Editing Hirsutism

{{Short description|Excessive hair growth on parts of the body where hair is usually minimal}}
{{Redirect|Hirsute|the botanical term|Indumentum}}
{{more citations needed|date=February 2022}}
{{Infobox medical condition (new)
| name          = Hirsutism
| synonyms      = 
| image         = 
| caption       = 
| pronounce     = 
| field         = [[Dermatology]], [[endocrinology]]
| symptoms      = 
| complications = 
| onset         = 
| duration      = 
| types         = 
| causes        = 
| risks         = 
| diagnosis     = 
| differential  = 
| prevention    = 
| treatment     = [[Birth control pills]], [[antiandrogens]], [[insulin sensitizers]]<ref name=Barr2018/>
| medication    = 
| prognosis     = 
| frequency     = 
| deaths        = 
}}
[[File:PMC4103002 ircmj-16-9410-g001.png|thumb|Hirsutism depicted in a female patient with [[PCOS]] and [[nonclassic congenital adrenal hyperplasia]]]]<!-- Definition and symptoms -->
'''Hirsutism''' is excessive body hair on parts of the body where hair is normally absent or minimal. The word is from early 17th century: from Latin ''hirsutus'' meaning "hairy".<ref>{{Cite web|title=hirsute adjective - Definition, pictures, pronunciation and usage notes {{!}} Oxford Advanced Learner's Dictionary |url=https://www.oxfordlearnersdictionaries.com/definition/english/hirsute|access-date=2021-07-22|website=www.oxfordlearnersdictionaries.com}}</ref> It usually refers to a male pattern of hair growth in a female that may be a sign of a more serious medical condition,<ref name=merck>{{cite web|url=http://www.merckmanuals.com/professional/sec10/ch124/ch124c.html|title=Merck Manuals online medical Library|publisher=Merck & Co.|access-date=2011-03-04}}</ref> especially if it develops well after [[puberty]].<ref>{{Cite journal|title=Hirsutism: Evaluation and Treatment|language=en|pmc=2856356|pmid=20418968|doi=10.4103/0019-5154.60342|volume=55|issue=1|year=2010|author=Sachdeva S|journal=Indian J Dermatol|pages=3–7 |doi-access=free }}</ref> Cultural stigma against hirsutism can cause much psychological distress and social difficulty.<ref>{{cite journal |vauthors=Barth JH, Catalan J, Cherry CA, Day A |title=Psychological morbidity in women referred for treatment of hirsutism |journal=J Psychosom Res |date=September 1993 |volume=37 |issue=6 |pages=615–9 |doi=10.1016/0022-3999(93)90056-L |pmid=8410747}}</ref> Discrimination based on facial hirsutism often leads to the avoidance of social situations and to symptoms of [[anxiety]] and depression.<ref name="Jackson J, Caro JJ, Caro G, Garfield F, Huber F, Zhou W, Lin CS, Shander D, Schrode K, and the Eflornithine HCl Study Group">{{cite journal |author1=Jackson J, Caro JJ |author2=Caro G, Garfield F |author3=Huber F, Zhou W |author4=Lin CS, Shander D |author5=Schrode K |others=the Eflornithine HCl Study Group  |name-list-style=amp |title=The effect of eflornithine 13.9% cream on the bother and discomfort due to hirsutism  |journal= International Journal of Dermatology|year= 2007|volume= 46|issue=9 |pages= 976–981 |doi=10.1111/j.1365-4632.2007.03270.x|pmid=17822506 |s2cid=25986442 }}</ref>

<!-- Cause and diagnosis -->
Hirsutism is usually the result of an underlying [[endocrine system|endocrine]] imbalance, which may be [[adrenal gland|adrenal]], [[ovary|ovarian]], or [[hypothalamus|central]].<ref name=hair>{{cite journal |vauthors=Blume-Peytavi U, Hahn S |title=Medical treatment of hirsutism |journal=Dermatol Ther. |date=Sep–Oct 2008 |volume=21 |issue=5 |pages=329-339}}</ref> It can be caused by increased levels of [[androgen]] hormones. The amount and location of the hair is measured by a [[Ferriman–Gallwey score]]. It is different from [[hypertrichosis]], which is excessive hair growth anywhere on the body.<ref name=merck/>

<!-- Treatment -->
Treatments may include certain [[birth control pill]]s, [[antiandrogens]], or [[insulin sensitizers]].<ref name="Barr2018">{{cite journal |last1=Barrionuevo |first1=P |last2=Nabhan |first2=M |last3=Altayar |first3=O |last4=Wang |first4=Z |last5=Erwin |first5=PJ |last6=Asi |first6=N |last7=Martin |first7=KA |last8=Murad |first8=MH |date=1 April 2018 |title=Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis |journal=The Journal of Clinical Endocrinology and Metabolism |volume=103 |issue=4 |pages=1258–1264 |doi=10.1210/jc.2017-02052 |pmid=29522176 |doi-access=free}}</ref>

<!-- Epidemiology -->
Hirsutism affects between 5 and 15% of women across all ethnic backgrounds.<ref>{{cite journal |author=Azziz R. |title=The evaluation and management of hirsutism |journal=Obstet Gynecol |date=May 2003 |volume=101 |issue=5 pt 1 |pages=995–1007 |pmid=12738163|doi=10.1016/s0029-7844(02)02725-4 }}</ref> Depending on the definition and the underlying data, approximately 40% of women have some degree of facial hair.<ref name="Blume">{{cite journal |vauthors=Blume-Peytavi U, Gieler U, Hoffmann R, Shapiro J |title=Unwanted Facial Hair: Affects, Effects and Solutions. |date=2007 |volume=215 |issue=2 |pages=139–146 |doi=10.1159/000104266 |pmid=17684377 |journal=Dermatology (Basel)|s2cid=9589835 }}</ref> About 10 to 15% of cases of hirsutism are idiopathic with no known cause.<ref name="pmid35292252" />

{{TOC limit|3}}

== Causes ==
{{See also|Hyperandrogenism#Causes}}

The causes of hirsutism can be divided into endocrine imbalances and non-endocrine etiologies. It is important to begin by first determining the distribution of [[body hair]] growth. If hair growth follows a male distribution, it could indicate the presence of increased androgens or hyperandrogenism. However, there are other hormones not related to androgens that can lead to hirsutism. A detailed history is taken by a provider in search of possible causes for hyperandrogenism or other non-endocrine-related causes. If the distribution of hair growth occurs throughout the body, this is referred to as [[hypertrichosis]], not hirsutism.<ref>{{Cite journal |last=Sachdeva |first=Silonie |title=Hirsutism: Evaluation and treatment |date=2010 |journal=Indian Journal of Dermatology |volume=55 |issue=1 |pages=3–7 |doi=10.4103/0019-5154.60342 |issn=0019-5154 |pmc=2856356 |pmid=20418968 |doi-access=free }}</ref>

=== Endocrine causes ===
Endocrine causes of hirsutism include:

* [[Ovarian cyst]]s such as in [[polycystic ovary syndrome]] (PCOS), the most common cause in women.<ref name="pmid18844715">{{cite journal |vauthors=Somani N, Harrison S, Bergfeld WF |title=The clinical evaluation of hirsutism |journal=Dermatol Ther |volume=21 |issue=5 |pages=376–91 |year=2008 |pmid=18844715 |doi=10.1111/j.1529-8019.2008.00219.x |s2cid=34029116 }}</ref> 
* [[Adrenal tumor|Adrenal gland tumor]]s, [[adrenocortical adenoma]]s, and [[adrenocortical carcinoma]], as well as [[adrenal hyperplasia]] due to [[pituitary adenoma]]s (as in [[Cushing's syndrome|Cushing's disease]]).<ref name="pmid21623779" />
* [[Inborn errors of steroid metabolism]] such as in [[congenital adrenal hyperplasia]], most commonly caused by [[congenital adrenal hyperplasia due to 21-hydroxylase deficiency|21-hydroxylase deficiency]].<ref name="pmid21623779">{{cite journal |vauthors=Unluhizarci K, Kaltsas G, Kelestimur F |title= Non polycystic ovary syndrome-related endocrine disorders associated with hirsutism |journal= Eur J Clin Invest |volume=42 |issue=1 |pages=86–94 |year=2012 |pmid=21623779 |doi= 10.1111/j.1365-2362.2011.02550.x |s2cid= 23701817 }}</ref>
* [[Acromegaly]] and [[gigantism]] ([[growth hormone]] and IGF-1 excess), usually due to [[pituitary tumor]]s.<ref name="pmid21623779" />

=== Non-endocrine causes ===
Causes of hirsutism not related to hyperandrogenism include:

* Familial: Family history of hirsutism with normal androgen levels.<ref name=":3">{{Cite journal |last1=Radi |first1=Suhaib |last2=Tamilia |first2=Michael |date=2019-12-30 |title=Adrenocortical carcinoma: an ominous cause of hirsutism |journal=BMJ Case Reports |volume=12 |issue=12 |pages=e232547 |doi=10.1136/bcr-2019-232547 |issn=1757-790X |pmc=6954802 |pmid=31892624}}</ref>
* Drug-induced: medications were used before the onset of hirsutism. The recommendation is to stop the medication and replace it with another.<ref name=":0" />
** [[Minoxidil]]<ref name="pmid26903750">{{cite journal | vauthors = Chellini PR, Pirmez R, Raso P, Sodré CT | title = Generalized Hypertrichosis Induced by Topical Minoxidil in an Adult Woman | journal = Int J Trichology | volume = 7 | issue = 4 | pages = 182–3 | year = 2015 | pmid = 26903750 | pmc = 4738488 | doi = 10.4103/0974-7753.171587 | doi-access = free }}</ref><ref name="pmid12702063">{{cite journal | vauthors = Dawber RP, Rundegren J | title = Hypertrichosis in females applying minoxidil topical solution and in normal controls | journal = J Eur Acad Dermatol Venereol | volume = 17 | issue = 3 | pages = 271–5 | year = 2003 | pmid = 12702063 | doi = 10.1046/j.1468-3083.2003.00621.x| s2cid = 23329383 }}</ref> 
** [[Androgen]]s like [[testosterone]], [[anabolic steroid]]s, and [[androgen]]ic [[progestin]]s<ref name=":3" /><ref name=":0" />
* [[Valproic acid]] and [[methyldopa]]<ref name=":3" /><ref name=":0" />
* [[Pregnancy]]: Due to changes in hormone production<ref name=":6" />
* [[Idiopathic disease|Idiopathic]]: When no other cause can be attributed to an individual's hirsutism, the cause is considered idiopathic by exclusion.<ref name=":0" /> In these cases, [[menstrual cycles]] and levels of conventionally tested androgens (testosterone, [[androstenedione]], and [[dehydroepiandrosterone sulfate]]) are normal.<ref name=":4">{{Cite journal |last1=Bode |first1=David |last2=Seehusen |first2=Dean A. |last3=Baird |first3=Drew |date=2012-02-15 |title=Hirsutism in Women |url=https://www.aafp.org/pubs/afp/issues/2012/0215/p373.html |journal=American Family Physician |language=en-US |volume=85 |issue=4 |pages=373–380|pmid=22335316 }}</ref> Around 10 to 15% of women with hirsutism have idiopathic hirsutism.<ref name="pmid35292252">{{cite journal | vauthors = de Kroon RW, den Heijer M, Heijboer AC | title = Is idiopathic hirsutism idiopathic? | journal = Clin Chim Acta | volume = 531 | issue = | pages = 17–24 | date = June 2022 | pmid = 35292252 | doi = 10.1016/j.cca.2022.03.011 | s2cid = 247419684 | url = | doi-access = free }}</ref> Idiopathic hirsutism may be due to increased production of [[dihydrotestosterone]] (DHT) in hair follicles and hence may actually still be due to hyperandrogenism.<ref name="pmid35292252" /> It may be detectable by measurement of DHT or DHT metabolites.<ref name="pmid35292252" />
** Rice et al. 2016 propose that idiopathic hirsutism is caused by epigenetic inheritance of discordant epigenetic markers. It is testable with current technology.<ref>{{Cite journal |last1=Rice |first1=William R. |last2=Friberg |first2=Urban |last3=Gavrilets |first3=Sergey |date=2016 |title=Sexually antagonistic epigenetic marks that canalize sexually dimorphic development |url=http://volweb2.utk.edu/~gavrila/papers/mol_ecol_16.pdf |journal=Molecular Ecology |language=en |volume=25 |issue=8 |pages=1812–1822 |bibcode=2016MolEc..25.1812R |doi=10.1111/mec.13490 |issn=0962-1083 |pmid=26600375 |s2cid=71599}}</ref>

{| class="wikitable"
|+
! Hormonal causes:<ref name=":3" />
! Description: 
! Clinical cues:
|-
| [[Polycystic ovary syndrome]]
| PCOS is a condition characterized by excess androgens that can lead to hirsutism, irregular periods, and even infertility. The excess androgens can lead to disruptions in normal body hormones in the [[Hypothalamic–pituitary–gonadal axis|hypothalamic-pituitary-gonadal axis]] leading to these symptoms.<ref name="pmid31384717">{{cite journal |vauthors=Witchel SF, Oberfield SE, Peña AS |title=Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls |journal=J Endocr Soc |volume=3 |issue=8 |pages=1545–1573 |date=August 2019 |pmid=31384717 |pmc=6676075 |doi=10.1210/js.2019-00078}}</ref> With PCOS, hair may grow on the face (like on the upper lip, chin, or jawline), chest, stomach, and back.<ref>{{Cite web |author=Emma |date=November 4, 2024 |title=What Are the First Signs of PCOS in Teenagers? |url=https://pcosnest.com/what-are-the-first-signs-of-pcos-in-teenager/ |website=PCOS Nest}}</ref>
| Characterized by having two of three Rotterdam criteria:

* Oligomenorrhea (fewer than eight menses in a year)
* Clinical or biochemical evidence of hyperandrogenism 
* Polycystic ovaries on ultrasound
<ref>{{Cite journal |last1=Legro |first1=Richard S. |last2=Arslanian |first2=Silva A. |last3=Ehrmann |first3=David A. |last4=Hoeger |first4=Kathleen M. |last5=Murad |first5=M. Hassan |last6=Pasquali |first6=Renato |last7=Welt |first7=Corrine K. |date=December 2013 |title=Diagnosis and Treatment of Polycystic Ovary Syndrome: An Endocrine Society Clinical Practice Guideline |journal=The Journal of Clinical Endocrinology & Metabolism |language=en |volume=98 |issue=12 |pages=4565–4592 |doi=10.1210/jc.2013-2350 |issn=0021-972X |pmc=5399492 |pmid=24151290}}</ref>
|-
| [[Cushing's syndrome]]
| Cushing syndrome occurs when there is an endogenous or exogenous elevated levels of cortisol. One cause of endogenous Cushing syndrome is an adrenocorticotrophic hormone-secreting pituitary adenoma that is responsible for high secretion of not just cortisol but also androgens from the pituitary gland.<ref name=":5">{{Cite journal |last1=Mihailidis |first1=John |last2=Dermesropian |first2=Racha |last3=Taxel |first3=Pamela |last4=Luthra |first4=Pooja |last5=Grant-Kels |first5=Jane M. |date=2015-06-04 |title=Endocrine evaluation of hirsutism |journal=International Journal of Women's Dermatology |volume=1 |issue=2 |pages=90–94 |doi=10.1016/j.ijwd.2015.04.003 |issn=2352-6475 |pmc=5418744 |pmid=28491965}}</ref>
| Cushing syndrome has an apparent symptoms including: Hirsutism weight gain, extra fat build up around the face, abdominal striae, and irregular menstruation.<ref name=":5" />
|-
| [[Congenital adrenal hyperplasia]]
| CAH can be attributed to several enzymatic deficiencies but the most common is [[Congenital adrenal hyperplasia due to 21-hydroxylase deficiency|21-beta-hydroxylase]]. In CAH, a missing enzyme responsible for normal cortisol synthesis creates a build-up of androgen precursors. This precursor gets shunted to the androgen synthesis pathway leading to increased levels of androgen. Classical CAH is discovered at birth due to increased androgens during development causing ambiguous genitalia. Meanwhile, non-classical CAH is found in puberty presenting as anovulation.<ref name=":4" />
| Can present similar to PCOS in non-classical CAH. Increase levels of 17-hydroxyprogesterone.<ref name=":3" /><ref name=":4" />
|-
| [[Androgen-secreting tumor]]s
| Tumors in the adrenal glands or in the ovaries leading to increase levels of androgens.<ref name=":4" />
| Rapid progression and [[virilization]] symptoms.<ref name=":3" />
|-
| Other less common hormonal causes: 
| [[Acromegaly]]: Elevated levels of [[insulin-like growth factor-1]].<ref name=":6">{{Citation |last1=Hafsi |first1=Wissem |title=Hirsutism |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK470417/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29262139 |access-date=2022-09-15 |last2=Badri |first2=Talel}}</ref> [[Hyperthyroidism]] or [[hypothyroidism]]: Elevated or decreased levels of thyroid hormones.<ref name=":6" /> [[Hyperprolactinemia]]: Elevated levels of [[prolactin]].<ref name=":6" />
| Each of these have their own distinct presentation.<ref name=":4" />
|}

==Diagnosis==
Hirsutism is a clinical diagnosis of excessive androgenic, terminal hair growth.<ref>{{Cite journal |last1=Ferriman |first1=D. |last2=Gallwey |first2=J. D. |date=November 1961 |title=Clinical assessment of body hair growth in women |url=https://pubmed.ncbi.nlm.nih.gov/13892577/ |journal=The Journal of Clinical Endocrinology and Metabolism |volume=21 |issue=11 |pages=1440–1447 |doi=10.1210/jcem-21-11-1440 |issn=0021-972X |pmid=13892577}}</ref> A complete physical evaluation should be done prior to initiating more extensive studies, the examiner should differentiate between widespread body hair increase and male pattern [[virilization]].<ref name=":0">{{Cite journal|last=Sachdeva|first=Silonie|date=2010|title=Hirsutism: Evaluation and treatment|journal=Indian Journal of Dermatology|volume=55|issue=1|pages=3–7|doi=10.4103/0019-5154.60342|pmc=2856356|pmid=20418968 |doi-access=free }}</ref> One method of evaluating hirsutism is the [[Ferriman-Gallwey score|Ferriman-Gallwey Score]] which gives a score based on the amount and location of hair growth.<ref name="pmid13892577">{{cite journal |vauthors=Ferriman D, Gallwey JD |title=Clinical assessment of body hair growth in women |journal=J. Clin. Endocrinol. Metab. |volume=21 |issue=11 |pages=1440–7 |date=November 1961 |pmid=13892577 |doi=10.1210/jcem-21-11-1440 |url=http://jcem.endojournals.org/cgi/pmidlookup?view=long&pmid=13892577 |access-date=2010-03-08 |archive-date=2021-08-28 |archive-url=https://web.archive.org/web/20210828111044/https://www.endocrine.org/journals/endocrine-press?view=long&pmid=13892577&view=long&pmid=13892577 |url-status=dead }}</ref> The Ferriman-Gallwey Score has various cutoffs due to variable expressivity of hair growth based on ethnic background.<ref>{{Cite journal |last1=Cheewadhanaraks |first1=Sopon |last2=Peeyananjarassri |first2=Krantarat |last3=Choksuchat |first3=Chainarong |date=May 2004 |title=Clinical diagnosis of hirsutism in Thai women |url=https://pubmed.ncbi.nlm.nih.gov/15222512/ |journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet |volume=87 |issue=5 |pages=459–463 |issn=0125-2208 |pmid=15222512}}</ref><ref>{{Cite journal |last1=Escobar-Morreale |first1=H. F. |last2=Carmina |first2=E. |last3=Dewailly |first3=D. |last4=Gambineri |first4=A. |last5=Kelestimur |first5=F. |last6=Moghetti |first6=P. |last7=Pugeat |first7=M. |last8=Qiao |first8=J. |last9=Wijeyaratne |first9=C. N. |last10=Witchel |first10=S. F. |last11=Norman |first11=R. J. |date=March 2012 |title=Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society |journal=Human Reproduction Update |volume=18 |issue=2 |pages=146–170 |doi=10.1093/humupd/dmr042 |issn=1460-2369 |pmid=22064667|doi-access=free }}</ref>

Diagnosis of patients with even mild hirsutism should include assessment of ovulation and ovarian [[Medical ultrasonography|ultrasound]], due to the high prevalence of [[polycystic ovary syndrome|polycystic ovary syndrome (PCOS)]], as well as [[17α-hydroxyprogesterone]] (because of the possibility of finding non-classic [[Congenital adrenal hyperplasia due to 21-hydroxylase deficiency|21-hydroxylase deficiency]]<ref name="pmid19338993">{{cite journal | vauthors = Di Fede G, Mansueto P, Pepe I, Rini GB, Carmina E | title = High prevalence of polycystic ovary syndrome in women with mild hirsutism and no other significant clinical symptoms | journal = Fertil. Steril. | volume = 94 | issue = 1 | pages = 194–7 | year = 2010 | pmid = 19338993 | doi = 10.1016/j.fertnstert.2009.02.056 | url = https://iris.unipa.it/bitstream/10447/36367/2/Fertility%20and%20Sterility%202010%2094%20194-7.pdf| hdl = 10447/36367 | hdl-access = free }}</ref>). People with hirsutism may present with an elevated serum [[Dehydroepiandrosterone sulfate|dehydroepiandrosterone sulfate (DHEA-S)]] level, however, additional imaging is required to discriminate between malignant and benign etiologies of adrenal hyperandrogenism.<ref>{{Cite journal |last1=d'Alva |first1=Catarina B. |last2=Abiven-Lepage |first2=Gwenaelle |last3=Viallon |first3=Vivian |last4=Groussin |first4=Lionel |last5=Dugue |first5=Marie Annick |last6=Bertagna |first6=Xavier |last7=Bertherat |first7=Jerôme |date=2008-11-01 |title=Sex steroids in androgen-secreting adrenocortical tumors: clinical and hormonal features in comparison with non-tumoral causes of androgen excess |url=https://eje.bioscientifica.com/view/journals/eje/159/5/641.xml |journal=European Journal of Endocrinology |language=en-US |volume=159 |issue=5 |pages=641–647 |doi=10.1530/EJE-08-0324 |pmid=18708437 |s2cid=6342456 |issn=0804-4643|doi-access= }}</ref>  Levels greater than 700 μg/dL are indicative of [[adrenal gland]] dysfunction, particularly [[congenital adrenal hyperplasia due to 21-hydroxylase deficiency]]. However, [[Polycystic ovary syndrome|PCOS]] and [[Idiopathic disease|idiopathic]] hirsutism make up 90% of cases.<ref name=":0"/>

== Treatment ==
Treatment of hirsutism is indicated when hair growth causes patient distress. The two main approaches to treatment are pharmacologic therapies targeting androgen production/action, and direct hair removal methods including electrolysis and photo-epilation. These may be used independently or in combination.<ref>{{Cite journal |last1=Martin |first1=Kathryn A |last2=Anderson |first2=R Rox |last3=Chang |first3=R Jeffrey |last4=Ehrmann |first4=David A |last5=Lobo |first5=Rogerio A |last6=Murad |first6=M Hassan |last7=Pugeat |first7=Michel M |last8=Rosenfield |first8=Robert L |date=2018-03-07 |title=Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society* Clinical Practice Guideline |journal=The Journal of Clinical Endocrinology & Metabolism |volume=103 |issue=4 |pages=1233–1257 |doi=10.1210/jc.2018-00241 |pmid=29522147 |issn=0021-972X|doi-access=free }}</ref>

=== Pharmacologic therapies ===
Common medications consist of antiandrogens, [[insulin sensitizer]]s, and [[oral contraceptive pill]]s. All three types of therapy have demonstrated efficacy on their own, however insulin sensitizers are shown to be less effective than antiandrogens and oral contraceptive pills.<ref name=":2">{{Cite journal |last1=Barrionuevo |first1=Patricia |last2=Nabhan |first2=Mohammed |last3=Altayar |first3=Osama |last4=Wang |first4=Zhen |last5=Erwin |first5=Patricia J |last6=Asi |first6=Noor |last7=Martin |first7=Kathryn A |last8=Murad |first8=M Hassan |date=2018-03-07 |title=Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis |journal=The Journal of Clinical Endocrinology & Metabolism |volume=103 |issue=4 |pages=1258–1264 |doi=10.1210/jc.2017-02052 |pmid=29522176 |s2cid=3783739 |issn=0021-972X|doi-access=free }}</ref> The therapies may be combined, as directed by a physician, in line with the patient's medical goals. [[Antiandrogen]]s are drugs that block the effects of [[androgen]]s like [[testosterone]] and [[dihydrotestosterone]] (DHT) in the body.''<ref name="pmid21623779" />'' They are the most effective pharmacologic treatment for patient-important hirsutism, however they have [[teratogenic]] potential, and are therefore not recommended in people who are pregnant or desire pregnancy. Current data does not favor any one type of oral contraceptive over another.<ref name=":2" />

''List of medications:''
<!---♦♦♦ Please keep the list in alphabetical order ♦♦♦--->
* [[Bicalutamide]]: A pure antiandrogen.<ref name="WilliamsBigby2009">{{cite book |first1=Hywel |last1=Williams |first2=Michael |last2=Bigby |first3=Thomas |last3=Diepgen |first4=Andrew |last4=Herxheimer |first5=Luigi |last5=Naldi |first6=Berthold |last6=Rzany | name-list-style = vanc |title=Evidence-Based Dermatology |url=https://books.google.com/books?id=SbsQij5xkfYC&pg=PA529 |date=22 January 2009 |publisher=John Wiley & Sons |isbn=978-1-4443-0017-8 |pages=529–}}</ref><ref name="pmid24455796">{{cite journal | vauthors = Erem C | title = Update on idiopathic hirsutism: diagnosis and treatment | journal = Acta Clinica Belgica | volume = 68 | issue = 4 | pages = 268–74 | year = 2013 | pmid = 24455796 | doi = 10.2143/ACB.3267 | s2cid = 39120534 }}</ref><ref name="pmid11915584">{{cite journal | vauthors = Müderris II, Bayram F, Ozçelik B, Güven M | title = New alternative treatment in hirsutism: bicalutamide 25 mg/day | journal = Gynecological Endocrinology | volume = 16 | issue = 1 | pages = 63–6 | date = February 2002 | pmid = 11915584 | doi = 10.1080/gye.16.1.63.66 | s2cid = 6942048 }}</ref> It is effective similarly to flutamide but is much safer as well as better-tolerated.<ref name="WilliamsBigby2009" /><ref name="pmid24455796" /><ref name="pmid11915584" />
* [[Birth control pill]]s that consist of an [[estrogen]], usually [[ethinylestradiol]], and a [[progestin]] are supported by the evidence.<ref name=":1" /><ref name="Barr2018" /> They are functional antiandrogens. In addition, certain birth control pills contain a progestin that also has antiandrogenic activity.<ref name="Ekback2017">{{cite journal |last=Ekback |first=Maria Palmetun |year=2017 |title=Hirsutism, What to do? |url=https://www.researchgate.net/publication/321245014 |format=PDF |journal=International Journal of Endocrinology and Metabolic Disorders |volume=3 |issue=3 |doi=10.16966/2380-548X.140 |issn=2380-548X |doi-access=free}}</ref> Examples include birth control pills containing [[cyproterone acetate]], [[chlormadinone acetate]], [[drospirenone]], and [[dienogest]].<ref name="Ekback2017" /><ref name="Blume-PeytaviWhiting2008" />
* [[Cyproterone acetate]]: A dual antiandrogen and [[progestogen]].<ref name="pmid24889738" /> In addition to single form, it is also available in some formulations of combined oral contraceptives at a low dosage (see below).<ref name="pmid24889738" /> It has a risk of [[hepatotoxicity|liver damage]].
* [[Eflornithine]]: Blocks [[putrescine]] that is necessary for the growth of hair follicles.<ref>{{Cite journal |last1=Wolf |first1=John E. |last2=Shander |first2=Douglas |last3=Huber |first3=Ferdinand |last4=Jackson |first4=Joseph |last5=Lin |first5=Chen-Sheng |last6=Mathes |first6=Barbara M. |last7=Schrode |first7=Kathy |last8=the Eflornithine HCl Study Group |date=January 2007 |title=Randomized, double-blind clinical evaluation of the efficacy and safety of topical eflornithine HCl 13.9% cream in the treatment of women with facial hair: Eflornithine treatment for unwanted facial hair |url=https://onlinelibrary.wiley.com/doi/10.1111/j.1365-4632.2006.03079.x |journal=International Journal of Dermatology |language=en |volume=46 |issue=1 |pages=94–98 |doi=10.1111/j.1365-4632.2006.03079.x|pmid=17214730 |s2cid=10795478 }}</ref>
* [[Finasteride]] and [[dutasteride]]: [[5α-Reductase inhibitor]]s.<ref name="Blume-PeytaviWhiting2008" /> They inhibit the production of the potent androgen DHT.<ref name="Blume-PeytaviWhiting2008" /> A meta-analysis showed inconsistent results of finasteride in the treatment of hirsutism.<ref name=":1" />
* [[Flutamide]]: A pure antiandrogen.<ref name="pmid24889738" /> It has been found to possess equivalent or greater effectiveness than spironolactone, cyproterone acetate, and [[finasteride]] in the treatment of hirsutism.<ref name="Publishers1999">{{cite book|author=Bentham Science Publishers|title=Current Pharmaceutical Design|url=https://books.google.com/books?id=9rfNZL6oEO0C&pg=PA717|date=September 1999|publisher=Bentham Science Publishers|pages=712–717}}</ref><ref name="pmid24889738" /> However, it has a high risk of liver damage and hence is no longer recommended as a first- or second-line treatment.<ref name="pmid28379593">{{cite journal | vauthors = Giorgetti R, di Muzio M, Giorgetti A, Girolami D, Borgia L, Tagliabracci A | title = Flutamide-induced hepatotoxicity: ethical and scientific issues | journal = Eur Rev Med Pharmacol Sci | volume = 21 | issue = 1 Suppl | pages = 69–77 | year = 2017 | pmid = 28379593 }}</ref><ref name="Ostrzenski2002">{{cite book|author=Adam Ostrzenski|title=Gynecology: Integrating Conventional, Complementary, and Natural Alternative Therapy|url=https://books.google.com/books?id=TYlZsGdwqrQC&pg=PA86|year=2002|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-2761-7|pages=86–}}</ref><ref name="Blume-PeytaviWhiting2008">{{cite book|author1=Ulrike Blume-Peytavi|author2=David A. Whiting|author3=Ralph M. Trüeb|title=Hair Growth and Disorders|url=https://books.google.com/books?id=pHrX2-huQCoC&pg=PA181|date=26 June 2008|publisher=Springer Science & Business Media|isbn=978-3-540-46911-7|pages=181–,369–}}</ref><ref name="Becker2001">{{cite book|author=Kenneth L. Becker|title=Principles and Practice of Endocrinology and Metabolism|url=https://books.google.com/books?id=FVfzRvaucq8C&pg=PA1196|year=2001|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-1750-2|pages=1196, 1208}}</ref> Flutamide is safe and effective.<ref name=":1">{{Cite journal|last1=van Zuuren|first1=Esther J|last2=Fedorowicz|first2=Zbys|last3=Carter|first3=Ben|last4=Pandis|first4=Nikolaos|date=2015-04-28|title=Interventions for hirsutism (excluding laser and photoepilation therapy alone)|url=http://www.cochrane.org/CD010334/SKIN_treatments-unwanted-male-pattern-hair-growth-women|journal=Cochrane Database of Systematic Reviews|volume=2015 |issue=4|pages=CD010334|language=en|doi=10.1002/14651858.CD010334.pub2|pmid=25918921|issn=1465-1858|pmc=6481758}}</ref>
* [[GnRH analogue]]s: Suppress androgen production by the gonads and reduce androgen concentrations to castrate levels.<ref>{{Cite journal |last1=Mongioi |first1=A. |last2=Maugeri |first2=G. |last3=Macchi |first3=M. |last4=Calogero |first4=A. |last5=Vicari |first5=E. |last6=Coniglione |first6=F. |last7=Aliffi |first7=A. |last8=Sipione |first8=C. |last9=D'Agata |first9=R. |date=February 1986 |title=Effect of gonadotrophin-releasing hormone analogue (GnRH-A) administration on serum gonadotrophin and steroid levels in patients with polycystic ovarian disease |url=https://pubmed.ncbi.nlm.nih.gov/3082098/ |journal=Acta Endocrinologica |volume=111 |issue=2 |pages=228–234 |doi=10.1530/acta.0.1110228 |issn=0001-5598 |pmid=3082098}}</ref>
* [[Metformin]]: Insulin sensitizer. Antihyperglycemic drug used for diabetes mellitus and treatment of hirsutism associated with insulin resistance (e.g. [[polycystic ovary syndrome]]). Metformin appears ineffective in the treatment of hirsutism, although the evidence was of low quality.<ref name=":1" />
* [[Spironolactone]]: An [[antimineralocorticoid]] with additional antiandrogenic activity at high dosages.<ref name="pmid18389188">{{cite journal |author=Karakurt F |title=Comparison of the clinical efficacy of flutamide and spironolactone plus ethinyloestradiol/cyproterone acetate in the treatment of hirsutism: a randomised controlled study |journal=Adv Ther |volume=25 |issue=4 |pages=321–8 |date=April 2008 |pmid=18389188 |doi=10.1007/s12325-008-0039-5 |name-list-style=vanc|author2=Sahin I |author3=Güler S |display-authors=3 |last4=Demirbas |first4=Berrin |last5=Culha |first5=Cavit |last6=Serter |first6=Rustu |last7=Aral |first7=Yalcin |last8=Bavbek |first8=Nuket|s2cid=23641936 }}</ref><ref name="pmid24889738">{{cite journal | vauthors = Somani N, Turvy D | title = Hirsutism: an evidence-based treatment update | journal = Am J Clin Dermatol | volume = 15 | issue = 3 | pages = 247–66 | year = 2014 | pmid = 24889738 | doi = 10.1007/s40257-014-0078-4 | s2cid = 45234892 }}</ref>

=== Other methods ===
<!---♦♦♦ Please keep the list in alphabetical order ♦♦♦--->
* [[Electrology]]
* [[Epilation]]
* [[Laser hair removal]]
* Lifestyle change, including reducing excessive weight and addressing [[insulin resistance]], may be beneficial. Insulin resistance can cause excessive testosterone levels in women, resulting in hirsutism.<ref>{{Cite journal |vauthors=Taylor SI, Dons RF, Hernandez E, Roth J, Gorden P | title = Insulin resistance associated with androgen excess in women with autoantibodies to the insulin receptor| pmid = 7149493 | volume=97 | issue=6 |date=December 1982 | pages=851–5 | doi=10.7326/0003-4819-97-6-851 | journal=Ann. Intern. Med.}}</ref>
* [[Shaving]]
* [[Waxing]]

==See also==
<!---♦♦♦ Please keep the list in alphabetical order ♦♦♦--->
* [[Androgenic hair]]
* [[Bearded lady]]
* [[Ferriman-Gallwey score]]
* [[Hair removal]]
* [[Hypertrichosis]]
* [[Laser hair removal]]
* [[Petrus Gonsalvus]]
* [[Polycystic ovary syndrome]] (PCOS)
* [[Pubic hair]]
* [[Social model of disability]]
* [[Trichophilia]]

==References==
{{Reflist}}

==External links==
*{{Wiktionary-inline}}
*{{Commons category-inline}}
{{Medical resources
|  DiseasesDB      = 20309 
|  ICD10           = {{ICD10|L|68|0|l|60}} 
|  ICD9            = {{ICD9|704.1}} 
|  ICDO            = 
|  OMIM            = 
|  MedlinePlus     = 003148 
|  eMedicineSubj   = med 
|  eMedicineTopic  = 1017 
|  eMedicine_mult  = {{eMedicine2|derm|472}} 
|  MeshID          = D006628
}}
* [https://web.archive.org/web/20060428190235/http://www.hairchick.com/excess_hair/hirsutism.php Why the Bearded Lady Was Never a Laughing Matter: Hirsutism]
* [https://web.archive.org/web/20160303232353/http://www.margencero.com/montoya/barbuda_english.html The Bearded Lady]

{{Disorders of skin appendages}}
{{Authority control}}

[[Category:Conditions of the skin appendages]]
[[Category:Ethnological show business]]