Hirsutism is defined as excess terminal (coarse, pigmented) hair that appears in a female
pattern in a woman. It affects about 10% of Caucasian women (more in Mediterranean
women) and usually results from subtle increases in androgens, but rarely may presage a
serious underlying condition.
In contrast, hypertrichosis is independent of androgens. The increased hair growth may
be localized or generalized, and affects any part of the body. Hypertrichosis may be
racial, hereditary, or be caused by drugs and some disease.
What should I ask?
• Enquire about onset, sites involved, and progression. Sudden onset and rapid
progression may indicate a virilizing tumour (rare).
• What is the psychological impact? What treatments have been tried?
• Look for symptoms suggesting hyperandrogenism or polycystic ovary syndrome
(PCOS), e.g. acne, androgenetic alopecia, menstrual irregularities, or infertility,
hyperprolactinaemia (galactorrhoea), adrenal pathology, pituitary tumour (visual
disturbance, headache), late-onset congenital adrenal hyperplasia (hirsutism, prepuberty,
premature pubarche, menstrual irregularity, primary amenorrhea), or virilization
(increased libido, deep voice).
• Drug history, including oral contraceptives.
• Family history of hirsutism, PCOS, androgenetic alopecia, or congenital adrenal
hyperplasia.
What should I look for?
• Exclude hypertrichosis by ensuring excess hair is limited to androgen- dependent areas,
and score using the Ferriman–Gallwey scale.
• Other cutaneous manifestations of excess androgens: female pattern hair loss—the
frontal hairline is preserved in women (unlike men), but hair on the vertex of the scalp
thins diffusely; acne and seborrhoea (oily skin on the central face).
• Signs of PCOS (the commonest cause) or another underlying cause.
• Signs of virilization: deep voice, cliteromegaly, breast atrophy, muscularity. If present,
examine for an ovarian or adrenal mass.
• Signs of a visual field defect if you suspect a pituitary adenoma.
What should I do?
• Investigation is recommended in moderate or severe hirsutism; hirsutism of any severity
if it is sudden in onset or progressing rapidly; and hirsutism associated with menstrual
irregularity or infertility, central obesity, acanthosis nigricans, or cliteromegaly.
• Treat the underlying cause.