Hirsutism

Symptoms Of Hirsutism

Hirsutism is a condition in which stiff or dark body hair appears on those body parts where women usually do not have hair. These areas include face, chest, lower abdomen, inner thighs, and back. Hirsutism is caused by high levels of androgen or male sex hormones. It can be accompanied by various other symptoms like:

• Decreased breast size

• Enlarged ovaries

• Enlarged shoulder muscles

• Acne

• Oily skin

• Enlarged clitoris

• Irregular periods

• Deepening of voice

Causes Of Hirsutism 

Increased levels of androgens (male sex hormones such as testosterone) or oversensitivity of the hair follicles to androgens can cause hirsutism.The conditions that can cause hirsutism include: 

Polycystic ovarian disorder (PCOS)

• Infertility
• Acne
• Mood changes
• Pelvic pain
• Headaches
• Sleep problem
• Weight gain/ obesity 

Genetic disorder

A group of genetic disorders that affect the adrenal glands (a pair of walnut-sized organs above the kidneys) like congenital adrenal hyperplasia can cause hirsutism.

Adrenal and ovarian tumor

Tumors of the adrenal glands, pituitary glands, and ovaries can sometimes lead to hirsutism. In the rare group of ovarian and adrenal tumors female sex hormone levels are often suppressed to or below the lower limit of normal, while the levels of androgen in the circulation is twice the upper limit of normal or higher. 

Idiopathic hirsutism 

Hirsutism with normal androgen levels is called idiopathic hirsutism. Idiopathic Hirsutism may be due to increased sensitivity to androgens. A typical example is familial Hirsutism, a typical symptom of this is a gradually increased growth of rough facial hair. 

Cushing’s syndrome 

Cushing syndrome is a sign of very long exposure of cortisol. Cortisol is a steroid hormone and its level is increased in case of high levels of stress and low blood glucose concentration. Along with excessive hair growth, some visible signs are having a big stomach but thin arms and legs. It can also lead to abnormal weak muscles, weak bones, breakouts, and sensitive skin.

Increased sensitivity to Androgens

Under a quarter of premenopausal women who have hirsutism have normal androgen levels. This happens due to increased sensitivity to androgens.

Certain medications

The following medications can lead to excessive hair growth or hirsutism:

• Anabolic steroids
• Testosterone
• Glucocorticoids
• Minoxidil
• Cyclosporine
• Phenytoin
• Diazoxide
• Progestin-containing medications

Risk Factors 

Several factors can influence your likelihood of developing hirsutism, including

Family history 

Several conditions that cause hirsutism, including congenital adrenal hyperplasia and polycystic ovary syndrome, run in families.Up to 50% of women with hirsutism have a family history of the disorder. 

Regional differences 

Women of Mediterranean, Middle Eastern, and South Asian ancestry are more likely to have more body hair with no identifiable cause than are other women.

Obesity 

Obesity or being overweight can cause an increase in androgen production, which can lead to hirsutism.

Diagnosis Of Hirsutism 

Medical history 

• A physician will look at the detailed medical history with a special focus on the menstrual cycle.

• Detailed history includes the age of onset of hirusitsm (puberty, middle age, menopause), rate of onset of symptoms (gradual or sudden), and any other signs or symptoms (acne, deepening of voice, infrequent menstruation, loss of breast tissue, increased muscle mass as in shoulder girdle, malodorous perspiration, etc). 

• The doctor will also inquire about the history of weight gain or diabetes and whether a drug history prior to onset should be taken.

Physical examination

Complete general physical examination is done including the palpation of the abdomen for any ovarian mass.

To evaluate hirsutism in females, the Ferriman-Gallwey score is used to measure the amount and location of the hair. The score is used to determine whether a patient’s hirsutism is considered mild, moderate, or severe. Ferriman–Gallwey Scoring System for Hirsutism evaluates the extent of hair growth (score 0-4) in 9 areas of the body. A score of 8-15 is mild, score >15 is moderate/severe. This score can be helpful in determining response to treatment.

Lab tests 

• Testosterone: Serum testosterone may be normal or elevated in case of PCOS (polycystic ovarian syndrome) and CAH (Congenital adrenal hyperplasia) but is significantly raised (>200 ng/ml) in case of malignant tumor of the adrenal or ovary.

• Dehydroepiandrosterone sulfate (DHEAS): DHEA stands for dehydroepiandrosterone. This is a hormone produced by the adrenal glands which are located above the kidneys. A raised DHEAS (>700 μg/dl) always indicates an adrenal cause, benign or malignant.

• 17 Hydroxy progesterone: This serum marker is unique for congenital adrenal hyperplasia.

• Cortisol: Cortisol is measured for those having signs and symptoms of Cushing's syndrome. Cushing syndrome occurs when the body makes too much of the hormone cortisol. 

• Serum Thyroid-stimulating hormone (TSH): Serum TSH is usually regarded as a marker of thyroid function. TSH is responsible for the synthesis and secretion of thyroxine (T4) and triiodothyronine (T3) by the thyroid gland. Hypophyseal hypothyroidism (a condition resulting from decreased production of thyroid hormones) can act as a cofactor in hirsutism causing raised TSH levels. 

• Prolactin: A prolactin (PRL) test measures the level of prolactin in the blood. Prolactin is a hormone made by the pituitary gland, a small gland at the base of the brain. High levels of prolactin may induce hirsutism via several mechanisms.

• LH/FSH (Luteinising hormone to follicular stimulating hormone): Luteinising hormone and follicular stimulating hormones play an important role in sexual development and functioning. The change in the LH to FSH ratio can disrupt ovulation. This ratio can be a useful indicator in diagnosing PCOS. 

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Imaging tests 

• Pelvic ultrasonography: A pelvic ultrasound is a test that uses sound waves to take pictures of the organs inside your pelvis. It is a noninvasive diagnostic exam that produces images that are used to assess organs and structures within the female pelvis. This test can be useful in detecting an ovarian neoplasm or a polycystic ovary.

• Computed tomography (CT) /Magnetic resonance imaging (MRI) of abdomen or pelvis: These imaging technologies create three-dimensional detailed images of the organs and tissues of the abdomen or pelvis.

Prevention Of Hirsutism 

Though, hirsutism cannot always be prevented, the following measures can control the causative factors of excessive hair growth like PCOS:

Maintaining a healthy weight

PCOS can be managed by losing weight. It can also improve reproductive health,lower the risk of heart disease and make it easier to manage diabetes. 

Exercising regularly

Burning more calories while reducing the number of calories you eat creates a calorie deficit. Exercise can help prevent excess weight gain and help maintain healthy weight. This in turn helps in maintaining the hormonal balance in the body. 

Eating a well-balanced diet

A well balanced diet should include high-fiber foods, lean proteins (skinless chicken and fish), and healthy fats (coconut, olive, and fish oils). Dairy, sugar, processed, baked and junk foods should be avoided. Foods like wheatgrass, barley grass, and spirulina, can help manage PCOS and hence prevent hirsutism.

Managing stress 

Too much stress can result in weight gain, difficulty losing weight and elevated levels of cortisol, which all predispose to excessive hair growth. Consider chatting with friends, doing a hobby, trying yoga, listening to music, journaling, or whatever else eases your stress levels.

Getting regular and adequate sleep

Adequate sleep can help in managing your stress and anxiety level. Including long walks in nature, yoga or meditation, switching off electronic devices at least two hours before sleeping can ensure sound sleep. 

Specialist To Visit

Sometimes it is difficult to diagnose the cause of hirsutism, a general practitioner may be concerned with the cause of the issue. The general practitioner can further suggest other doctors according to the needs of the patient. 

• Endocrinologist: Specializes in the function and disorders of the endocrine system of the body. The doctor will help you with managing conditions like congenital adrenal hyperplasia and will also help with managing associated conditions such as diabetes. Once the underlying cause is treated, the hirsutism will gradually disappear.

• Dermatologists: Specializes in the study of the skin and its disorders. In the case of familial hirsutism, which means excessive hair growth runs in your family’s genes, an appointment with a dermatologist can be taken. 

• Psychologist: If a person experiences any psychological issues such as anxiety or depression, a person may be referred to a psychiatrist for medical support. 

• Dietician: If a person is having obesity issues, you can discuss how to maintain a healthy weight and work on a nutrition plan together with a dietitian.

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Treatment Of Hirsutism 

Lifestyle modifications are first-line treatments in women with polycystic ovary syndrome, particularly if they are overweight. It has been shown that obese women with polycystic ovary syndrome who manage to lose more than five percent of their initial body weight have a significant improvement in their biochemical profile, including a reduction of testosterone, an increase in sex hormone-binding globulin, and an improvement in their Ferriman-Gallway scores. 

All medical therapies require a minimum of 8 weeks before the noticeable result appears. 

Cosmetic therapies (temporary solution)

Most women adapt to the removal of hair by different epilation methods, such as plucking, shaving, and waxing before presenting to the clinic. Though these methods are simple and inexpensive, these methods are temporary and have side effects like physical discomfort, scarring, irritant dermatitis, and discoloration.

Electrolysis (50% efficacy)

Hair follicles are damaged by inserting a needle that emits a pulse of electrical current into each hair follicle. With repeated treatments, the efficacy ranges from 15 to 50% permanent hair loss. However, it is difficult to treat large areas like hairs on the chest or upper back with electrolysis and it can be time-consuming.

Laser hair treatment (80% reduction)

Lasers have gained wide popularity in the past two decades and can achieve permanent reduction of hair (not removal). 

Laser therapy works on the principle of selective photothermolysis where the laser energy acts specifically to destroy the target (melanin) and it acts specifically on anagen hair follicles. Therefore, multiple treatments are required to get a significant (i.e. 80%) reduction. An ideal candidate for laser hair removal is a patient with light skin color and dark-colored hair. 

The possible side effects like skin irritation, swelling, and redness can be explained by the dermatologist.

 Mostly used lasers  are the 755-nm alexandrite laser, 800-nm diode laser, and 1064-nm Nd: YAG laser and pulsed light sources

Medications

Before starting any medications, the right diet and exercise are advised for all women with PCOS. For all obese women, weight loss as a therapy should be advised. The drugs usually used in the treatment of hirsutism are:

1. Oral contraceptive pills (OCP): OCP is the first-line treatment for hirsutism, particularly in women desiring contraception. These estrogen/progesterone combinations act by 

• Reduction of gonadotropin secretion and thereby reducing ovarian androgen production.
• Inhibiting adrenal androgen production.
• Increasing levels of SHBG (Sex hormone-binding globulin, which is a protein that binds to the sex hormones testosterone and estrogen) resulting in lower levels of free testosterone.

Various drugs used as OCPs are:

• Ethinyl estradiol 

• Norgestimate

• Desogestrel

• Norethindrone

• Ethynodiol diacetate 

• Drospirenone

2. Anti- androgen therapy

• Spironolactone (SPA):  It is an androgen blocker and competes with Dihydrotestosterone (DHT) (a sex hormone created from testosterone in the body) for binding to the androgen receptor. Spironolactone is more effective in treating hirsutism when combined with Oral Contraceptives, because, together, these drugs have complementary anti-androgenic actions. 
• Cyproterone acetate (CPA): It has strong progestogenic and anti-androgen properties. It produces a decrease in circulating androstenedione (androstenedione is a precursor of testosterone and other androgens) levels and has been used as an effective treatment for hirsutism. However, CPA has steroidal side effects and can cause abnormalities in liver function and menstrual irregularities.
• Flutamide: It is used primarily in the management of prostate cancer, but has been used off-label for managing hirsutism.

Note: Although anti-androgens are an effective therapy for hirsutism, their use is not suggested because of the potential adverse effects on a developing male fetus in the uterus. However, in women who cannot conceive, or who are using a reliable contraceptive method, anti-androgens may be considered for monotherapy.

3. 5-alpha-reductase inhibitors (5-RA inhibitors) 

Finasteride, a 5-alpha reductase inhibitor, is effective in the treatment of Idiopathic hirsutism (IH). 

4. Gonadotropin-releasing hormone (GnRH agonists) 

This therapy is reserved for women with severe hirsutism who don't respond to oral contraceptives (OC) and antiandrogens. GnRH analogs reduce ovarian stimulation, estrogen production, and hence testosterone. This therapy is used in combination with an oral contraceptive pill containing estrogen and progestin. An example of this class of this drug is leuprolide acetate.

5. Corticosteroids

Glucocorticoids: The main use of corticosteroids (dexamethasone and prednisone) has been to treat hirsutism associated with congenital adrenal hyperplasia .

6. Biological modifiers 

• Topical eflornithine hydrochloride: This is a new agent, which is used as a topical cream for decreasing or arresting facial hair growth in women. It is thought to inhibit hair growth by inhibiting an enzyme involved in keratin synthesis. Gradual improvement is seen in six to eight weeks. It can also be used in combination with laser treatments for better effects.
• Insulin lowering agents: Insulin-sensitizing agents may improve hirsutism by reducing insulin levels and, therefore, circulating free and biologically active androgens. An example of this drug is metformin.

Home-care For Hirsutism

Home remedies

• Spearmint tea (pudina): This tea is among the best natural remedies for hirsutism. Drinking spearmint tea regularly is shown to have a strong anti-androgenic activity which can help manage hirsutism.

• Zinc: Zinc works by blocking an enzyme involved in testosterone metabolism that causes excessive and unwanted hair growth. Some of the sources of zinc include chickpeas, pumpkin seeds, yogurt, beans, beef, chicken, and oyster. 

• Cinnamon (dalchini): It is one the best natural remedies for hirsutism. In women with PCOS, it is known to improve insulin sensitivity and lipid profile. 

• Folic acid: It helps in balancing the levels of homocysteine, which is a common amino acid found in the blood. This is also helpful in improving reproductive health.

• Licorice (mulethi) tea: One of the main compounds of the tea, glycyrrhizic acid, has proven to be effective in halting hair growth for those suffering from unwanted hair growth.

• Flax seeds (alsi): Flax seeds can cause reduction in Body Mass Index (BMI), total serum testosterone, and free serum testosterone levels, leading to decrease in excessive hair growth.

• Astragalus polysaccharide: Astragalus polysaccharides can be effective in improving insulin resistance, high androgen hormone status, and lipid metabolism in patients with PCOS.

Alternative Therapies For Hirsutism 

Diet 

• Reduce calorie intake, especially during the evening. Distribute calorie intake into 5 to 6 meals per day. This keeps the weight under control and reduces the chances of obesity and hence, hirsutism.

• Eat foods with a low glycemic index (GI) that do not increase blood glucose levels sharply such as non-starchy vegetables and legumes. Include at least 20g of protein with every meal like eggs, chicken, fish, shellfish, and turkey.

• Drink lots of fresh, filtered water between meals, about half your body weight in ounces per day

• Increase your intake of vitamin B, especially B2, B3, B5, and B6.

• Avoid trans fat. Eating foods with trans fat contributes to issues such as hormonal imbalance and symptoms like hirsutism. Trans fat is found in packaged processed foods such as cookies, cakes, unhealthy vegetable oils, pastries, and crackers replace these with healthy fats like avocado oil, nuts, and seeds. 

Acupuncture 

Acupuncture is a traditional Chinese medicine technique that involves sticking finely pointed needles in areas of the body known as acupuncture points. It has shown promise in management of excessive hair growth.

Yoga and exercise 

Doing yoga and exercises regularly can help improve blood circulation, help the body to feel fresh and prevent it from feeling fatigued all the time. They are useful in reducing stress or pressure on the body and have also proven to relieve stress, manage anxiety, and pain management.

Hot water bath 

A hot water bath has muscle relaxant properties, the heat from the water can improve the blood circulation in the body and also ease tension in the muscles. 

Living With Hirsutism 

Self-management can help in taking care of yourself. 

• Know about your condition: Sometimes hirsutism can affect the mental health of a person and it can lead to anxiety and depression. Talking to your near and dear ones can eliminate cases of emotional drainage and thus an effective treatment plan. 

• Exercising daily: It increases the blood circulation of the body and frees the mind from tension and stress. 

• Take your medicine on time: Medicines if prescribed, should be taken regularly under medical supervision.

• Talk with a doctor openly in case of any questions related to the issues faced: Feel free to ask as many questions that come to his mind. 

• Lower stress levels: Practicing meditation and yoga help in eliminating stress and keeps the person happy. 

• Take adequate sleep: Sleep activates and calms the body and mind. This makes the person feel less fatigued.