Hirsutism

Hirsutism- the body hair dilemma

Many women are bothered by what they consider to be an excessive or unwanted amount of body hair. In westernised countries such as Australia, women have often become used to the idea that having minimal facial and body hair is more attractive. As a result, many women use a range of cosmetic techniques to hide or remove unwanted hair.

Body and facial hair growth is mostly a result of our genetics and varies a great deal between racial groups and individuals.  In Australia there are many ethnic communities and there are large differences between these ethnic groups as to what is considered to be normal or desirable. In countries where standards of dressing for women is liberal, where the weather is warm and activities like swimming are common, having dark hair growth on one’s upper thighs, abdomen or back can cause embarrassment, low self-esteem and restrictions in lifestyle. For most women, unwanted facial hair generates the greatest anxiety.

What is normal body hair?

The number of hair follicles each woman has is genetically programmed before birth. Hair follicles exist on every part of the body except lips, palms and soles of the feet. Most of our body hair is fine and uncoloured. Hair growth is controlled by our sex hormones, with androgens, for example testosterone, mainly being responsible for stimulating hair growth and increasing the darkness of body and facial hair. Hair follicles in certain parts of the body are more sensitive to the effects of androgens. We call these areas “androgen-sensitive” areas of the body. These areas include the upper lip, chin, lower abdomen and pubic region, upper arms and inner thighs. Androgen levels speed the growth of hair as well as increase the thickness and darkness of hairs.

The term hirsutism is used to describe the growth of excessive, thick, dark hair in women in a pattern not considered normal for women. For some women this is simply genetic and their blood hormone levels are completely normal. Other women may have elevated androgens such as testosterone circulating in their blood causing their increased hair growth.

Women experiencing excess body hair that is more than a minor cosmetic nuisance should seek medical advice to exclude an underlying hormonal problem. This is more likely if a woman is also experiencing acne and/or irregular periods. A sudden increase in hair growth may be a cause for concern and indicates the need for medical assessment. However most women with hirsutism do not have a specific hormonal abnormality.

Hirsutism is a common feature of a condition called polycystic ovarian syndrome which may be linked to obesity and diabetes. Polycystic ovarian syndrome (PCOS) is the most common medical condition underlying excessive hair growth in women. The ovaries in this instance are not actually full of cysts but have an increased number of follicles which appear as mini cysts as a result of failed ovulation. Women with PCOS tend to over-produce testosterone. (See information sheet on PCOS).

A much less common medical condition causing excessive body hair growth is congenital adrenal hyperplasia. This is an inherited condition usually diagnosed in childhood but may become apparent later in life. It is more common in certain ethnic groups and is diagnosed with specific blood tests.

Fortunately ovarian and adrenal tumours producing abnormal quantities of androgens are rare. They are usually associated with a sudden and significant increase in hair growth and other symptoms such as acne or voice deepening.

What tests should be done?

Women with mild to moderate increased hair growth that has developed very gradually and who have regular periods do not need any investigations. Women with more severe hirsutism and regular periods should have their blood androgen profile checked. Women with irregular periods, or who have stopped menstruating, need more extensive testing, including an ultrasound to evaluate the appearance of the ovaries.

Management of hirsutism

In the absence of any underlying medical problem the aim of any treatment for hirsutism is to achieve an acceptable cosmetic outcome. Women with PCOS may require therapy specific to PCOS management.

Common cosmetic approaches include bleaching with peroxide, heavy makeup, shaving, plucking, waxing and depilatory creams. These methods are time consuming and may be expensive. They are effective for mild forms of hirsutism, but for patients with moderate to severe hirsutism their effects are only temporary. Problems with such treatments include skin irritation from bleaches and depilatory creams, infection around the hair follicles with plucking, burns from waxing and the development of stubble after shaving.

Both electrolysis and laser therapy require trained personnel to provide treatment.  Treatments need to be repeated and are expensive.   Electrolysis may be rapid and cost effective where the hair density is sparse. Laser therapy allows larger areas to be treated over a short time period.

Electrolysis

Electrolysis produces permanent destruction of the hair. A benefit compared with laser treatment is that it can be used on both dark and light skinned patients and those with fair hair. It may be painful. Side effects of redness and swelling are generally temporary. Acne and ingrown hairs may occur and inflammation may cause changes in the skin colour. Scarring may occur in certain patients. Success depends on the skill of the operator.
 People with pacemakers should not undergo electrolysis.

Lasers and Intense Pulsed Light (IPL) treatment

Laser and light source treatment target melanin (pigmentation) in the hair bulb which absorbs the light emitted by the laser or light source. This light energy changes into heat causing destruction of the hair bulb. If adjacent skin is also dark, the laser energy is absorbed into the surrounding skin. This may cause damage to the skin or it may interfere with absorption of the laser into the hair bulb so that hair destruction is less effective. So, fair skinned individuals with dark hair will absorb more light directly into the hair bulb and will get a better result. White or gray hair is a poor target for laser treatment.

There is evidence to suggest that some lasers produce a short-term effect of reducing hair growth by about half for up to six months after treatment.

The most common side effects are redness and swelling which usually resolve within 24 hours after treatment. It can be mildly painful because of the heat energy created. Other side effects may include an increase or decrease in skin colouring.

Medical treatments

Eflornithine cream (Vaniqa) is a cream which slows hair growth. It is available in Australia by prescription for delaying re-growth of unwanted facial hair in women following depilation such as waxing or plucking. It is applied twice daily to facial areas such as the upper lip or chin.

Studies following women for up to six months indicate that Vaniqa cream significantly reduces hirsutism in women with unwanted facial hair. Vaniqa works in two out of three women after about six to eight weeks of treatment. It works in women with light or dark hair and with light or dark skin colouring.

Because it is effective within a few weeks it works well with other treatments. Combining Vaniqa and laser therapy to treat hirsutism makes the laser more effective. Hair growth returns to its normal rate about 8 weeks after stopping the treatment. Side effects are few but may include acne, local skin irritation and rash. It must not be used in if you have severe kidney disease and is not recommended during pregnancy and breast feeding.

Oral Pharmacological Agents

Pharmacological (drug) treatment is recommended when hirsutism is severe or when cosmetic measures have failed.  Six to twelve months of any treatment is necessary to decide if it is effective. The drugs are only effective when they are used and the benefits fade when they are discontinued. A good way to tell if treatment is effective is to see if cosmetic hair removal (such as waxing or plucking) is reduced during treatment.

Medical treatment can be divided into two main categories–drugs that reduce production of the androgen hormone and medications that block androgen action - these are called anti-androgens. As these medications decrease the effect of androgen (testosterone) action, reduced libido is a common unwanted side effect

Oral Contraceptive Pill (OCP)

The OCP is ideal for women requiring regulation of their periods or contraception. The OCP stops eggs being released by the ovaries. This reduces the production of the androgen hormone and can reduce hair growth. There are oral contraceptive pills that contain a hormone with specific anti-androgen activity, and these have been shown to reduce hair growth over six months.

Cyproterone acetate

Cyproterone acetate can be taken in a low dose as part of an OCP or alone in postmenopausal women. In women with acne and minimal hirsutism, the low dose in the OCP (2mg/day) may be adequate, but women with
moderate to severe hirsutism usually require higher doses to achieve a satisfactory response . The most common side effects include lowered libido, diarrhoea, nausea, weight gain, breast tenderness, and headache.

Spironolactone

Spironolactone is often used first in treating hirsutism, being as effective as cyproterone acetate. The recommended starting dose is 100mg twice a day and should be continued for at least six to twelve months to achieve the best outcome. In women with regular periods spironolactone may cause irregular bleeding, whereas in women with irregular periods, menstrual regularity may occur. If necessary, menstrual cycles can be regulated by also using an oral contraceptive pill.

Flutamide

Flutamide has been shown to be as effective as cypterone acetate and spironolactone, reducing hair growth by seventy percent after a year of treatment. In high doses liver damage is a rare side effect. This has not been seen in the much lower doses commonly used for treating women with hirsutism.  Flutamide is not currently available for the treatment of hirsutism in Australia.

Finasteride

Finasteride blocks the conversion of testosterone to a more potent form. In one study hair growth was reduced by almost half after 6 months of treatment, and when combined with an OCP the effects were greater. It is not clear if finasteride is as effective as spironolactone, cyproterone acetate or flutamide. Side effects with finasteride have not been commonly reported but may include headache, depression, breast tenderness and decreased libido. Women who may become pregnant should not use finasteride as it can cause genital abnormalities in the male fetus.

Conclusion

Excessive hair growth is a common problem for women. Cosmetic management is sufficient for most women but medical treatment is an option when hair growth is severe. For most women drug treatment is only a temporary measure while a long-term cosmetic program is established.