A mixture of vellus and terminal hair covers the lower arms and legs in both men and women. Therefore, if excessive hair growth is present only on a woman's lower legs and forearms, it is not considered to be evidence of hirsutism.
Figure 1 : Terminal hair is longer, coarser, and darker than vellus hair
Hair growth occurs in cycles, but the hairs usually do not grow at the same time. While some hairs grow. others rest. and some are shed. Rapid hormonal changes, such as those associated with oral contraceptives (birth control pills) or pregnancy, can cause the growth cycles of many hairs to shift and occur at the same time. Hair may suddenly appear to grow and shed more than usual. Hair growth patterns disrupted by these rapid hormonal changes usually return to normal within six to 12 months.
ABNORMAL HAIR GROWTH
Most often, excess facial and body hair is the result of abnormally high levels of androgens, (male hormones) in the blood. Androgens are present in both men and women, but men have much higher levels. In men. androgens are produced primarily by the testes and the adrenal glands. In women, androgens are secreted by the ovaries and the adrenal glands. In individuals whose hair follicles arc sensitive, androgens may cause hairs to change from vellus to terminal hairs. Once a vellus becomes a terminal hair it usually does not change hack and requires electrolysis for permanent removal.
Androgens cause some terminal hairs to grow faster and thicker, particularly in men. but they can also cause balding. Androgens increase sebum production, which results in oily skin and acne. Excess androgens can cause irregular or absent ovulation and menstruation. If a woman's androgen level is very high. such as when a tumor is present. she might begin to experience male-like balding, deepening of the voice, and decreased breast size. These effects occur very rarely, however. To some degree, estrogen (female hormones) reduces the effect of androgens in women. The circumstances described below can lead to high androgen levels and hirsutism in women.
DETERMINING THE CAUSE OF HIRSUTISM
Physicians trained to treat hirsutism and related problems generally include reproductive and medical endocrinologists. Some gynecologists, dermatologists, and general practitioners have also acquired the necessary expertise. During the initial medical consultation, the physician may first try to distinguish between terminal hairs growing in a pattern similar to male hair growth, which indicates hirsutism, from hair growth perceived by the patient to be excessive. Many women have what they perceive to be excessive hair growth, although it is not hormonally related and may be due to ethnic or racial tendencies. If hirsutism is diagnosed, the causes are usually investigated by blood tests, ultrasound or special x-rays. Hormone suppression or stimulation tests to evaluate the function of the ovaries and adrenal glands may also be performed. These tests measure blood hormone levels both before and after the administration of a specific hormone medication. After the causes of hirsutism have been identified, an appropriate treatment can be recommended. Any unwanted hair remaining after treatment may he cosmetically removed by electrolysis.
CAUSES OF HIRSUTISM
Polycystic Ovarian Syndrome (PCOS)
PCOS is a common cause of hirsutism and is frequently associated with obesity irregular or absent ovulation. and infertility. PCOS is a condition in which many cysts (hence the term "polycystic") develop on the ovaries and produce excess amounts of androgens. Menstrual periods may become irregular or cease, and ovulation no longer occurs. The causes and treatments of PCOS are discussed in the second half of this section.
Around the time of menopause, ovaries stop producing estrogen but continue to produce androgens. The drop in estrogen may allow the androgens to have a greater impact, leading to an increase in the number of dark terminal hairs, especially on the face.
There are obvious familial and racial differences in the sensitivity of hair follicles to androgens. In some women the skin is very sensitive to even low levels of androgens. and the hair follicles may produce terminal hairs more frequently. This tendency to develop hirsutism is often hereditary. It a woman's mother or grandmother had increased body hair or acne. then the woman is at a greater risk of developing these skin changes.
Women from certain ethnic backgrounds are more likely to develop hirsutism. For example. Caucasians have more hair follicles per surface area than African Americans. and their hair follicles are more sensitive to androgens. Therefore Caucasians are more prone to hirsutism. Asians and Native Americans have fewer and less sensitive hair follicles and are less likely to develop hirsutism. even if their androgen levels are elevated.
Medication Side Effects
Drugs with characteristics of androgens may cause hirsutism. Danazol a drug used to treat endometriosis. and anabolic steroids, used by some bodybuilders to increase muscle mass. are both chemically related .to androgens. However, these drugs are usually prescribed in very small dosages and for short periods of time. So the development of hirsutism is minimized. Other medications associated with increased hair growth include dilantin. minoxidil. and diazoxide. Patients on these medications develop acne more frequently than hirsutism.
Ovarian or Adrenal Tumors
On very rare occasions, an androgen-producing tumor may develop in the ovaries or adrenal glands. These tumors cause hirsutism to develop and progress rapidly and may be associated with male-like balding. If a woman's androgen levels are high her physician may order further tests to determine if tumors are present in the ovaries or the adrenal glands. Fortunately, most of these tumors are not cancerous.
Late-Onset Adrenal Hyperplasia
The adrenal glands, located just above each kidney, produce androgens. The most common disease of the adrenal glands that can result in hirsutism is an inherited disorder called late-onset adrenal hyperplasia. Although this is a genetic disorder, it can be easily treated once diagnosed. Adrenal hyperplasia. which may be associated with irregular menstrual cycles, causes the adrenal glands to produce an increased amount of androgens. The adrenocorticotropic hormone (ACTH) stimulation test checks for the presence of late-onset adrenal hyperplasia.
The Insulin Resistance Syndrome
Some patients are born with a defect in the ability of insulin to control glucose (sugar) levels, which results in overproduction of insulin to avoid the development of excessive levels of glucose. In turn. the overproduction of insulin can stimulate the ovaries to overproduce androgens. leading to hirsutism. acne. and irregular ovulation. Excessive insulin may lead to diabetes mellitus. high blood pressure heart disease, and excessive growth and darkening of the skin, which generally occurs around the neck and crease areas of the skin.
How Is HIRSUTISM TREATED?
There are several drugs used to treat hirsutism. Birth control pills (oral contraceptives) are the most commonly suggested hormonal treatment. These pills prevent ovulation and decrease the ovarian production of androgens. Estrogen in the pills causes the liver to produce and release more of a hormone-binding protein that traps androgens and causes them to be less effective. In addition to slowing excessive hair growth, the pills may provide the added advantages of regulating the menstrual cycle and protecting against unwanted pregnancies.
Spironolactone is a drug that directly blocks the effect of androgens on the skin. It initially was prescribed as a diuretic or "water pill" and may cause an increase in urinary frequency. This drug is safe and inexpensive, even in the higher doses used to treat hirsutism. Physicians often prescribe birth control pills in conjunction with spironolactone because it may disrupt the menstrual cycle. Other side effects may include dry skin, heartburn, headaches, and fatigue. About two-thirds of the women on high-dose spironolactone will have a significant decrease in hirsutism. Effective new antiandrogen medications are presently undergoing clinical testing and may be in common use within the next several years.
Low doses of the drugs dexamethasone, prednisone, or hydrocortisone may be prescribed for overactive adrenal glands. Some women taking dexamethasone experience dizziness during the day or have difficulty falling asleep, although these complaints generally improve after the first few days. In high doses, these drugs have more serious side effects including weight gain. thinning of the skin and bones and decreased defense against infection. These side effects are seldom seen at the low doses used for treating hirsutism. Other medications currently being evaluated for treatment of hirsutism include GnRH agonists and estrogen therapy.
Cosmetic removal of excess hair in women with hirsutism should always he combined with medical therapy. Otherwise, the hirsutism usually gets worse and treatment is unnecessarily delayed. For temporary hair removal, many women with mild hirsutism pluck the unwanted hairs. However, plucking rips the hair from its living root and can irritate sensitive skin. and if the shafts become infected, the hair may curl into the skin and possibly cause pimples or acne. Waxing, another alternative, is essentially the same as plucking and carries the same risks of infection, especially in male hormone sensitive areas. Depilitating agents, chemicals that dissolve the hair shafts, may cause irritation to facial skin. which is particularly sensitive. Bleaching can be used in small areas of the body. particularly the upper lip to make excessive hair less noticeable, but excessive bleaching may lead to irritation and damage of the skin.
Although not satisfying to many women, shaving is probably the simplest and safest way to temporarily remove hair. Shaving is frequently required and may result in irritating stubble, but an electric razor may produce less skin irritation than a blade. Shaving seldom has medical side effects.
Electrolysis is the only permanent way to remove unwanted hair. During this procedure, a very fine needle is inserted into the follicle next to each hair shaft. A mild electric current is sent through the needle to permanently kill the hair follicle. Since hair follicles are treated one at a time. it is somewhat impractical to use this technique to remove hairs from very large areas of the body. Although quite effective, on occasion electrolysis may result in .skin infections or some degree of scarring. Electrolysis is moderately painful, depending on the area of skin being treated, and numerous treatments are usually required. Nevertheless, electrolysis is a very effective way to remove unwanted hair and is almost always required, in combination with medical therapy, for the treatment of hirsutism. It is best to delay electrolysis for at least six months after beginning hormone treatment so that the growth of new terminal hairs will be reduced and the existing terminal hairs may be finer and easier to treat. Physicians can often refer patients to a reputable electrologist. Home electrolysis kits rarely work because the follicle is so deep
within the skin.
WHAT TO EXPECT FROM HIRSUTISM TREATMENT
Hormone treatment generally prevents new terminal hairs from developing and may slow the growth rate of existing hairs. Terminal hairs do not usually fall out or disappear until their life cycle is complete, and hormonal therapy does not speed this process. Terminal hairs must be removed with electrolysis. Generally about six months of hormone therapy is required before the rate of hair growth decreases significantly. Once a hormone treatment has proven to be effective, it may be continued indefinitely. Electrolysis can be used to permanently remove any remaining hair. Because it is usually not possible to cure the hormonal problem that causes hirsutism, excessive hair growth will frequently return if medical treatment is stopped.
POLYCYSTIC OVARIAN SYNDROME
Polycystic ovarian syndrome (PCOS) is a term used to describe a group of conditions which cause the ovaries to produce excessive androgens. The ovaries may become enlarged and produce many small cysts (fluid-filled sacs), hence the name "polycystic" (Figure 2). Symptoms of PCOS include hirsutism. acne. obesity. irregular, absent, or heavy menstrual periods, lack of ovulation. and infertility. Other names for PCOS are polycystic ovarian disease or Stein-Leventhal syndrome. All of these refer to the same basic set of conditions. Despite questions surrounding the cause of PCOS. many advances have been made in treating this disorder.
Figure 2 : The Polycystic ovary may become enlarged with many small cysts
NORMAL OVARIAN FUNCTION
In order to understand the nature of PCOS, it is important to know how the ovaries work. In a woman of reproductive age. the ovaries have two important functions: they produce eggs and release estrogen and progesterone into the bloodstream. These hormones prepare the egg for fertilization and prepare the fallopian tubes for transporting a fertilized egg to the uterus. Once the egg is fertilized and becomes a developing embryo, estrogen and progesterone create a suitable environment in the uterus for the embryo to implant and grow in the uterine lining (endometrium).
The pituitary gland, located at the base of the brain, controls egg and hormone production by releasing two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH). In response to FSH, the ovary will begin to grow a follicle just as the menstrual period begins. The cells surrounding the follicle produce significant amounts of androgens in response to LH. The enlarging follicle not to be confused with a hair follicle, appears as a small cyst on the surface of the ovary that can often be detected by ultrasound. The follicle produces estrogen and contains a maturing egg.
Ovulation occurs approximately two weeks before the onset of the menstrual period. The largest follicle ruptures and releases the egg, which is picked up by the fallopian tube. Following ovulation, the cells lining the ruptured follicle begin to produce progesterone. The empty follicle collapses, and the remaining follicle cells develop a yellow color. The collapsed follicle is known as the corpus luteum a term which literally means a "yellow body." The corpus luteum secretes estrogen and large quantities of progesterone throughout the second half of the cycle, which is called the luteal phase. The progesterone serves to help prepare the uterus for a possible pregnancy.
If conception takes place, the egg is fertilized in the fallopian tube and remains in the tube for up to three or four days. It then enters the uterus and becomes embedded (implants) in the endometrium. The combination of progesterone and estrogen traveling through the bloodstream to the uterus prepares the endometrium for a fertilized egg. If a fertilized egg does not implant, the secretion of estrogen and progesterone declines about two weeks after ovulation, and the lining of the uterus is shed. This results in menstruation, and the cycle begins again.
OVARIAN DISRUPTION AND PCOS
The ovulatory cycle is easily disrupted by hormonal changes. When disruption occurs, ovulation may not take place, and follicular growth in the ovary stalls. Disruption may be caused by excess LH. leading to overproduction of androgens by the ovary. Insufficient secretion of FSH. which is necessary to stimulate the developing follicle, may also cause disruption. This disruption can result in excessive amounts of estrogen and androgens. If ovarian disruption continues multiple small cysts form in the ovary from follicles that failed to mature and ovulate Lack of ovulation results in infertility.
Stimulated by continuous exposure to estrogen, the endometrium becomes excessively thickened and may cause heavy and/or irregular bleeding. Over many years endometrial cancer may result due to continuous high levels of estrogen (unopposed by progesterone) stimulating the endometrium. If elevated androgen levels persist for a long time. hirsutism and acne may occur.
A physician can often diagnose PCOS by obtaining the patient's medical history and conducting an examination. Blood hormone levels are often measured in order to confirm the diagnosis, and an ultrasound may be performed. The use of ultrasound helps distinguish PCOS from other disorders that can cause multiple small cysts in the ovaries, but most of these conditions are not associated with excessive secretion of androgens. If menstrual periods have been irregular or absent for a long period of time. an endometrial biopsy may be necessary to evaluate the endometrium and rule out pre-cancerous cells. The biopsy involves taking a sample of the endometrium and examining it under a microscope.
Women whose mothers had PCOS should watch carefully for symptoms and visit their physician regularly. Menstrual irregularity since puberty is an indication to look for other PCOS symptoms. Furthermore. PCOS patients with female children should watch for symptoms and inform their children that they are at risk. As a general rule medical attention should be sought for irregular or absent menstrual Periods Early treatment of PCOS may decrease the development of acne and hirsutism. Women with PCOS may be at increased risk for diabetes and may need to be screened for this disorder.
FACTORS ASSOCIATED WITH PCOS
Many factors can disrupt ovarian function. Because PCOS is not fully understood, it is often difficult to determine why it occurs. Obesity is one factor commonly associated with PCOS and may aggravate the condition. It is thought that fatty tissues produce excess estrogen which can affect the pituitary gland and result in insufficient secretion of FSH. Insufficient FSH prevents ovulation and may worsen PCOS The pituitary can overstimulate the cells in the ovaries which secrete androgens or the adrenal glands can become overactive and produce symptoms similar to those associated with PCOS. As noted earlier, insulin resistance can also lead to overproduction of androgens by the ovaries. The excess androgens produced by the adrenal glands or the ovaries may then be converted into estrogen in fatty tissue and subsequently suppress FSH.
The treatment of PCOS is relatively simple and based upon the goals of the patient. Some patients may be concerned primarily with fertility, while others are more concerned about menstrual cycle regulation, hirsutism. or acne. Regardless of the primary goal. patients should describe all symptoms to their physician as specifically as possible. PCOS should be treated even if fertility is not a concern because of the risks of long-term exposure to androgens and estrogen unopposed by progesterone. These risks include developing hirsutism. acne. heart disease diabetes, and uterine cancer.
For many PCOS patients, weight loss improves the hormonal condition, but overweight PCOS patients may have difficulty losing weight. A permanent weight loss plan is essential. Physicians can often recommend a weight control plan or clinic. Area hospitals and support groups are also helpful. Although tempting, fat diets and diet pills are usually not effective and in many cases cause additional health problems.
Increasing physical activity is an important step in any weight reduction program. An aerobic activity such as walking or swimming should be started slowly. Speed and distance can be gradually increased. Regular activity improves state of mind as well as aiding in weight reduction.
If fertility is the immediate goal. ovulation may be induced with either clomiphene citrate, gonadotropins. which are a mixture of LH and FSH. or purified FSH. Clomiphene is simple to use and relatively cost-effective. Approximately 10 percent of pregnancies with clomiphene are twins: triplets or more are rare. Clomiphene interacts with the brain and causes the pituitary to increase FSH secretion. In many cases, it works well to induce ovulation. Sometimes increasing the dosage or the length of treatment is necessary. The physician may also recommend dexamethasone, a drug designed to suppress the adrenal gland, to supplement clomiphene therapy.
If clomiphene does not work within approximately six cycles, gonadotropins may be used. This medication is more expensive and has a higher incidence of side effects, such as hyperstimulation (excessive swelling) of the ovaries and multiple pregnancy. It is generally reserved for patients who do not ovulate in response to clomiphene. Purified FSH may also be used if clomiphene does not work. but its use and risks arc similar to gonadotrupins. Individual needs and response to therapy will determine the appropriate medication. The patient and physician should discuss options and decide which one is best.
Hormonal treatment is frequently successful in temporarily correcting the problems associated with PCOS. If treatment is stopped however, symptoms usually reappear. The best hormone treatment for PCOS is low-dose oral contraceptives. which decrease ovarian hormone production and help reverse the effects of excessive androgen levels. However, birth control pills are not recommended for women who smoke and are over age 35. If hirsutism is also a problem, the use of spironolactone. alone or combined with birth control pills, may be useful. Rarely the use of GnRH agonists to decrease ovarian androgen production is needed. When the patient is ready to conceive, she may then start treatment to induce ovulation.
Sometimes neither fertility nor contraception are desired, and hirsutism is not a problem. If this is the case. regular uterine bleeding can he induced with monthly courses of a progesterone medication. This will regulate the menstrual cycle and prevent endometrial problems associated with excessive estrogen exposure.
In very rare cases, ovulation is not achieved with either clomiphene or gonadotropins. and ovarian surgery may be needed to stimulate ovulation. This surgery can often be performed through laparoscopy.
PSYCHOLOGICAL ASPECTS OF HIRSUTISM AND PCOS
Dealing with hirsutism and PCOS can be emotionally difficult. Many women avoid certain social situations because they feel unfeminine. uncomfortable, and self-conscious about their excessive hair growth. It may be embarrassing to share these feelings with other people. PCOS patients may also worry about future fertility. It is very important that women discuss these concerns with their physician as soon as possible to explore the medical and cosmetic treatments available to treat these disorders.
Hirsutism is a common disorder that can usually be diagnosed and successfully treated with hormone medication. Any unwanted hair remaining after medical treatment can be permanently removed by electrolysis. Hirsutism is frequently a result of hereditary factors which predispose the patient to develop this medical disorder. A women whose mother or grandmother experienced excessive hair growth should watch for early signs of hirsuti.sm in herself and her children especially during adolescence. Hirsutism may be an indication of a more serious endocrine problem .such as PCOS.
PCOS is a poorly understood disorder that can cause abnormal hair growth, acne. irregular or heavy menstrual periods, lack of ovulalion. and infertility. Despite questions surrounding the causes of PCOS. advances have been made in both understanding and treating the condition. In the vast majority of cases, patient goals and concerns can be addressed in a relatively short period of time. and treatment is often successful.