Monday April 20 2009

Excessive hairiness in women is “likely to be a sign of an underlying medical condition,” BBC online has warned. The news service reports that 70-80% of cases female hairiness (medically known as hirsutism) are caused by polycystic ovarian syndrome, an abnormality of the ovaries. The news is based on a new medical review of hirsutism, estimated by authors to affect between 5-15% of women.

The educational paper, which is aimed at medical staff specialising in the field of gynaecology, covers normal hair growth, the causes of hirsutism and current practice in diagnosing and treating the condition. It concludes, as does the BBC report, that women with the problem should not be afraid to seek medical advice. The researchers say that how much hair is considered as excessive may be subjective, but those who suffer with hirsutism and polycystic ovarian syndrome (PCOS) should see their GP, as there are several effective treatments available.

Where did the story come from?

Dr Rebecca Swingler, a specialist registrar in Obstetrics and Gynaecology at St Michael’s Hospital in Bristol wrote this review with two consultant colleagues. Sources of funding are not reported.

The study was published in The Obstetrician & Gynaecologist, a peer-reviewed journal for continuing professional development from the Royal College of Obstetricians and Gynaecologists.

What kind of scientific study was this?

This was a narrative review of research on female hirsutism, aimed at specialist readers who might want to learn more about assessing the condition or to understand common and less common causes. It advises on using a sensitive and sensible approach to management of the condition.

In this review, the researchers detail the background of the condition and, based on approximately 30 references, describe current practice for evaluating and managing the condition.

PCOS (literally meaning ‘of many cysts’) is a complex condition that affects the ovaries and the levels of several male-type (androgen) hormones in the blood. The ovaries in women with the condition are often bigger than average, and the outer surface of the ovary has an abnormally large number of small follicles or cysts. It can cause infertility and is a common cause of female hirsutism, accounting for 70–80% of all cases.

No single blood test or characteristic can definitively identify hirsutism.  As such, the diagnosis is usually based on a combination of two out of three of the following criteria (after the exclusion of other causes):

• Reduced ovulation or lack of ovulation.
• Clinical hyperandrogenism or biochemical increase in androgens (male hormones in the blood).
• Typical features on an ultrasound scan.

What were the results of the study?

For evaluation of  hirsutism the researchers say that in-depth questioning is required. This should include asking about any drugs used, changes in weight and facial contours, the presence of acne, hair loss/balding, and any relevant details in their medical or family history, such as premature male balding and diabetes.

The authors also say that the clinical diagnosis of hirsutism tends to be subjective and is based upon determining hair type and growth by visual assessment. The researchers propose using an objective scoring system called the Ferriman–Gallwey system that scores the density of hair between zero and four at a total of 11 different body sites.

The authors propose that in cases of moderate-to-severe hirsutism (a Ferriman–Gallwey score of more than 15), it is likely that there is excess of the male hormone (androgen) and that the possible causes of this hormone level should be investigated. Although “free testosterone levels” in the blood is the most sensitive measure of the excess androgens, there is no uniform laboratory standard test and results vary between laboratories.

Other signs of PCOS can include levels of other hormones also being raised, and a pelvic ultrasound of the ovaries can also help in the diagnosis of PCOS (though may also appear to be normal). The authors also stress that there is an importance of excluding malignancy in people with sudden onset and rapid progression of male pattern hairiness or with an abdominal mass.

The range of treatments discussed includes weight loss and lifestyle changes, with a weight reduction of 5–10% apparently inducing an improvement in hirsutism by 40–55% within six months. There are also cosmetic methods and physical methods, such as electrolysis and laser photothermolysis.

As well as discussing the importance of stopping prescription drugs that may cause hirsutism, the authors describe possible treatments for the condition, including those that act against the male androgenic hormones. They describe the pros and cons of the combined oral contraceptive pill and pills that contain cyproterone acetate, which can alter hormone levels. They specifically talk about the medicines spironolactone, finasteride, flutamide and metformin. The role of cell cycle inhibitors and gonadotrophin-releasing hormone agonists are also described.

Regarding follow-up after treatment, the researchers suggest that a sympathetic approach, including emotional support, is required as the condition can affect self-esteem. This can be especially true when it occurs in adolescents and young women who may have body image issues.

What interpretations did the researchers draw from these results?

The researchers say that the lengthy treatment for hirsutism “can be expensive and painful, have adverse effects and it may not be instantly satisfactory.”  They also emphasise the importance of making sure that women on some hormone treatments, such as anti-androgens, also use effective contraception.

Finally, the authors point to the possibility of combining therapies, such as cosmetic therapy with hormonal manipulation and weight loss to improve the success rate of treatment.

What does the NHS Knowledge Service make of this study?

This is a review aimed at a specialist audience, which summarises the evaluation and current treatments available for male-pattern hairiness in women. It is thought that many women are affected but that the actual number may be underestimated because women can be reluctant to seek help. Further research would help in identifying the extent of the problem.

There is a range of treatments available to reduce problematic hair growth, so those who are affected by hirsutism should be reassured that there is help available to them through medical professionals.