Semin Reprod Med 2003; 21(3): 285-294 DOI: 10.1055/s-2003-43306
Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662
The Diagnosis and Management of Hirsutism
Adrienne B. Neithardt1
, Randall B. Barnes2
1 Department of Obstetrics and Gynecology, Northwestern University Medical School and Prentice Women's Hospital, Chicago, Illinois
2 Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Northwestern University Medical School and Prentice Women's Hospital, Chicago, Illinois
ABSTRACT
Approximately 10% of women of childbearing age are hirsute, which is defined as the presence of coarse terminal hairs in androgen-dependent areas on the face and body. It not only is a source of psychological discomfort but also may be a sign of an underlying medical condition. This article reviews the pathophysiology, diagnosis, evaluation, and treatment of hirsutism.
KEYWORDS
Hirsutism - hyperandrogenism - antiandrogens - hair removal
REFERENCES
1
Deplewski D, Rosenfield R.
Role of hormones in pilosebaceous unit development.
Endocr Rev .
2000;
21
362-392
2
Ferriman D, Gallwey J D.
Clinical assessment of body hair growth in women.
J Clin Endocrinol Metab .
1961;
21
1440-1447
3
Knoochenhauer E S, Key T J, Kahsar-Miller M, Waggoner W, Boots L R, Azziz R.
Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study.
J Clin Endocrinol Metab .
1998;
83
3078-3082
4
Azziz R, Carmina E, Sawaya M.
Idiopathic hirsutism.
Endocr Rev .
2000;
21
347-362
5
Paus R, Cotsarelis G.
Mechanisms of disease: the biology of hair follicles.
N Engl J Med .
1999;
341
491-497
6 Habif T P. Clinical Dermatology. 3rd ed. St. Louis: Mosby-Year Book 1996: 739-740
7
Jaworsky C, Gilliam A C.
Update on dermatopathology: immunology of the human hair follicle.
Dermatol Clin .
1999;
17
561-569
8
Gilliam A C, Kremer I B, Yosida Y. et al .
The human hair follicle: a reservoir of CD40+ B7-deficient Langerhans cells that repopulate epidermis after UVB exposure.
J Invest Dermatol .
1998;
110
422-427
9
Staricco R G.
Amelanotic melanocytes in the outer sheath of the human hair follicle and their role in the repigmentation of regenerated epidermis.
Ann N Y Acad Sci .
1963;
100
239-255
10 Paus R. Immunology of the hair follicle. In: Bos JD, ed. Skin Immune System 2nd ed. Boca Raton, FL: CRC Press 1997: 377-398
11
Christoph T, Muller-Rover S, Audring H. et al .
The human hair follicle immune system: cellular composition and immune privilege.
Br J Dermatol .
2000;
142
862-873
12 Speroff L, Glass R H, Kase N G. Clinical Gynecologic Endocrinology and Infertility 6th ed. Philadelphia: Lippincott Williams & Wilkins; 1999 40-51: 523-556
13 Chuong C-M. Molecular Basis of Epithelial Appendage Morphogenesis: Molecular Biology Intelligence Unit 1. Austin, TX: RG Landes; 1998
14
Zhou P, Byrne C, Jacobs J, Fuchs E.
Lymphoid enhancing factor 1 directs hair follicle patterning and epithelial cell fate.
Genes Dev .
1995;
9
100-113
15
Hardy M H.
The secret life of the hair follicle.
Trends Genet .
1992;
8
55-61
16
Ebling F J.
Hair.
J Invest Dermatol .
1976;
67
98-105
17
Messenger A G.
The control of hair growth: an overview.
J Invest Dermatol .
1993;
101
4S-9S
18
Lindner G, Botchkarev V A, Botchkareva N V. et al .
Analysis of apoptosis during hair follicle regression.
Am J Pathol .
1997;
151
1601-1617
19
Lorenzo E M.
Familial study of hirsutism.
J Clin Endocrinol .
1970;
31
556-564
20
Hatch R, Rosenfield R L, Kim M H, Tredway D.
Hirsutism: implications, etiology, and management.
Am J Obstet Gynecol .
1981;
140
815-830
21
Hock D, Seifer D.
New treatments of hyperandrogenism and hirsutism.
Obstet Gynecol Clin .
2000;
27
567-581
22 Berek J, Adash E, Hillard P. Novaks' Gynecology. 12th ed. Baltimore: Williams & Wilkins 1996: 834-836
23
Ryan K J.
Biological aromatization of steroids.
J Biol Chem .
1959;
234
234-268
24
Ryan K J, Smith O W.
Biogenesis of steroid hormones in the human ovary.
Recent Prog Horm Res .
1965;
21
367
25
Azziz R, Zacur H A.
21-Hydroxylase deficiency in female hyperandrogenism: screening and diagnosis.
J Clin Endocrinol Metab .
1989;
69
577-584
26
Glickman S P, Rosenfield R L.
Androgen metabolism by isolated hairs from women with idiopathic hirsutism is usually normal.
J Invest Dermatol .
1984;
82
62-66
27
Wiebe R H, Morris C V.
Effect of an oral contraceptive on adrenal and ovarian androgenic steroids.
Obstet Gynecol .
1984;
63
12-14
28
Barnes R B.
Diagnosis and therapy of hyperandrogenism.
Baillieres Clin Obstet Gynaecol .
1997;
11
369-396
29
Lobo R A.
Ovarian hyperandrogenism and androgen-producing tumors.
Endocrinol Metab Clin North Am .
1991;
20
773-805
30
Ehrman D A, Barnes R B, Rosenfield R L.
Polycystic ovary syndrome as a form of functional ovarian hyperandrogenism due to dysregulation of androgen secretion.
Endocr Rev .
1995;
16
322-353
31
Barnes R B, Rosenfield R L, Burstein S, Ehrman D A.
Pituitary-ovarian responses to nafarelin testing in the polycystic ovary syndrome.
N Engl J Med .
1989;
320
559-565
32
Rosenfield R L, Barnes R B, Ehrman D A.
Studies of the nature of 17-hydroxyprogesterone hyperresponsiveness to gonadotropin-releasing hormone agonist challenge in functional ovarian hyperandrogenism.
J Clin Endocrinol Metab .
1994;
79
1686-1692
33
Chetkowski R J, Defazio J, Shamonki I. et al .
The incidence of late-onset congenital adrenal hyperplasia due to 21-hydroxylase deficiency in hirsute women.
J Clin Endocrinol Metab .
1984;
58
595-598
34
Kutten F, Coullin P, Girard F. et al .
Late-onset adrenal hyperplasia in hirsutism.
N Engl J Med .
1985;
313
224-231
35
White P C, New M I, Dupont B.
Congenital adrenal hyperplasia.
N Engl J Med .
1987;
316
1580-1586
36
Carmina E.
Prevalence of idiopathic hirsutism.
Eur J Endocrinol .
1998;
139
421-423
37
Mowszowicz I, Melanitou E, Doukani A. et al .
Androgen binding capacity and 5α-reductase activity in pubic skin fibroblasts from hirsute patients.
J Clin Endocrinol Metab .
1983;
56
1209-1213
38
Couzinet B, Pholsena M, Young J, Schaison G.
The impact of a pure anti-androgen (flutamide) on LH, FSH, androgens and clinical status in idiopathic hirsutism.
Clin Endocrinol (Oxf) .
1993;
39
157-162
39
Thorneycroft I H.
Current issues in oral contraceptive therapy: update on androgenicity.
Am J Obstet Gynecol .
1999;
180
288-294
40
Azziz R, Ochoa T M, Bradley Jr L E. et al .
Leuprolide and estrogen versus oral contraceptive pills for the treatment of hirsutism: a prospective randomized study.
J Clin Endocrinol Metab .
1995;
80
3406-3411
41
Heiner J S, Greendale G A, Kawakami A K. et al .
Comparison of a gonadotropin-releasing hormone agonist and a low does oral contraceptive given alone or together in the treatment of hirsutism.
J Clin Endocrinol Metab .
1995;
80
3412-3418
42
Chang R J, Laufer L R, Meldrum D R. et al .
Steroid secretion in polycystic ovarian disease after ovarian suppression by a long-acting gonadotropin-releasing hormone agonist.
J Clin Endocrinol Metab .
1983;
56
897-903
43
Andreyko J L, Monroe S E, Jaffe R B.
The treatment of hirsutism with a gonadotropin-releasing hormone agonist (nafarelin).
J Clin Endocrinol Metab .
1986;
63
854-859
44
Steingold K, De Ziegler D, Cedars M. et al .
Clinical and hormonal effect of chronic gonadotropin-releasing hormone agonist treatment in polycystic ovarian disease.
J Clin Endocrinol Metab .
1987;
65
773-778
45
Rittmaster R S.
Differential suppression of testosterone and estradiol in hirsute women with the superactive gonadotropin-releasing hormone agonist leuprolide.
J Clin Endocrinol Metab .
1988;
67
651-655
46
Falsetti L, Pasinetti E.
Treatment of moderate and severe hirsutism by gonadotropin-releasing hormone agonists in women with polycystic ovarian syndrome and idiopathic hirsutism.
Fertil Steril .
1991;
56
427-433
47
Elkind-Hirsch K E, Anania C, Mack M, Malinak R.
Combination gonadotropin-releasing hormone agonist and oral contraceptive therapy improves treatment of hirsute women with ovarian hyperandrogenism.
Fertil Steril .
1995;
63
970-978
48
Carr B R, Breslau N A, Givens C. et al .
Oral contraceptive pills, gonadotropin-releasing hormone agonists, or use in combination for the treatment of hirsutism: a clinical research center study.
J Endocrinol Metab .
1995;
80
1169-1178
49
Yucelten D, Erenus M, Gurbuz O, Durmusoglu F.
Recurrence rates of hirsutism after 3 different antiandrogen therapies.
J Am Acad Dermatol .
1999;
41
64-68
50
Rittmaster R S.
Clinical review 73: medical treatment of androgen dependent hirsutism.
J Clin Endocrinol Metab .
1995;
80
2559-2563
51
Carmina E, Lobo R A.
Peripheral androgen blockade versus glandular suppression in the treatment of hirsutism.
Obstet Gynecol .
1991;
78
845-849
52
Mowszowicz I, Wright F, Vincens M. et al .
Androgen metabolism in hirsute patients treated with cyproterone acetate.
J Steroid Biochem .
1984;
20
757-761
53
Hammerstein J, Meckies J, Leo-Rossberg I. et al .
Use of cyproterone acetate (CPA) in the treatment of acne, hirsutism and virilism.
J Steroid Biochem .
1975;
6
827-836
54
Young R L, Goldzieher J W, Elkind-Hirsch K.
The endocrine effects of spironolactone used as an antiandrogen.
Fertil Steril .
1987;
48
223-228
55
Lobo R A, Shoupe D, Serafini P, Brinton D, Horton R.
The effects of two doses of spironolactone on serum androgens and anagen hair in hirsute women.
Fertil Steril .
1985;
43
200-205
56
Evans D J, Burke C W.
Spironolactone in the treatment of idiopathic hirsutism and the polycystic ovarian syndrome.
J R Soc Med .
1986;
79
451-453
57
Barth J H, Cherry C A, Wojnarowaka F, Dawber R P.
Spironolactone is an effective and well tolerated systemic anti-androgen therapy for hirsute women.
J Clin Endocrinol Metab .
1989;
68
966-970
58
McMullen G R, Van Herle J A.
Hirsutism and the effectiveness of spironolactone in its management.
J Endocrinol Invest .
1993;
16
925-932
59
Cumming D C, Yang J C, Rebar R W, Yen S SC.
Treatment of hirsutism with spironolactone.
JAMA .
1982;
247
1295-1298
60
Chapman M G, Dowsett M, Dewhurst C J, Jeffcoate S L.
Spironolactone in combination with an oral contraceptive: an alternative treatment of hirsutism.
Br J Obstet Gynaecol .
1985;
92
983-985
61
Simard J, Luthy I, Guay J, Belanger A, Labrie F.
Characteristics of interaction of the antiandrogen flutamide with the androgen receptor in various target tissues.
Mol Cell Endocrinol .
1986;
44
261-270
62
Muderris I I, Bayram F, Sahin Y, Kelestimur F.
A comparison of two doses of flutamide (250 mg/d and 500 mg/d) in the treatment of hirsutism.
Fertil Steril .
1997;
68
644-647
63
Erenus M, Gurbuz O, Durmusoglu F. et al .
Comparison of the efficacy of spironolactone versus flutamide in the treatment of hirsutism.
Fertil Steril .
1994;
61
613-616
64
Moghetti P, Tosi F, Tosi A. et al .
Comparison of spironolactone, flutamide and finasteride in the treatment of hirsutism: a randomized, double blind, placebo-controlled trial.
J Clin Endocrinol Metab .
2000;
85
90-94
65
Cusan L, Dupont A, Gomez J L, Tremblay R R, Labrie F.
Comparison of flutamide and spironolactone in the treatment of hirsutism: a randomized controlled trial.
Fertil Steril .
1994;
61
281-287
66
Lapointe J, Fournier A, Richard V, Labrie C.
Androgens down-regulate bcl-2 protooncogenes expression in ZR-75-1 human breast cancer cells.
Endocrinology .
1999;
140
416-421
67
Tolino A, Petrone A, Sarnacchiaro F. et al .
Finasteride in the treatment of hirsutism: new therapeutic perspectives.
Fertil Steril .
1996;
66
61-65
68
Fruzzetti F, Delorenzo D, Parini D, Ricci C.
Effects of finasteride, a 5α-reductase inhibitor, on circulating androgens and gonadotropin secretion in hirsute women.
J Clin Endocrinol Metab .
1994;
79
831-835
69
Moghetti P, Castello R, Magnani C M. et al .
Clinical and hormonal effects of the 5α-reductase inhibitor finasteride in idiopathic hirsutism.
J Clin Endocrinol Metab .
1994;
79
1115-1121
70
Ciotta L, Cianci A, Calogero A E. et al .
Clinical and endocrine effects of finasteride, a 5α-reductase inhibitor, in women with idiopathic hirsutism.
Fertil Steril .
1995;
64
299-306
71
Ogawa H, Hattori M.
Regulation mechanisms of hair growth.
Curr Probl Dermatol .
1983;
11
159-170
72
Hynd P L, Nancarrow M J.
Inhibition of polyamine synthesis alters hair follicle function and fiber composition.
J Invest Dermatol .
1996;
106
249-253
73 Schrode K, Huber F, Staszak J. et al .Randomized, double-blind, vehicle-controlled safety and efficacy evaluation of eflornithine 15% cream in the treatment of women with excessive facial hair. Poster presented at American Academy of Dermatology Annual Meeting; March 11-14, 2000; San Francisco
74 Patient information leaflet and prescribing information for Vaniqa (Bristol-Myers Squibb) Available at: http//www.vaniqa.com/pdf/pi.pdf .
75
Oh H-S, Smart R C.
An estrogen receptor pathway regulated the telogen-anagen hair follicle transition and influences epidermal cell proliferation.
Proc Natl Acad Sci U S A .
1996;
93
12525-12530
76
Olsen E.
Methods of hair removal.
J Am Acad Dermatol .
1999;
40
143-155
77 Schoen L A, Lazar P. The Look You Like. New York: Marcel Dekker 1990: 133-144
78
Ramos-E-Silva M, De Castro C M, Carneiro L V.
Hair removal.
Clin Dermatol .
2001;
19
437-444
79
Dierickx C.
Hair removal by lasers and intense pulsed light sources.
Semin Cutan Med Surg .
2000;
19
267-275
80
Dierickx C, Alora M B, Dover J S.
Laser hair removal.
Dermatol Clin .
1999;
17
357-366
81
Draelos Z.
Cosmetics: an overview.
Curr Probl Dermatol .
1995;
7
43-64
82
Anderson R R, Parrish J A.
Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation.
Science .
1983;
220
24-27
83
Grossman M C, Dwyer P, Wiberley J. et al .
PDT for hirsutism.
Lasers Surg Med .
1995;
7(suppl)
44-47
84
Wheeland R G.
Laser-assisted hair removal.
Dermatol Clin .
1997;
15
469-477