometimes signaling underlying hormonal or metabolic disorders. Understanding hirsutism involves recognizing its symptoms, differentiating its types, identifying its causes, and exploring effective treatment strategies. This article provides a comprehensive, evidence-based overview of hirsutism to empower patients, families, and healthcare providers with the knowledge needed to manage this common yet often misunderstood condition.

Symptoms of Hirsutism

Hirsutism is more than just unwanted hair—it can affect self-esteem, social interactions, and may indicate more significant health concerns. Early recognition of its signs is essential for timely intervention.

Symptom	Description	Frequency/Severity	Sources
Excess terminal hair	Coarse, dark hair in androgen-dependent areas	Common in moderate/severe cases	3 5 7
Male-pattern distribution	Hair growth on face, chest, abdomen, back	Varies by ethnicity and severity	2 3 6 7
Menstrual irregularities	Irregular or absent periods, often co-occurring	Sometimes present	2 3 4 5
Psychosocial distress	Anxiety, social fears, low self-esteem	Significant impact	1 3 5 10

Table 1: Key Symptoms

What Does Hirsutism Look Like?

Hirsutism is characterized by the growth of coarse, pigmented (terminal) hair in places where women typically have little or no hair, such as the upper lip, chin, chest, lower abdomen, inner thighs, and back. The Ferriman-Gallwey score is often used by clinicians to assess the extent of hair growth in these areas 3 6 7. Women may notice a gradual increase in hair thickness and darkness, often starting in adolescence or early adulthood.

Beyond Hair: Associated Symptoms

While excess hair is the hallmark, hirsutism can also be associated with other symptoms depending on the underlying cause:

• Menstrual abnormalities: Irregular or absent periods are common when hirsutism is related to hormonal imbalances, particularly polycystic ovary syndrome (PCOS) 2 3 4 5.
• Acne or oily skin: Increased androgens can also trigger acne, a clue that the issue may be hormonal 2 3 5.
• Signs of virilization: In severe cases, women may experience deepening of the voice, increased muscle mass, or enlargement of the clitoris—signs that warrant immediate medical attention 2 4 7.

Psychological and Social Impact

Hirsutism often causes significant distress. Studies show higher levels of anxiety, social fears, and decreased quality of life among affected women, regardless of the underlying cause 1 3 5 10. The emotional burden can sometimes outweigh the physical inconvenience, emphasizing the need for a compassionate, patient-centered approach.

Types of Hirsutism

Not all hirsutism is the same. Identifying the type is crucial for diagnosis and management, as it guides both the search for underlying causes and the selection of treatment strategies.

Type	Distinguishing Feature	Prevalence/Notes	Sources
Idiopathic Hirsutism	Normal hormones, regular cycles	25–39% of cases	3 4 6
PCOS-related	With polycystic ovaries, hyperandrogenism	Most common (37–53%)	3 4 6 7
Adrenal Origin	Due to adrenal hyperplasia/tumors	Rare (<2%)	4 6 7
Drug-induced	Triggered by medications	Uncommon (<1%)	4 6
Postmenopausal	Develops after menopause	Notable in older women (9%)	6

Table 2: Types of Hirsutism

Idiopathic Hirsutism

This type describes women who have excess terminal hair but normal ovulatory function and androgen levels 3 4 6. The cause may relate to increased sensitivity of hair follicles to normal androgen levels or increased local conversion of androgens in the skin. Idiopathic hirsutism is more common in some populations and may have a strong familial/genetic component.

PCOS-Related Hirsutism

Polycystic ovary syndrome (PCOS) is the leading cause of hirsutism, accounting for up to half or more of all cases 4 6 7. Women with PCOS often present with hirsutism, irregular periods, acne, and sometimes obesity. The underlying problem is excess ovarian androgen production.

Adrenal Origin

Adrenal gland disorders, such as congenital adrenal hyperplasia (CAH) or adrenal tumors, can lead to hirsutism. These are rare but significant because they may signal a potentially serious condition 4 6 7. CAH is often diagnosed in adolescence, while adrenal tumors can present with a sudden onset of severe symptoms.

Drug-Induced and Postmenopausal Hirsutism

Certain medications—like anabolic steroids, danazol, or some anti-epileptics—can trigger hirsutism 4 6. After menopause, decreased estrogen and relative androgen excess may lead to new or worsening facial hair in older women 6. This type is generally milder but can be distressing.

Causes of Hirsutism

Understanding what causes hirsutism is key to effective management. While most cases are benign, some may indicate serious health concerns that need prompt attention.

Cause	Mechanism	Relative Frequency	Sources
PCOS	Ovarian androgen excess	Most common (37–53%)	2 3 4 6 7
Idiopathic	Unknown, likely genetic/local factors	25–39%	3 4 6
Adrenal disorders	Adrenal hyperplasia or tumors	Rare (<2%)	4 6 7
Medications	Androgenic drugs	Rare (<1%)	4 6 10
Obesity/metabolic	Increased androgen production	Associated with PCOS	2 4 7
Others (tumors, Cushing’s)	Tumor secretion of androgens	Very rare	2 4 7

Table 3: Causes of Hirsutism

Polycystic Ovary Syndrome (PCOS)

PCOS is the most common underlying cause of hirsutism 2 3 4 6 7. It involves multiple hormonal disturbances, especially excess production of androgens by the ovaries. PCOS is also associated with menstrual irregularities, obesity, infertility, and increased risk of diabetes and cardiovascular disease.

Idiopathic Hirsutism

When no hormonal or metabolic abnormality is found, the diagnosis is idiopathic hirsutism 3 4 6. This type may be due to genetic predisposition, increased sensitivity of hair follicles to androgens, or enhanced local conversion of testosterone to more potent forms in the skin.

Adrenal Disorders

• Congenital adrenal hyperplasia (CAH): Caused by enzyme defects in adrenal steroid synthesis, leading to excess androgen production 4 6 7.
• Adrenal tumors: These can cause rapid onset and severe hirsutism and are medical emergencies 2 4 7.

Medication-Induced Hirsutism

Certain drugs can cause hirsutism by increasing androgen levels or mimicking their effects. These include anabolic steroids, danazol, and some anti-seizure medications 4 6 10. Discontinuing the offending drug often leads to improvement.

Obesity and Metabolic Factors

Obesity is both a risk factor and a consequence of hormonal disturbances that drive hirsutism, particularly in PCOS. Increased adipose tissue can raise androgen levels by altering hormone metabolism 2 4 7.

Rare and Serious Causes

Very rarely, hirsutism can signal a life-threatening tumor of the ovary or adrenal gland, or conditions like Cushing's syndrome. These often present with rapidly progressive symptoms and other signs such as hypertension or changes in body shape 2 4 7.

Treatment of Hirsutism

Treating hirsutism aims to reduce unwanted hair, address underlying causes, and improve quality of life. A personalized, often multi-modal approach works best.

Treatment	Approach/Mechanism	Indications/Effectiveness	Sources
Lifestyle changes	Weight loss, exercise	Especially in PCOS	8 10
Hair removal	Shaving, waxing, laser, electrolysis	All severities; laser long-lasting	8 9 10
Pharmacological	OCPs, antiandrogens, topical eflornithine	Moderate-severe or PCOS-related	8 9 10
Treat underlying	Address tumors, hormonal disorders	Mandatory in serious cases	2 4 7

Table 4: Treatment Approaches

Lifestyle Modification

For women with PCOS or obesity, weight loss and physical activity can significantly reduce androgen levels and improve both metabolic and reproductive health 8 10. Even a modest reduction in weight can lead to noticeable clinical improvement.

Hair Removal Techniques

• Mechanical: Shaving, plucking, waxing—simple but must be repeated frequently 8 9 10.
• Laser and electrolysis: Offer longer-term or permanent hair reduction, especially effective for facial and body hair 8 9 10. Lasers are preferred for larger areas, while electrolysis is suitable for small or resistant patches.

Pharmacological Interventions

• Oral contraceptive pills (OCPs): First-line therapy for most women, especially those with PCOS. OCPs suppress ovarian androgen production and increase sex hormone-binding globulin, reducing free testosterone 8 9 10.
• Antiandrogens: Spironolactone is the most commonly used, followed by finasteride and cyproterone acetate. They block androgen effects at the hair follicle. These are typically added if OCPs alone are insufficient after 6 months 8 9 10.
• Topical agents: Eflornithine cream can slow facial hair growth and is best used alongside other methods 3 8 10.

Important Note: Antiandrogens should not be used alone unless effective contraception is ensured due to risk of feminizing a male fetus if pregnancy occurs 8 9 10.

Treating Underlying Disorders

If an adrenal or ovarian tumor is identified, surgical intervention may be required 2 4 7. Glucocorticoids or gonadotropin-releasing hormone analogs may be used in specific, less common forms of hirsutism such as congenital adrenal hyperplasia 2 3 10.

Psychological Support

Given the high rates of anxiety and social distress, psychological counseling or support groups can be invaluable for many women 1 3 10.

Conclusion

Hirsutism is common, complex, and can be distressing, but it is manageable with a systematic, personalized approach. Key points include:

• Recognize symptoms: Excess terminal hair in a male-pattern distribution, with possible menstrual or skin changes 3 5 7.
• Identify the type: Distinguishing between idiopathic, PCOS-related, adrenal, drug-induced, or postmenopausal hirsutism guides management 3 4 6 7.
• Understand the causes: Most cases are due to PCOS or idiopathic factors, but rare serious causes must be excluded 2 3 4 6 7.
• Treat comprehensively: Combine lifestyle changes, mechanical and pharmacological therapies, and address underlying health issues. Psychological support is essential 8 9 10.
• Set realistic expectations: Results can take 6 months or more, and lifelong management may be necessary for sustained improvement 10.

By integrating medical, cosmetic, and psychological care, women with hirsutism can achieve better health—and greater confidence in their daily lives.