Red flag symptoms: Hirsutism

There are a number of possible causes for this symptom, explains Dr Pipin Singh

Hirsutism is more common in dark-haired women (Photograph: SPL)
Hirsutism is more common in dark-haired women (Photograph: SPL)
  • Menstrual irregularities
  • Inability to conceive
  • New-onset headaches and changes in vision
  • Galactorrhoea
  • Signs of virilism (for example, deepening voice)
  • Abdominal pain, bloating or distention

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Hirsutism can be very embarrassing for female patients and needs to be handled empathically and sensitively. It has a number of possible aetiologies.

A detailed exploration of the patient’s thoughts, fears and feelings about their problem will allow you to tailor your management plan.

Patients who present with this symptom may have carried out online research and formulated their own plan about what they think should be done.

Possible causes
  • Idiopathic
  • Familial
  • Polycystic ovary syndrome
  • Drugs, such as steroids
  • Prolactinoma
  • Acromegaly
  • Ovarian tumour
  • Adrenal tumour


Establish how long the patient has noticed the excessive hair growth, where on the body it is and how rapidly it is progressing.

It is important to know about symptoms, such as headaches, visual field changes, galactorrhoea, menstrual irregularities, excessive weight gain, neck swellings, mood changes and any difficulty conceiving. Other key questions are:

  • Has there been any abdominal pain, bloating or distention?
  • Have there been any features of virilism, such as deepening voice or changes in external genitalia?
  • What drugs is the patient taking?
  • Is there a family history of any similar problems and if so, was a diagnosis made?
  • Does the patient smoke, drink alcohol or use recreational drugs?

Establish why the patient has presented now and how this symptom is affecting them on a daily basis. Ask if their work is being affected.


Examination will be guided by the history and will include:

  • Examination of areas that are affected by excess hair
  • BP
  • BMI
  • Confrontational visual fields
  • Pupillary examination
  • Neck examination for goitre if relevant
  • Suspected ovarian pathology may warrant abdominal examination and bimanual examination  
  • Other examinations, if rarer causes are indicated, may involve examination of the female genitalia or signs of Cushing’s syndrome


Investigations to consider in primary care may include:

  • Hormonal profile, such as early morning testosterone, SHBG (to calculate the free androgen index), LH, FSH, prolactin, TSH
  • Serum cortisol
  • Urinary cortisol
  • Serum cholesterol
  • Serum growth hormone
  • HbA1c
  • Neck ultrasound
  • Transvaginal ultrasound scan
  • MRI pituitary gland – depending on local pathways

When to refer

Referral will depend on the potential cause. Idiopathic causes can be managed in primary care with reassurance and options regarding treatment.

Suspected significant conditions, such as hypothalamic pituitary causes, ovarian or adrenal causes, will require referral to the appropriate specialty for further investigations of the cause.

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  • Dr Singh is a GP in Northumberland

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