Hirsutism: What is it? Signs, Symptoms, Causes, Diagnosis and Treatment

Abnormal hair growth, especially facial hair growth, is one of the most indicative symptoms of PCOS.

The medical term for this condition is hirsutism.

Although not all women with PCOS have it, for those who do it can be one of the most embarrassing and time-consuming symptoms.

Hirsutism is an excess of body hair in men and women in parts of the body where hair is normally absent or minimal, such as the chin or chest in particular, or the face or body in general.

It can refer to a male pattern of hair growth that can be a sign of a more serious medical condition, especially if it develops long after puberty. It can be caused by elevated levels of androgen hormones.

The amount and location of hair is measured with a Ferriman-Gallwey score. Hirsutism is usually the result of an underlying endocrine imbalance , which can be adrenal, ovarian, or central.

Common treatments for hirsutism are the birth control pill (BCP) and spironolactone .

Hirsutism affects between 5-15% of all women in all ethnic groups. Based on the definition and the underlying data, estimates indicate that approximately 40% of women have some degree of unwanted facial hair.

What hormones are responsible for hirsutism?


Androgens are a group of hormones that are generally found in higher levels in men. The androgen you are probably most familiar with is testosterone.

Another androgen is DHEA-S, which is produced by the adrenal glands when the body is under stress .

Your liver is responsible for regulating hormone levels. However, when hormone levels are unexpectedly high, you cannot manage them effectively, and excess hormones remain in the blood.

The unfortunate result of this is that hormones can wreak havoc on the body. For women with PCOS, androgen levels are generally higher.

Excess levels of them enter the hair follicles on the face and chest. As a result, they turn very fine hair that normally grows into thick, dark hair.

Androgens can also get into the hair follicles on the head and cause hair loss. This condition is called androgenic alopecia. Excess androgens can also leak into the glands under the skin and cause acne.

Hirsutism is incredibly common in women with PCOS. In fact, 95% of women with hirsutism also have PCOS.

Polycystic ovary syndrome is caused by a certain combination of genes and environmental factors. These factors include inflammation, stress, hypothyroidism, and the birth control pill, but the most common is insulin resistance .


Insulin is your storage hormone. It binds to specific receptors on certain cells and tells them to open up and glucose to enter. This allows the body to store glucose.

Although this process is efficient for most people, some people can develop insulin resistance. This occurs when insulin does not work properly and the body subsequently cannot store excess glucose effectively.

High levels of insulin stimulate the ovaries to produce more androgens. They also reduce the amount of sex hormone binding globulin (SHBG). The sex hormone binding globulin acts like a sponge for excess hormones. If it is low, the level of excess hormones will be much higher.

Studies have shown that high insulin has a double impact on hirsutism. Not only does it increase the androgens that contribute to hirsutism (and decrease sex hormone binding globulin), it also causes hirsutism independently.

A study of 749 women with PCOS showed that high insulin was actually a bigger contributing factor in unwanted hair growth, compared to high androgen levels.

Signs and symptoms

Hirsutism is a frequent symptom in dermatology, endocrinology, and gynecology clinics, and is considered to be the cause of many psychological disorders and social difficulties.

Facial hirsutism often leads to avoidance of social situations and symptoms of anxiety and depression .

If you experience any of the following symptoms, your stress hormones could be causing or contributing to hirsutism:

  • Feeling fatigued all the time
  • Waking up tired, even after 8 hours of sleep.
  • Feeling exhausted after a little exercise.
  • Feeling tired but awake at night.

Causes of hirsutism

You may not realize it, but you are not actually generating new hair. All women have hair on their faces, but it is usually so fine and short that it is not noticeable. Our bodies are covered in hair.

The only places we don’t have is on the soles of the feet, the palms of the hands, and the lips. But not all areas of the body have the same type of hair: there are two different types:

  • Villus hairs are short, soft hairs (less than 2 m in length) that cover areas of the body that you would generally consider “hairless,” that is, the face, chest, and back.
  • Terminal hairs are the thick, pigmented hairs that make up hair, eyelashes, eyebrows, pubic hair, scalp, etc.

In “male pattern” female hair growth (hirsutism), the villi become terminal hairs due to hormones, such as insulin and androgens.

This process only occurs in areas that are sensitive to these hormones, that is, the chin and beard area, the upper lip, the chest, the stomach and the back.

The hair on the scalp and eyelashes (where we often want thicker hair) is not sensitive to these hormones. In fact, hair can fall out in these areas.

Increasing evidence implicates high circulating levels of insulin in women for the development of hirsutism. The following are conditions and situations that have been associated with hyperandrogenism and therefore hirsutism in women:

  • Hyperinsulinemia (excess insulin) or hypoinsulinemia (insulin deficiency or resistance as in diabetes).
  • Ovarian cysts, as in polycystic ovary syndrome (PCOS), the most common cause in women.
  • Ovarian tumors such as granulosa tumors, thecomas, Sertoli-Leydig cell tumors (androblastomas), and gindaneblastomas, as well as ovarian cancer.
  • Hyperthecosis
  • The pregnancy.
  • Tumors of the adrenal glands, adrenocortical adenomas and adrenocortical carcinoma, as well as adrenal hyperplasia due to pituitary adenomas (as in Cushing’s syndrome ).
  • hCG-secreting tumors.
  • Inborn errors of steroid metabolism, as in congenital adrenal hyperplasia, most commonly caused by 21-hydroxylase deficiency.
  • Acromegaly and gigantism (growth hormone and excess IGF-1), usually due to pituitary tumors.
  • Use of certain medications such as androgens / anabolic steroids, phenytoin, and minoxidil.

Causes of hirsutism not related to hyperandrogenism include:


A full physical evaluation should be performed before starting larger studies, the examiner should differentiate between generalized increase in body hair and male pattern virilization.

After the physical exam, lab studies and imaging studies may be done to rule out other causes.

Many women present with an elevated level of serum dehydroepiandrosterone sulfate (DHEA-S). Levels greater than 700μg / dL are indicative of adrenal gland dysfunction , particularly congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

However, polycystic ovary syndrome and idiopathic hirsutism constitute 90% of cases. Other blood values ​​that can be evaluated in the treatment of hirsutism include:

  • Androgens: androstenedione, testosterone.
  • Thyroid function panel: thyroid stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4).
  • Prolactin.
  • If an underlying cause cannot be identified, the condition is considered idiopathic.

Treatment for hirsutism

You may feel like you’ve tried everything to combat unwanted hair growth. However, the only mistake many women make is not treating the root cause of the problem properly.

Many women with unwanted hair seek hair removal methods. You simply haven’t been given the tips and tools to correct your excess hormones.


The drugs consist primarily of antiandrogens, drugs that block the effects of androgens such as testosterone and dihydrotestosterone (DHT) in the body, and include:

Spironolactone : an antimineralocorticoid with additional antiandrogenic activity in high doses.

Spironolactone adapts to the testosterone receptors in the hair follicles, thus preventing testosterone from doing harm. However, like all drugs, it has side effects.

It kills your sex drive, affects your adrenal glands, causes fatigue and you cannot take it when you are pregnant as it causes birth defects. Spironolactone also does nothing to help treat insulin resistance.

Cyproterone Acetate : a double antiandrogen and progestin. In addition to the single form, it is also available in some low-dose combined oral contraceptive formulations. You have a risk of liver damage.

Flutamide : a pure antiandrogen. It has been found to be equivalent to or greater than spironolactone, cyproterone acetate, and finasteride in treating hirsutism. However, it has a high risk of liver damage and is therefore no longer recommended as a first or second line treatment.

Bicalutamide : a pure antiandrogen. It is effective in a similar way to flutamide, but it is much safer and better tolerated.

Birth Control Pills : The birth control pill also works to block androgens, but it actually increases insulin resistance by 30-40%. This is why the pill should never be a treatment for PCOS.

They consist of an estrogen, usually ethinyl estradiol, and a progestin. They are believed to work by:

 1) Stimulate the production of sex hormone binding globulin in the liver, which lowers free testosterone concentrations in the blood.

2) Suppress the secretion of luteinizing hormone (LH) from the pituitary gland, which decreases the production of testosterone by the gonads.

Therefore, they are functional antiandrogens. Also, certain birth control pills contain a progestin that also has antiandrogenic activity.

Examples include birth control pills that contain cyproterone acetate, chlormadinone acetate, drospirenone, and dienogest.

Finasteride and dutasteride : 5α-reductase inhibitors. They inhibit the production of the potent androgenic dihydrotestosterone.

Gonadotropin-releasing hormone analog : Suppresses androgen production by the gonads and reduces androgen concentrations to castration levels.

Metformin : Metformin is another drug that is frequently prescribed for insulin resistance, this antihyperglycemic drug is used for diabetes mellitus.

However, it is also effective in treating hirsutism associated with insulin resistance (eg, polycystic ovary syndrome).

Eflornithine : blocks putrescine that is necessary for the growth of hair follicles.

In cases of hyperandrogenism specifically due to congenital adrenal hyperplasia, administration of glucocorticoids will return androgen levels to normal.

The birth control pill and spironolactone are comparable to helping a hemophiliac patient. Neither of them do anything to fix the cause of the problem. No drug makes you more sensitive to insulin or prevents your body from pumping out excess testosterone.

They are literally only a temporary help, if you want to get pregnant (and stop taking the medications), the hair growth and other symptoms will return, worse than ever.

Other methods

  • Hair removal.
  • Shaved off.
  • Laser hair removal.
  • Electrology

Lifestyle change, including reducing excess weight and addressing insulin resistance, can be beneficial. Insulin resistance can cause excessive levels of testosterone in women, resulting in hirsutism.

One study reported that women who stayed on a low-calorie diet for at least six months lost weight and reduced insulin resistance.

His levels of sex hormone-binding globulin increased, which reduced the amount of free testosterone in his blood. As expected, the women reported a reduction in the severity of their hirsutism and acne symptoms.

Medications and laser hair removal are often recommended to reduce or remove unwanted hair. However, they do not help treat the causes of hirsutism: excess androgens and insulin resistance.