Background: Although hirsutism is broadly defined as excessive hairiness, the common clinical use of the term is in reference to women with excess growth of terminal hair in a male pattern. In this sense, hirsutism is one of the most common endocrine disorders, affecting approximately 10% of women in the US. In these women, the hairiness implies the presence of abnormal androgen action, which may represent a serious or, more likely, a nonserious medical problem. Regardless of the etiology, hirsutism can produce mental trauma and emotional anguish. Even mild cases of hirsutism may be viewed by the patient and others as a presumptive loss of femininity. In more severe cases, it can be a cosmetic catastrophe. The major objectives in the management of hirsutism are to rule out a serious underlying medical condition and to devise a plan of treatment.


Pathophysiology: Both hormones and the intrinsic characteristics of the hair follicle determine the quality of hair growth. Vellus hairs are fine, unpigmented hairs that cover most of the body before puberty. Pubertal androgens promote the conversion of these vellus hairs to coarser pigmented terminal hairs. The level and duration of exposure to androgens, the local 5 alpha-reductase activity, and the intrinsic sensitivity of the hair follicle to androgen action determine the extent of conversion from vellus to terminal hair. Some terminal-hair growth, however, is androgen-independent, eg, scalp, eye brows, and lashes.

The development of terminal hair or reversion back to a vellus pattern may not immediately be evident because of the characteristics of the hair cycle. This cycle has 2 phases that include active hair growth (anagen phase) and a resting period (telogen phase), which follows the anagen phase. During the resting period, the hair shaft separates from the dermal papillae at the follicle base and no further growth takes place. Eventually, growth restarts and the old hair is pushed out by the new hair shaft formed by the reactivated papillae. The cycle may take months to complete, and this causes a delay in hair-growth response to changes in the androgen milieu.

Dihydrotestosterone is the androgen that acts on the hair follicle to produce terminal hair. This hormone is derived from both the blood stream and local conversion of a precursor, testosterone. The local production of dihydrotestosterone is determined by 5 alpha-reductase activity in the skin. Differences in the activity of this enzyme may explain why women with the same plasma levels of testosterone can have different degrees of hirsutism.


Mortality/Morbidity: The mortality and morbidity of hirsutism are determined by the underlying cause. The majority of women with idiopathic hirsutism have no associated mortality or morbidity. On the other extreme, a small number of women may have malignant disease with a grave prognosis.

Race: Ethnic origin has a large effect on terminal hair growth in normal women. Northern, fair-skinned Europeans have the least terminal hair, whereas southern, dark-skinned Mediterranean women have the greatest amount of terminal hair. The difference in the racial patterns of normal terminal hair growth may be related to genetic differences of 5 alpha-reductase activity in the skin. With the exception of congenital adrenal hyperplasia (CAH), the prevalence of diseases causing hyperandrogenism and hirsutism has not been shown to be different among races.

Sex: As a medical problem, hirsutism predominates in women. While hirsutism can occur in men, it is more difficult to recognize because of the wide variability of healthy male terminal-hair growth. Hirsutism in prepubertal children occurs equally in both sexes, usually is a sign of precocious puberty, and may signify a serious underlying disease. This discussion, however, focuses on adult women.

Age: The age of onset of hirsutism depends on the etiology.


History: An accurate history of the patient’s onset of hirsutism and developmental milestones can be helpful in the etiologic diagnosis.

Physical: The most important goal in the clinical evaluation of a patient with hirsutism is to rule out significant underlying disease. To do this, seek to understand the cause of hyperandrogenism, if this is present.

Causes: Multiple diseases can cause hyperandrogenism and hirsutism (see Picture 3).


Adrenal Adenoma
Adrenal Carcinoma
C-11 Hydroxylase Deficiency
C-17 Hydroxylase Deficiency
Cushing Syndrome
Malignant Lesions of the Ovaries
Ovarian Cancer
Ovarian Polycystic Disease

Other Problems to be Considered:

Androgen-secreting adrenal tumors
Androgen-secreting ovarian tumors
Exogenous androgens
Congenital adrenal hyperplasia
Idiopathic hirsutism


Lab Studies:

Imaging Studies:


Medical Care: The treatment of hirsutism begins with a careful explanation to the patient about the cause of her problem and with reassurance that she is not losing her femininity. Then, direct intervention, if possible, at the underlying disorder. If hirsutism persists (or the patient has idiopathic hirsutism), other cosmetic or systemic treatment may be necessary. In some cases, cosmetic measures may be sufficient. In others, the slow progress of systemic therapy may necessitate more immediate cosmetic treatment. The most effective strategy is to combine systemic therapy, which has a slow onset of effectiveness, with mechanical depilation (shaving, plucking, waxing, and depilatory creams).

Hirsutism requires a careful and systematic clinical evaluation coupled with a rational approach to treatment. Throughout this process, the patient must understand that even though diagnostic testing can be time consuming (and even inconclusive), it sometimes is essential for determining an effective intervention. In other cases, counseling and education may be all that is needed. For the patient who desires treatment, a wide variety of pharmacologic strategies can be followed. Informing the patient that current systemic therapy is imperfect is important. Furthermore, none of the drugs used to treat hirsutism have Food and Drug Administration (FDA) approval for such use. Only initiate therapy in patients who give informed consent after a complete explanation of the potential benefits and risks of a particular treatment and alternative approaches.


The most effective strategy in treating hirsutism is to combine systemic therapy, which has a slow onset of effectiveness, with mechanical depilation (shaving, plucking, waxing, depilatory creams).

Systemic therapies directed at hirsutism can be divided into those that decrease ovarian or adrenal androgen production and those that inhibit androgen action in the skin.

Drug Category: Oral contraceptives -- Inhibit ovarian androgen production. They probably are the first choice for young women with hirsutism who do not want to become pregnant. OCs are inexpensive, and they promote regular uterine bleeding. OCs can be used in combination with antiandrogens or other agents. They have a significant failure rate in hirsutism for several reasons. Low-dose oral contraceptives and progestin-only minipills fail to suppress ovulation in as many as 50% of women. Ovarian function continues at a variable rate, and ovarian androgens continue to be produced. Second, the progestins in OCs are attenuated derivatives of testosterone and have variable degrees of androgenic activity in women. The degree depends on the type of progestin and, more importantly, on individual susceptibility.

Drug Name
Estrogen-progestin combinations (Ortho-Novum, Ortho-Tri-Cyclen, Triphasil) -- Reduces secretion of LH and FSH from the pituitary by decreasing amount of gonadotropin-releasing hormones.
Adult Dose 1 tab qd
Pediatric Dose Not established
Contraindications Documented hypersensitivity, thrombophlebitis, undiagnosed vaginal bleeding, cerebral apoplexy
Interactions May reduce hypoprothrombinemic effects of anticoagulants; estrogen levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; an increase in corticosteroid levels may occur when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and decreased contraception; increase in fluid retention caused by estrogen intake may reduce seizure control
Pregnancy X - Contraindicated in pregnancy
Precautions Caution in patients with hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, thromboembolic disease, asthma, depression, and renal or cardiac dysfunction

Drug Category: Glucocorticoids -- Used to inhibit adrenal androgens. These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Suppress ACTH-dependent adrenal androgen synthesis. Used with variable success in women with adrenal hirsutism, CAH, and idiopathic adrenal hyperandrogenism.

Drug Name
Prednisone (Deltasone, Orasone, Meticorten) -- May inhibit ACTH-dependent androgen synthesis through negative feedback.
Adult Dose 5 mg PO qhs
Pediatric Dose Not established
Contraindications Documented hypersensitivity, viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, fungal or tubercular skin infections, GI disease
Interactions Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Drug Name
Dexamethasone (Decadron, AK-Dex, Alba-Dex) -- May inhibit ACTH-dependent androgen synthesis through negative feedback.
Lower doses (eg, 0.25 mg) may prove to be effective with fewer adverse effects.
Adult Dose 0.5-1 mg/d PO hs
Pediatric Dose Not established
Contraindications Documented hypersensitivity, active bacterial or fungal infection
Interactions Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, weight gain, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, and growth suppression may occur

Drug Category: Antiandrogen -- Used to block androgen action.

Drug Name
Spironolactone (Aldactone) -- Decreases testosterone production. Can be combined with OCs for added effects.
Adult Dose 50-200 mg/d PO
Pediatric Dose Not established
Contraindications Documented hypersensitivity, anuria, renal failure, hyperkalemia
Interactions May decrease effect of anticoagulants; potassium and potassium-sparing diuretics may increase toxicity
Pregnancy D - Unsafe in pregnancy
Precautions Caution in renal and hepatic impairment; contraception is imperative in sexually-active women

Drug Category: 5 alpha-reductase inhibitor -- Indicated for treatment of benign prostatic hyperplasia and male pattern baldness. Unlabeled use for treatment of female hirsutism.

Drug Name
Finasteride (Proscar, Propecia) -- Specific inhibitor the intracellular enzyme that converts testosterone into the androgen 5a-dihydrotestosterone (DHT). Efficacy in hirsutism is similar to spironolactone.
Only to be used in women who are postmenopausal with no chance of becoming pregnant.
Adult Dose 5 mg/d PO
Pediatric Dose Do not administer
Contraindications Documented hypersensitivity; not to be used in children, pregnancy, or women who may potentially become pregnant
Interactions None reported
Pregnancy X - Contraindicated in pregnancy
Precautions Caution in hepatic impairment; may cause ambiguous genitalia development in the male fetus during first trimester of pregnancy


Patient Education:


Medical/Legal Pitfalls:


Caption: Picture 1.
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Caption: Picture 2.
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Caption: Picture 3.
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Caption: Picture 4. Etiologic diagnosis of hirsutism
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Caption: Picture 5.
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