Red flag symptoms: Hirsutism

The potential causes for this condition are many and varied, writes Dr Lizzie Croton.

Red flag symptoms
  • Pelvic or abdominal mass
  • Excessive virilisation
  • Severe psychological distress

Hirsutism is the excessive growth of thicker, darker hair in women. It grows in an androgen-dependent pattern in areas where hair is usually minimal or absent. This common condition affects 5-10% of women.

Ask the patient about the distribution of hair (masculine pattern) and symptoms of virilism, such as acne, deeper voice, increased libido, menstrual dysfunction, problems conceiving and excessive perspiration.

Examine the skin for excessive terminal hair (thicker hairs usually found on the brows and head). Common sites are the face, chest, linea alba, areolae, buttocks and thighs.

There may be male pattern truncal obesity and temporal hair recession. Pelvic and abdominal examination may yield ovarian or adrenal masses.


A high total testosterone concentration and a history of rapid virilisation suggest an androgen-secreting ovarian or adrenal tumour. In polycystic ovary syndrome (PCOS), total testosterone is often normal. Women with PCOS often have an increased LH/FSH ratio (>2), but this is not diagnostic for PCOS.

Congenital adrenal hyperplasia (CAH) is investigated by measuring morning 17-hydroxyprogesterone in the first half of the menstrual cycle.

A value of 5nmol/L has a high sensitivity for diagnosis of CAH.

Causes of hirsutism
  • Familial
  • Normal menses
  • Obesity
  • Drug induced
  • PCOS
  • Menopause
  • Androgen-secreting tumour
  • CAH
  • Cushing's syndrome
  • Severe insulin resistance
  • Prolactinoma
  • Hypothyroidism


Treatment for idiopathic hirsutism is unnecessary if the patient is unconcerned about its appearance. Management is directed at underlying causes, such as being overweight.

Topical therapies include depilation, such as waxing/plucking and electrolysis/laser hair removal. Drug therapies include combined oral contraceptives (COCs) with antiandrogenic progesterones, insulin-sensitising agents and low-dose antiandrogens. Response may take up to 18 months.

GnRH agonists can be used second line in women unable to tolerate COCs. Eflornithine may be tried if COCs are contraindicated or unsuccessful. It should be discontinued if no benefit is seen in four months.

Indications for referral are severe hirsutism or hair growth exhibiting rapid progression, serum testosterone or prolactin more than twice the upper limit of normal, and suspicion of ovarian or adrenal tumour.

  • Dr Croton is a GP in Birmingham

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