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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Woman to Woman Woman to Woman
 

The Hairy Problem of Hirsutism


January 14, 2013

By Alice Y. Chang M.D.

Harvard Medical School

For many of us, ridding our body of unwanted hair is simply part of our cosmetic routine – whether it is under the arms, the legs, the bikini line or the eyebrows.

But other women do more serious battle with hair on the upper lip, chin or the back and chest. Sometimes, unwanted body hair is more than just a cosmetic problem. It is called hirsutism, and it may indicate a health problem, such as hormone irregularities.

Is Your Hair Growth Abnormal?

In some cultures and ethnic groups, body hair on women may be natural and accepted. Not so in the United States. Women pluck, shave, wax or more! When defining normal, look to your roots — not your hair roots but your female relatives. Do you look like them? You may actually have to ask them about their hair removal routine to find out the real story.

Next, take a closer look at the hair in question. To make a diagnosis of hirsutism, you need to know the type and location. There are two types of hair on your body. There is "terminal" hair — usually longer, thicker and darker. This hair is normally found on your scalp, eyebrows, eyelashes, underarm and pubic areas. The second type of hair, called "vellu" hair, is found elsewhere on the body. It is shorter, softer and lighter in color. Some people call this "peach fuzz" type of hair and may have it on their bellies, chins, legs and arms. In hirsutism, you have terminal type hair on the chin and/or upper lip, chest or back.

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What Causes Hirsutism?

Most women with hirsutism have elevated levels of male-type hormones such as testosterone and other androgens. These stimulate hair growth.

Clues that a woman's excessive body hair may be related to elevated male hormones include:

  • Abnormal menstrual periods — If your periods have always been irregular, or you have stopped having regular cycles, you likely have an underlying medical condition as a cause of hirsutism.

 

  • A change in hair pattern — If you have recently developed hair on new parts of your body, especially terminal hair, you might have new production of hormones that deserves an evaluation. In very rare cases, this new hair production could be a sign of a tumor that is producing hormones.

 

  • Frontal balding — Because the hair loss is from higher testosterone levels, it is a male-type hair loss, front and center on the top of your head. This usually happens in more extreme cases of hormonal abnormalities.

 

  • Acne — Especially if the acne starts or persists into adulthood and is found in other places aside from the face.

 

  • Deepening of voice — This occurs with higher levels of androgens.

The most common cause of hirsutism is polycystic ovarian syndrome (PCOS). The exact cause of PCOS is unknown, but the main features include irregular periods, higher androgen levels, persistent ovarian cysts, and infertility. Women with PCOS also have pre-diabetes and are at a higher risk of diabetes and heart disease.

If you have abnormal hair growth and irregular periods, ask your health care professional about this diagnosis and request to have your blood sugar level checked. It is also important for you to have at least four periods a year to prevent abnormalities of your uterine lining and to prevent bone loss.

Less commonly, certain medications and other hormonal conditions of the pituitary and adrenal glands may also cause hirsutism.

If all your hormone tests are normal, and you do not have any other reason for hirsutism, you may be diagnosed with idiopathic hirsutism (hirsutism without a known cause). Even if the hirsutism is not caused by elevated androgens, you may still benefit from one of the hormonal treatments discussed below.

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Treatment Options

 

The goals of treatment are to slow down and reduce hair growth. For women with and without hormonal abnormalities, the following first-step options exist, in the order of least to most expensive:

  • Shaving or plucking — This is cheap and often effective for many women, even if it has to be a near daily routine. It is more practical for small areas, the legs, arms and face. There is a potential problem with ingrown hairs developing with these techniques, especially in the pubic area.

 

  • Depilation — Over-the-counter hair-removal creams can be more convenient because you don’t have to use them as often as a razor. But make sure you use creams formulated for the right body part, particularly if selecting one for the face. These creams can cause skin irritation, burns or allergic reactions. Try a small area of skin first before you use it.

 

  • Waxing This method can also be more convenient and useful for larger areas of skin since it only has to be repeated about once every four to six weeks. It is usually used for the upper lip, eyebrows and bikini line. To avoid major skin irritation, first test a small area of skin.

 

  • Electrolysis — Expense is the issue here, but this is an effective way to get rid of hair. Sometimes you get lucky, and the hair follicle is destroyed and won’t grow back, but usually treatments have to be repeated. There is a higher risk of scarring with electrolysis than laser.

 

  • Laser treatment — The most permanent way to rid yourself of hair is the most expensive alternative. Because it can discolor skin, women with fair skin and darker terminal hairs tend to get the best cosmetic results.

 

  • Prescription medication — Vaniqa is a topical medication that is FDA-approved to prevent hair growth. The downside to this medicine is that it must be used daily and indefinitely to prevent hair growth. This can get costly, since most insurance providers will not cover this expense.

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Treating Hormonal Problems

If you find out from your doctor that you do have high levels of androgens, you have additional treatment options. Remember that with any of these treatments, it can take six months to a year to see a significant effect. Even when your hormone levels change, you have to wait for your current hairs to fall out. The hair's growth cycle can take three to six months.

  • Weight loss — For women who are overweight or obese, weight loss can lower androgen levels, slow hair growth and restore normal periods. Resuming normal ovarian function can further lower androgen levels.

 

  • Birth control pill — If your periods are irregular or absent, a birth control pill can help to restore your hormonal balance. As your hormone levels change, this may lower the androgens that stimulate hair development. Birth control pills have reduced hair growth in at least 60% of women with elevated androgen levels. You should avoid birth control pills that contain "norgestrel" or "levonorgestrel." Better progesterone options include norethindrone, desogestrel and norgestimate. Sometimes, a normal rather than a low-dose estrogen pill may be more effective.

 

  • Antiandrogens — Certain medications can block the effects of testosterone or lower its levels. Because any of these options could cause birth defects, they are only prescribed along with a birth control pill.
    • Spironolactone is a medication usually used to treat heart failure because it lowers fluid retention. It also interferes with testosterone's effects and can decrease the production of testosterone by the ovary. This is the only anti-androgen approved by the food and drug administration in the United States.
    • Additional treatments that have been studied include flutamide that is usually used in the treatment of prostate cancer and finasteride, a treatment used in benign prostatic hyperplasia (BPH). Flutamide may be more effective than spironolactone but has a potentially dangerous though rarely reported side effect of liver damage.

     

  • Treatment of polycystic ovarian syndrome (PCOS) — In the treatment of PCOS, metformin, a medication that improves insulin sensitivity has been shown to restore normal menstrual cycles, ovulation and fertility. As a result, it may normalize hormone levels, and hirsutism may also improve.

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Where to Go From Here

If you have any concerns about your body-hair growth or think you may need a hormonal treatment, you should first talk to your health care professional about being tested. Blood tests for abnormal hair growth include testosterone, SHBG (sex hormone binding globulin); DHEAS (dihydroepiandrosterone sulfate); FSH (follicle stimulating hormone); LH (luteinizing hormone); and prolactin. Since many women with abnormal hair growth and irregular periods have the condition PCOS, it is important to test for the diagnosis so that you can be forewarned about any potential infertility problems and understand your risks of diabetes and heart disease in the future. Taking action now could help you to avoid problems in the future.

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Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.

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