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Patient Guide to the Evaluation and Treatment of Hirsutism in
Premenopausal Women



Why were the guidelines written?

This patient guide is based on The Endocrine Society’s Clinical Guideline written to help physicians who are evaluating and treating hirsutism in premenopausal women. Hirsutism refers to excessive growth of terminal hair(the kind of hair that grows on head) in areas where women typically grow fine (“peach fuzz”) hair. The distribution of hair follows a male pattern, appearing on the face, back, chest, etc. Hirsutism can be mild, moderate, or severe.

Hirsutism can have a major impact on a woman’s sense of well-being. Even isolated, mild hirsutism can be emotionally distressing to some women. Any women who are troubled by hirsutism should not be hesitate to ask her doctor about treatment options. The Clinical Guidelines make recommendation about those treatment options.


Why were the guidelines developed?

The Clinical Guidelines were developed after an extensive review of the best research studies related to the evaluation. And treatment of hirsutism in premenopausal women. An international expert panel of The Endocrine Society examined studies that were published in “peer-reviewed” medical journals(that is,studies tha twere revaluted by other scientists). The panel’s “Recommendations” and “suggestions “ were reviewed and approved by several committees and, finally, by the general membership of The Endocrine Society.No funding for the guidelines came from any pharmaceutical or medical device company.


What causes hirsutism?

Women naturally produce male hormones (androgens). The development and severity if hirsute generally depends upon the level of male hormones in the blood and the sensitivity of the hair follicle.

When the woman has more male hormones than normal, it is most often due to a disorder called polycystic ovary syndrome(PCOS). In addition to hirsutism, women with PCOS may have irregular or absent menstrual period and/or infertility. Acne, obesity, and an increased risk of diabetes are also common in women with PCOS.

Hirsutism may be caused by other disorders of male hormone overproduction, but these or not common. Medications such as anabolic steroids that contain male hormones can cause hirsutism.

When a women has hirsutism but does not have high levels of androgens, this called “idiopathic hirsutism” because the specific cause of the excessive hair growth cannot be identified.


When should androgen levels be measured in hirsute women?

The Clinical Guideline recommended not measuring androgen level in women with mild hirsutism and no other symptoms because results are unlikely to show any medical disorder. The Clinical Guideline suggest or serve hirsutism, or any hirsutism that begins suddenly, grow rapidly, or is associated with other symptoms like irregular or absent menstrual periods, or obesity(especially at the waist).


How is hirsutism managed or treated?

Before consulting a doctor about their hirsutism, many women first try measure, such a plucking, shaving, or bleaching to hide or remove hair. If a woman feels the cosmetic measures are not adequate, the Clinical Guidelines suggest either medication or direct hair removal methods (laser or electrolysis). These can be used either separately or in combination. In deciding between these options, a patient should take account her own preferences, whether or not direct hair removal is possible in the area(S) of concern, as well as accessibility and affordability of treatments.


Cosmetic Measures

Bleaching with products containing hydrogen peroxide and sulfates masks the presence of undesired hair. Side effects include irritation, itching, and possible skin discoloration.

Temporary (lasting few days to weeks) methods of hair removal include removing hair from the skin surface (depilation) and extracting hair in the follicles (epilation). Shaving is a popular depilation method that removes hair down to just below the surface of the skin. Shaving does not affect the growth, but leaves a blunt tip rather than the tapered tip of uncut hair. This make the hair look thicker. Chemical depilatories contain sulfur and have an unpleasant odor. Skin irritation can occur.

Epliation methods, such as plucking or waxing, are relatively safe and expensive, but can be painful. Scarring swelling, and particularly in women color, skin darkening may occur.

Medication

The Clinical Guideline recommends treatment with birth control pills for most hitsute women who are unsuccessfully treated with cosmetic measured. These medications lower levels of male hormones. Between 60% and 100% of women with hirsutism will notice improvement over a period of 6 to 12 months. Birth control pills can also help establish regular menstrual cycles in hirsute women with irregular or absent menstrual cycles.

Another option is drugs that block the action of the male hormones ( anti –androgens) but these have limitations. Because they can cause birth defects, The Clinical Guidelines recommend against their use unless adequate contraception is used. The choice between birth control pills and anti androgens depends on patient preferences regarding effectiveness, side effects, and costs.

Because of various side effects and /or not working well, the Clinical Guidelines suggest against the use of flutamide topical anti-androgen creams, and insulin lowering drug such as rosiglitazone, pioglitazone, or metformin, as therapy for hirsutism.

The Clinical Guidelines suggest a trail of at leat 6 moths before making changes in does, changing medication, or adding medication.


Direct Hair Removal

For women who choose hair removal therapy, the Clinical Guidelines suggest light source assisted hair reduction (photoepilation), which is widely used in the treatment of unwanted hair. Photoepilation methods include lasers and non lasers light sources, such as intence pulsed light. Several Photoepilation devices are approved by the U.S. Food and Drug Administration for “ permanent hair reduction” (“not permanent hair removal”). The choice of a Photoepilation method depends on a woman’s skin and hair color. White this type of hair removal is long lasting and large areas of skin can be treated at the same time, treatment sessions are expensive.

For women undergoing Photoepliation therapy who desire a faster initial response, the Clinical Guidelines suggest adding eflornithine cream drug treatment. These creams slow hair growth but doesn’t prevent it. For women with known excessively high androgen levels who choose hair removal therapy, the Clinical Guidelines suggest also taking medication such as birth control pills to minimize hair regrowth.

Electrolysis has been available for many years for the management of unwanted hair. With this technique, a fine needle is inserted into the hair follicle and an electrical current is applied. Electrolysis can be painful and time consuming because it treats each hair individually. It is cost effective options for small areas of hirsutism. It can be used on any skin or hair color. Possible side effects include skin swelling and redness followed by changes in skin color and /or scarring.


Why can you do to help your treatment process?

You and your doctor should be partners in your care. It is important that you provide your doctor with a full medical history, including use of prescription and non-prescription medications. You should desire any symptoms, such as menstrual irregularities, you have had in addition to excessive hair growth. Discuss your treatment options and what you can expect to them. Whatever treatment approach you take, you should be aware that hirsutism is usually an ongoing problem. It can be managed but may not be permanently resolved.

Note that women with hirsutism who are trying to conceive or are already pregnant cannot take medications used to treat hirsutism, and should ask their doctors about the safety of other hair removal methods during pregnancy.

Modified Ferriman-Gallwey Scoring System for Hirsutism