1 Unwanted Hair and Hirsutism
2 Unwanted Hair and Hirsutism What is hirsutism? 4 Why should you treat unwanted hair? 5 What is normal hair growth? 5 What can cause hirsutism? 6 What tests might be done? 8 How does the patient feel about her hair growth? 9 What treatments are available? 10 Facial and Body hair growth scoring 16
3 4 5 What is hirsutism? Hirsutism means excessive or unwanted hair on the face or body on androgen dependent areas in women (i.e. in places usually seen in men). Upper lip, chin, chest, abdomen (tummy), or back are common areas for hirsutism. This is different from hypertrichosis, which is defined as an excess of hair in men or women at any site (even in non-androgen-dependent regions). The normal amount of body hair varies widely among women. When coarse hairs grow where women typically do not grow coarse hair, such as the upper lip, chin, chest, abdomen (tummy), or back, the condition is called hirsutism. Hirsutism is not limited to dark haired people, all hair colours (blonde, red, grey) may also be coarse and grow in unwanted areas. What is considered normal for a woman and what is considered hirsutism depends on factors such as culture and race. Unwanted facial hair is usually the main concern to women. Symptoms associated with excessive hair growth may include: greasy skin acne menstrual cycle changes decreased breast size masculine signs (such as deepening of the voice) increased muscle size hair loss on the scalp change in libido (sex drive) If a patient has any of these symptoms, or if they think that a medicine they are taking might be making the unwanted hair growth worse, they should contact a doctor. Why should you treat unwanted hair? Unwanted hair growth in women is considered abnormal in our society and this can cause distress or embarrassment and affect a woman psychologically. Hypertrichosis (generalised excessive hair) or hirsutism (excessive hair on androgen dependent areas in women) are rarely caused by a serious illness. However, in some cases, hypertrichosis and hirsutism may be caused by a medical condition. This can easily be investigated by a doctor. However, quite often women do not realise that there are treatments available to reduce hair growth or to eliminate hair. Therefore they do not even talk to their doctor about it. If a patient has trouble controlling body or facial hair by cosmetic methods, or is upset by the condition, she should discuss this with her doctor. S/he may refer the patient to a specialist if s/he thinks that this is necessary. The specialist may be an endocrinologist, dermatologist or gynaecologist, who can provide reassurance, arrange appropriate tests and discuss possible treatments. What is normal hair growth? The body is completely covered with hair, except the lips, the palms of the hands and the soles of the feet. But on most of the body, the hair is so fine and soft that you cannot see it easily. Normally, a human being has two types of hairs: 1. Terminal hairs (coloured and thicker hair on the scalp, but also found on eyebrows, eyelashes, groin, and under the arms) 2 Vellus hairs (fine and light, normally not coloured. These hairs can become terminal hairs in the presence of male-type hormones) Women have the same number of hair follicles (places where hair is produced) on their body and face as men do. In women, most of the hair follicles on the face and the body produce fine and light (vellus type) hair. The male hormone, testosterone, makes hairs on men grow thicker, darker and longer, so that they appear more noticeable. All women produce small amounts of testosterone and this allows terminal hairs to appear in the groin and armpit areas, and around the brown circles of the nipple. This is normal and happens from around puberty. However, when there are higher levels of male hormones in women, terminal hairs can develop over the shoulders, over parts of
4 Ethnic/Racial Women from some ethnic groups (e.g. from Mediterranean countries) are more likely to have darker, more dense hair. There is no underlying medical condition causing the excess hair, and this is termed ethnic hypertrichosis. 3. Polycystic Ovary Syndrome (PCOS) This is a common cause of hirsutism and may be associated with other symptoms such as acne, irregular periods, infertility and obesity. The condition is usually diagnosed in adulthood, but the symptoms often start in the teenage years. Women with hirsutism caused by PCOS don't always have other symptoms of the condition. the back, upper legs and abdomen. The amount of terminal hair increases with age in women, and some races naturally grow longer and darker hair (even on the body) although they do not produce any extra hormones. What can cause hirsutism? If the unwanted hair growth is mild and the patient s periods are regular, it is unlikely that there is a serious medical problem. If the hirsutism is severe, and/or the patient has irregular periods, or any other symptoms (e.g. baldness or deepening of the voice), there may be a medical reason for the hirsutism. Hirsutism can be caused by several different factors. The best treatment will depend upon which factor is causing the unwanted hair growth. Reasons for hirsutism include: 1. Inherited/familial In most women, hirsutism is inherited and may be present in other female relatives. These women tend to have normal amounts of testosterone, but their hair follicles are more sensitive to testosterone and so grow more quickly and thicker. The increased hair growth is usually noticed in the late teenage years, and tends to gradually get more severe as the woman gets older. 4. Medication Some drugs are able to induce hair growth in general, and some drugs can contribute to hirsutism, e.g. Glucocorticoids Cyclosporin (immunosuppressor used in organ transplant patients, in psoriasis, atopic dermatitis and in arthritis) Progestative implants, intra uterine devices (IUDs) with progesterone or progestagen Body building drugs, i.e. anabolic steroids Phenytoin (or epanutin - used in epilepsy) Phenothiazines 5. Over-production of male-type hormones All women produce small amounts of male-type hormones such as testosterone in the adrenal glands, the ovary and in fat and muscle tissue. Hirsutism can develop if one or more of these sites increase their production. Blood tests and abdominal scans can help to find out where and why the hormones
5 8 9 are being over-produced. Obesity can cause changes in how the hormones are regulated, and so lead to hirsutism. Increased weight may increase the amount of the male hormone produced by the body and so in addition weight loss may enhance the result of any treatment. The levels of male and female hormones in the blood may be tested. Occasionally, other hormone tests are needed and these may be done by an endocrinologist or gynaecologist. Sometimes, a scan of the ovaries or other glands may be helpful. 6. Congenital Adrenal Hyperplasia In rare cases, hirsutism may be caused by an increase in hormone production by the adrenal glands. This condition is called Congenital Adrenal Hyperplasia and is hereditary. Often it is not diagnosed until teenage years or later. The condition is usually treated with small amounts of steroids. 7. Benign and malignant tumors In very rare cases androgen producing tumors of the ovaries or the adrenal gland can lead to a sudden onset of excessive hair growth, and other signs of virilisation. Although it is very rare it is important to detect as early as possible this cause. 8. Others E.g. hyperprolactinaemia, Cushing s disease, acromegaly (which are quite rare). How does the patient feel about her hair growth? Some people find it easy to discuss their worries with their doctor. For others, this can be more difficult; especially with an embarrassing or upsetting condition such as hirsutism. A patient may find the answers to the following questions useful, to help her explain how she feels to her doctor. 1. Does your unwanted hair growth interfere with your daily life? 2. Do you check your hair growth in the mirror more often than before? 3. In the last few weeks, have you felt that other people are looking at your excessive hair growth more often? 4. Does your unwanted hair growth sometimes make you feel sad or are you worried about it? 5. Are you very keen to reduce your unwanted hair growth? What tests might be done? A physical examination will probably carried out and also following questions should be answered. Do other members of your family also have excessive amounts of hair? What medications are you taking? Have your periods been regular? Are you pregnant? Have you noticed other signs of excess male hormones such as increased muscle mass, deepening voice, acne, or decreased breast size? If the patient answered yes to at least three of these questions, she worries. It is also common for women to remove their unwanted hair before they visit their doctor, or go outside the house (especially if the unwanted hair is on the face). This can make it difficult for the doctor to assess how severe the hair growth is. In this case, it might be useful for the patient to use the scoring scale at page 16 to show her doctor, or to document treatment changes where the unwanted hair is, giving an idea of how severe the growth is.
6 10 11 What treatments are available? Women with hirsutism should be tested for a medical cause, and should then be treated. If there is no underlying cause, hair management is the only way forward. Treatment of hirsutism depends on the cause of the problem. If it is a racial, ethnic, or family trait, no medical treatment may be necessary or prescribed. Instead, a patient may choose to see a beautician for removal of unwanted hair or be advised on home methods for removing unwanted hair. Weight loss is an important treatment for hirsutism. In overweight women, weight loss can decrease male hormone levels and reduce hair growth. 1. Cosmetic Treatment Bleaching is an option for dark hair and makes the excessive hair less obvious. Bleaching works well on the arms, thighs, and just below the nose. The results are immediate, but bleaching needs to be done frequently, depending on how quickly the hair grows. Bleaching may also leave skin red, cause rash/skin irritation, can be painful, is time-consuming, and can make hair more obvious Depilatory creams dissolve the hair, and the results are immediate, but the treatment needs to be done frequently, which can be uncomfortable. Depilatory creams may also cause irritation to the skin. Shaving: electric shavers are probably better than the wet type, as there is less tendency to irritate or damage the skin. The results are immediate, but shaving needs to be done frequently, and can also cause a rash/skin irritation, and is time-consuming. Shaving can also leave stubble, and although shaving does not influence the hair thickness the newly grown hair appears thicker. Waxing pulls hairs out from the roots. The results are immediate, but waxing needs to be done frequently and the hair must be allowed to grow long enough to be able to repeat the procedure. Waxing may also leave skin red, cause rash/skin irritation, can lead to pimples full of pus, can be painful, and is time-consuming. Electrolysis may cause permanent hair loss, but takes time as a small area is treated every few weeks, and unskilled treatment may cause scarring. Electrolysis uses electrical current to damage individual hair follicles so they do not grow back. This is expensive and requires multiple treatments. Tweezing is good for removing a few hairs, such as around the eyebrows. The results are immediate, but tweezing needs to be done frequently. Tweezing may also leave skin red, cause rash/skin irritation, can be painful, and is time-consuming. 2. Medical Treatment In most cases, hirsutism will return once the medical treatment is stopped. Examples of drugs* that may be prescribed are: Eflornithine cream: a prescription cream applied twice per day to slow the growth of unwanted facial hair. First effects can usually be seen after 8 weeks of treatment. Therefore, in the beginning it should ideally be combined with another form of therapy such as laser, waxing etc.
7 12 13 Ethinyl estradiol/cyproterone acetate or ethinyl estradiol/drospirenone. These combinations contain oestrogen (a female hormone) and a low dose of other hormones which have an anti-male hormone action see below. These hormones may not suit everyone, especially women over the age of 40 years. Side effects include bleeding between periods, tender breasts, nausea (feeling sick) and headaches, especially in the first few months. The hormones should not be given to women who are overweight, smoke, or have a job or lifestyle that means they sit down a lot. This is because the medicine can increase the risk of a blood clot in people with these factors. Cyproterone acetate or drospirenone (anti-androgens). Anti-androgens work against male hormones. Women should not become pregnant during and for up to 3 months following treatment with anti-androgens as they can interfere with a baby s development. Cyproterone acetate is also available in doses that are larger and more effective than the dose found in the combination product. The main disadvantage is that higher doses are more likely to produce side effects including weight gain, depression, and loss of libido (sex drive). Higher doses should therefore only be given to women with moderate or severe hirsutism and always with a safe contraceptive method, in women of childbearing age. Spironolactone is a weak diuretic (water tablet) that has some anti-androgen activity. Like cyproterone, safe contraception should be practised to avoid pregnancy. Side effects include tender breasts and irregular periods. Metformin. This drug is normally used in the treatment of diabetes. In recent years it has been shown to be beneficial to women with PCOS (see above). The main side effects of metformin are nausea, abdominal cramps, flatulence (wind), diarrhoea and constipation. * NB - some drugs may not be available in all countries 3. Photoepilation Therapy Photoepilation therapy is the most efficient method for coloured (dark) hair. Significant improvement is usually achieved after at least 5 7 sessions (depending on the laser or light source type, colour of hair etc.), and the benefits are long term. However, the treatment is expensive, it can cause burning and/or stinging sensation, can be painful, and sessions should only be performed every 4 8 weeks to enable the hair follicle to enter a new growth phase. Laser treatment damages individual hair follicles so they do not grow back. Lasers may not work well on blonde, red or grey hair. Several treatments are often required, but regrowth can be slowed by using lasers in combination with eflornithine cream. Complications can result from any topical treatment or hair removal procedure. It is important to follow all directions for any hair removal product and to be aware of the risks involved with any professional hair removal procedure. 4. Psychological Management If a patient s unwanted hair growth is troubling her, affecting her daily life, causing her anxiety, or making her depressed, she should talk to her doctor. Her doctor will be able to advise about available psychotherapy treatment. Facial and Body hair growth scoring The Ferriman-Gallwey Score This scale can be used to decide how severe hirsutism is. Each area is given a number from 1 to 4. If there is only a little extra hair growth, the area is given a score of 1, rising to a score of 4 for areas with a lot of excess hair growth. A patient can discuss how to use this scale with her doctor; she could use it to show him/her where she feels her excess hair growth is, and how severe it is. Also, the scale can be used to monitor the success of treatment, by scoring at regular intervals. A doctor will advise how to use the scale in the best way for each patient.
8 14 Notes 15 Facial and body hair growth scoring Name: Date of birth: Assess for Hirsutism as follows: Dates A few hairs at outer margin Small moustache at outer margin Moustache extending halfway from outer margin Moustache extending to mid-line A few scattered hairs Scattered hairs with small concentrations Complete cover, light and heavy Circumareola hairs With mid-line hair in addition Fusion of these areas, with threequarter cover Complete cover A few scattered hairs Rather more, still scattered Complete cover, light and heavy A sacral tuft of hair With some lateral extension Three quarter cover Complete cover A few mid-line hairs Rather more, still mid-line Half and full cover A few mid-line hairs Mid-line streak of hair A mid-line band of hair An inverted V shape grow Adapted from Ferriman and Gallwey (Ferriman D, Gallwey JD J Clin Endocrinol Metab. 1961;21: )
9 16 This document is a consensus of opinion from the Experts of the Skin Academy. Sponsored by an unrestricted educational grant from Almirall Laboratoires, Spain.
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