Red flag symptoms
- 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
- Acne
- Rapidly increasing hirsutism
- Thinning skin, easy bruising, striae
- Clitoromegaly
- Proximal muscle weakness
Hirsutism can be very embarrassing for female patients and needs to be handled empathically and sensitively. 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
- Cushing's disease or syndrome
History
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 find out about other symptoms, such as headaches, visual field changes, galactorrhoea, menstrual irregularities, excessive weight gain, neck swellings, mood changes and any difficulty conceiving.
- Has the patient noticed any easy skin bruising, striae or thinning of the skin?
- 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 and investigation
Examination will be guided by the history and may 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 checking for signs of Cushing’s syndrome
Investigations to consider in primary care may include:
- Hormonal profile, such as early morning testosterone, sex hormone binding globulin (SHBG) - to calculate the free androgen index - LH, FSH, prolactin, TSH
- CA125
- Serum cortisol
- 24-hour urinary cortisol
- Serum cholesterol
- Serum growth hormone
- HbA1c
- Neck ultrasound
- Transvaginal ultrasound scan
- MRI of the pituitary gland – depending on local pathways
When to refer
Referral will depend on the potential cause of the hirsutism. Idiopathic causes can be managed in primary care with reassurance and options for treatment focusing on hair removal, such as shaving, waxing or topical eflornithine. Co-cyprindiol may also be an option.
Suspected significant conditions, such as hypothalamic pituitary causes, ovarian or adrenal causes, will require referral to the appropriate specialty for further investigations. This may warrant a two-week wait referral if a pituitary tumour, ovarian tumour or adrenal secreting tumour is suspected.
- Dr Singh is a GP in Northumberland. This is an updated version of an article that was first published in June 2015.
