What is hirsutism?
Hirsutism is when a woman has excessive hair growth.
The hair is normally thick and dark and grows on the:
- face – for example, the upper lip and chin
- lower back
Read more about the symptoms of hirsutism.
Hirsutism is caused by an excess of male sex hormones called androgens or an increased sensitivity to androgens. In most cases, this is caused by polycystic ovary syndrome.
Read more about the causes of hirsutism.
Who is affected?
Hirsutism may affect one to three women in every 20 who have not yet started the menopause (when a woman’s periods stop).
After the menopause, the change in the balance of hormones can make excess hair more common. Up to three quarters of older women may have slightly increased facial hair. Hirsutism in post-menopausal women is also known as ovarian hyperthecosis.
Are there any treatments for hirsutism?
There is no cure for hirsutism, but there are treatments to manage the condition.
There are a number of hair-removal methods that may help, such as shaving, waxing or bleaching, although these can sometimes lead to irritated skin or inflamed hair follicles (folliculitis).
In some cases (in women who have not yet started the menopause), taking a contraceptive pill may control hirsutism.
There are also a number of unlicensed medications (medicines that have not been specifically tested for this purpose) known to be effective.
As the life cycle of hair is around six months, treatment can take this long to work so it is important to start treatment as soon as possible.
Read more about treating hirsutism.
Hirsutism can have a significant psychological effect on the person. If the excess hair is on the face, this can cause embarrassment and affect quality of life.
Hirsutism causes excessive hair growth in women. The hair is usually thick and dark, rather than fine and fair.
You may have excess hair on your:
- upper lip
- lower jaw (chin)
- tummy – in a line from your belly button down to your pubic hair
- anal and genital area
- the front of your thighs (the top of your legs)
Besides an excessive amount of hair, you may also have other symptoms, such as:
What causes hirsutism?
Hirsutism is caused by male sex hormones (chemicals produced by the body) called androgens. Androgens are present in all women, but those with hirsutism have either:
- an increased production of androgens, or
- an increased sensitivity to androgens
There are several different types of androgens. The most well known is testosterone. In men, testosterone is involved in making sperm and in the development of male sexual characteristics, such as the voice getting deeper. Testosterone is also found in small amounts in women, where it may:
- increase your libido (sex drive)
- affect your menstrual cycle (your periods)
- affect your fertility
Testosterone levels may be normal in around half of all women with hirsutism.
Other androgens include:
These are precursors of testosterone, which means they will go on to become testosterone.
The causes of hirsutism varies in women, depending on whether they are premenopausal or menopausal.
These terms and possible causes are explained below.
Premenopausal means before you have started the menopause (when a woman’s periods stop). There are a number of different causes that may explain hirsutism in premenopausal women.
Polycystic ovary syndrome (PCOS)
Most of the excess androgen activity in premenopausal women is because of an underlying condition known as polycystic ovary syndrom (PCOS).
PCOS is a condition in which women have a number of small cysts (fluid-filled sacs) around the edge of their ovaries (the pair of reproductive organs that produce eggs and sex hormones in females). As well as causing excessive hair growth, PCOS can also cause:
- irregular periods
- weight gain
Many women with PCOS have an imbalance of male sex hormones, such as high levels of testosterone, but it is not known what causes this.
Just under a quarter of premenopausal women with hirsutism have normal androgen levels. It is thought that if your androgen levels are normal, your hirsutism may be caused by an increased sensitivity to the androgens.
This means although you have the same amount of these hormones, you are more sensitive to them and they have a greater effect on your body.
In a small number of cases, hirsutism in premenopausal women may be caused by:
- Cushing’s syndrome – a rare hormonal disorder that causes sudden weight gain and bloating around the chest and stomach
- congenital adrenal hyperplasia – an inherited condition that affects the adrenal glands (two glands above the kidneys that produce steroid hormones and male and female sex hormones)
- a tumour (growth) that produces androgens
- medicines – such as anabolic steroids (drugs that are often used illegally to build muscle and improve athletic performance)
- acromegaly – a hormonal disorder that causes the body to produce too much growth hormone, causing abnormal growth of the hands and feet
- being overweight or obesity – you will be advised to lose weight
In around 10% of cases of hirsutism, there are no obvious causes. This is known as idiopathic hirsutism.
Menopausal women are those who have started the menopause (when a woman’s periods stop) and have not had a period for a year. During the menopause, several of your body's hormones change, which can cause symptoms such as hot flushes.
In some women, as your hormone levels change, you will be left with a high amount of testosterone (an androgen), which can cause hirsutism. Hirsutism in post-menopausal women is also known as ovarian hyperthecosis.
If you think you have hirsutism, see your doctor as soon as possible. Hirsutism is a common problem which is easily treated.
Your doctor will look for excessive amounts of hair on your body, including on your:
- thighs (upper legs)
As some people have more hair than others anyway, there is no clear definition of when excess hair becomes hirsutism. However, if your excess hair is thick and dark instead of fine and fair, then you may have hirsutism.
Assessing the severity
Your doctor may assess the severity of your hirsutism by grading the growth of your hair in different areas of your body. This will be done by:
- looking at the hair growth in nine different body areas, including the upper lip, chin, chest and upper arms
- grading this hair growth from zero to four, with zero meaning no hair and four meaning heavy hair growth
This will then give you a score from zero to a maximum of 36. Generally, a score above 15 is considered moderate to severe hirsutism.
Finding the cause
As well as diagnosing hirsutism and assessing its severity, your doctor will try to find out if there is an underlying cause (see Hirsutism – causes). They may ask if:
- you have other symptoms, such as irregular periods or weight gain – these can be signs of polycystic ovary syndrome (PCOS – a condition that causes a number of symptoms, including cysts in your ovaries)
- your hirsutism has come on suddenly – this may a sign of a tumour (growth)
- you are taking any medication that may cause hirsutism
If your symptoms suggest another condition is causing your hirsutism, you may need further tests, such as:
- a blood test to check your levels of testosterone (the male sex hormone)
- an ultrasound scan (when high-frequency sound waves are used to create an image of your womb) to look for cysts (fluid-filled sacs) if your doctor thinks you may have PCOS
- testing a urine sample for the stress hormone cortisol if your doctor thinks you may have Cushing’s syndrome (a rare hormonal disorder)
If you do not have any other symptoms and your hirsutism is mild, then further tests are not usually necessary.
Treatment for hirsutism
Hirsutism can't be cured, but there are treatments to help control the condition.
There are a number of things you can do yourself which may help. If you are overweight, losing weight can reduce the production of androgens.
Hair removal and treatment
There are a number of ways to remove or disguise excess hair.
Shaving – quick and easy and will not make the hair grow back quicker or thicker. However, you may find you have to shave everyday, it may cause irritation and there is unpleasant stubble growth between shaves.
Bleaching – can make dark hair look better in the short term, but may irritate your skin and is not effective for everyone.
Waxing, plucking or threading – can reduce regrowth if done regularly, but can be painful and may cause scarring or folliculitis (inflammation of a hair follicle).
Electrolysis – when electricity is used to destroy hair cells and remove hair permanently. However, it takes many treatments over a long time, it can be painful and may cause scarring or changes to your skin colour.
Laser hair removal – involves powerful beams of light (lasers) which destroy the hair. It can last several months and is more effective on women with pale skin and dark hair.
Your doctor can discuss the different methods with you in more detail if you wish. The method that you choose will depend on:
- what works for you – if your skin becomes irritated because of one of these hair-removal methods, it can be itchy, look unpleasant and make regrowth worse
- what you can afford – electrolysis and laser hair removal may only be available in specialist clinics
If your hirsutism is mild, hair-removal methods may be all the treatment you need. However, if the hirsutism is affecting your quality of life, you may require further treatment, such as medication.
If your hirsutism requires further treatment, you may be prescribed contraceptive pills. These are only suitable if you have not yet started the menopause (when a woman’s periods stop).
You may be prescribed:
- a combined oral contraceptive or
Both of these may take at least six months to work. This is because hairs that have already grown live for around six months anyway.
Combined oral contraceptive
Combined contraceptive pills that contain drospirenone, such as Yasmin, suppress androgens (male sex hormones), therefore they can be used to treat hirsutism. Drospirenone is anti-androgenic, which means it prevents the androgens from working and so prevents excess hair growth.
Combined oral contraceptive pills are usually the first choice of treatment in premenopausal women, and are particularly useful if long-term treatment is necessary.
Co-cyprindiol is a contraceptive pill that contains ingredients that make it anti-androgenic (prevents the androgens from working). It is used to treat both acne (a skin condition that causes spots) and hirsutism.
Once the medication has treated your hirsutism, you should stop taking co-cyprindiol after three or four more 28-day cycles. This is because the risk of venous thromboembolism (a blood clot in a vein) is higher if you are taking co-cyprindiol than with other types of oral contraceptives.
Co-cyprindiol will not be suitable for you if you or anyone in your close family has a history of blood clots.
If your hirsutism returns after you stop taking co-cyprindiol, your doctor may recommend starting treatment with it again. Alternatively, you can try changing to a combined contraceptive pill.
Both combined contraceptive pills and co-cyprindiol can cause side effects, including:
- changes in body weight
- breast tenderness
- mood changes, such as irritability or a low mood
- nausea (feeling sick)
Eflornithine is an alternative medication that can be prescribed to both premenopausal women and menopausal women (women who have started the menopause). You may be prescribed eflornithine if:
- you have mild excess hair growth on your face
- hair-removal treatments alone are not effective
- contraceptive pills are either not suitable for you or have not worked
Eflornithine is a cream that can be applied thinly to your face twice a day to slow hair growth.
It should be thoroughly rubbed in and you can wear make-up on top if you wish. However, you should not wash your face for at least four hours after applying the cream.
Eflornithine acts on your hair follicles (the small hole in your skin that an individual hair grows out of) to prevent hair growth. You should notice an effect within six to eight weeks. If no benefit is seen after four months, treatment will be stopped.
If eflornithine works then you will need to continue using it, as hair growth will return around eight weeks after you stop using it.
Eflornithine is not suitable if you are pregnant or breastfeeding.
Eflornithine can cause side effects, including:
- a burning or stinging sensation when you apply the cream
- acne (a skin condition that causes spots)
Your doctor may refer you for further treatment with a specialist, such as an endocrinologist (a specialist in hormone conditions), if:
- treatment has not worked after 6 to 12 months
- the hair growth gets worse despite treatment
If your doctor suspects an underlying cause for your condition (see Hirsutism – causes), they may also refer you to a specialist. For example:
- a high level of testosterone in your blood or hirsutism that comes on quickly may indicate a tumour (growth) – your doctor may therefore refer you to an oncologist, a doctor who specialises in treating tumours
- sudden weight gain around your face may be a sign of Cushing’s syndrome, a rare hormonal disorder – your doctor may then refer you to an endocrinologist
There are several other medications used to treat hirsutism. However, because many are unlicensed for the treatment of hirsutism, they will only be prescribed by a specialist, not your doctor.
Unlicensed medication means manufacturers of the medications have not applied for a licence for it to be used in treating hirsutism. In other words, the medication has not undergone clinical trials (research that tests one treatment against another) to see if it is effective and safe in the treatment of hirsutism.
Many specialists will use an unlicensed medication if they think it is likely to be effective and benefits of treatment outweigh any associated risk. If your specialist is considering prescribing an unlicensed medication, they should tell you it is unlicensed, and should discuss possible risks and benefits with you.
Some possible alternative medications are explained below.
Anti-androgens are medications that suppress androgens, which means they prevent androgens from working which prevents excess hair growth. Possible types of anti-androgens include:
- cyproterone acetate
Some of these may be prescribed in combination with contraceptive pills (see above).
One review of a number of different studies found weak evidence to suggest that anti-androgens are effective for treating hirsutism. The review also suggested anti-androgens may work best when combined with other medication, such as contraceptive pills.
Side effects were not reported in the studies that this review looked at.
Finasteride is a type of medication known as a 5-alpha-reductase inhibitor. It works by preventing testosterone (an androgen) from turning into a stronger form of testosterone inside your body’s cells. Finasteride is normally used in men to treat an enlarged prostate gland (a small gland, found only in men, located in the pelvis).
When finasteride is taken for its usual purpose (to treat men) it can cause side effects, such as:
- lip and facial swelling
- decreased sex drive
- breast tenderness
Few side effects have been reported when finasteride is used in women, so the above may not apply.
Insulin-sensitising medication makes your body more sensitive to insulin. Insulin is a hormone produced by the pancreas, a gland located behind the stomach.
A high amount of insulin in the blood (hyperinsulinaemia) is thought to play a role in causing hirsutism. Because insulin-sensitising medication makes your body more responsive to insulin, your body does not need as much insulin and so produces less of it. The level of insulin in your blood should therefore fall, and your hirsutism may improve.
Possible insulin-sensitising mediations include:
So far, there is only limited research into the benefits of insulin-sensitising medication for hirsutism. Some research found a small benefit, while some suggested that insulin-sensitising medication is no better than alternative medications already available. Conclusions may change in future if more long-term studies are carried out.
Gonadotrophin-releasing hormone (GnRH) analogues
Gonadotrophin-releasing hormone (GnRH) analogues are synthetic (man-made) hormones. They are used to treat hormone-related conditions, such as endometriosis (a condition in which small pieces of the womb lining are found outside the womb).
Possible GnRH analogues include:
These may causes side effects, such as:
- hot flushes
- dryness or bleeding of the vagina
For a full list of side effects, see the patient information leaflet that comes with your medication.
Complications of hirsutism
As well as the physical signs of excess hair, hirsutism can cause psychological (mental) harm including depression, embarrassment and lack of self-confidence.
It is important to see your doctor if you have hirsutism as there are a number of treatments you can try (see Hirsutism – treatment).
Folliculitis is inflammation (redness and swelling) of a hair follicle (the small hole in your skin that an individual hair grows out of). This can cause painful spots to form at the site of the follicle. The following hair-removal methods may cause folliculitis:
Folliculitis may take a few weeks to resolve, and may mean that you cannot continue removing hair until it has cleared up.