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 (Photo: Dr P Marazzi/Science Photo Library)
Hirsutism is more common in dark-haired women (Photo: Dr P Marazzi/Science Photo Library)

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.

Visit MIMS Learning for an interactive version of this article and a CPD certificate

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

Almost 4,000 GPs rejoin GMC register as COVID-19 deaths surge

Almost 4,000 GPs rejoin GMC register as COVID-19 deaths surge

Around 3,800 GPs have rejoined the medical register barely a week after the government...

Prime minister Boris Johnson and health secretary Matt Hancock infected with COVID-19

Prime minister Boris Johnson and health secretary Matt Hancock infected with COVID-19

Prime minister Boris Johnson and health and social care secretary Matt Hancock are...

'Lovely' Essex GP feared to be first UK doctor to die from COVID-19

'Lovely' Essex GP feared to be first UK doctor to die from COVID-19

An Essex GP is feared to have become the first UK doctor to die after being infected...

How PCNs are adapting to the COVID-19 pandemic

How PCNs are adapting to the COVID-19 pandemic

Primary care networks (PCNs) are hosting virtual training sessions and re-writing...

Guidance updated for pregnant healthcare staff in coronavirus outbreak

Guidance updated for pregnant healthcare staff in coronavirus outbreak

All GPs who are pregnant should have the choice to stop work in patient-facing roles...

More than 550 GPs sign up within 24 hours to support NHS111

More than 550 GPs sign up within 24 hours to support NHS111

More than 550 GPs have signed up within 24 hours to take calls for NHS 111 as the...