Medical management of facial hirsutism

• Working Party – Lavery, Mackie, Kownacki, Smith, Scanlon, Conway & Messenger •

Definition

• The presence of terminal coarse hair growth in male patterns in women with normal or elevated circulating androgen levels

Aetiology

• Most common causes:
  • polycystic ovary syndrome (PCOS), defined as occuring when two of the following are present:
    • oligo- or anovulation
    • clinical and/or biochemical signs of hyperandrogenism
    • polycystic ovaries
  • idiopathic hirsutism (normal androgen levels and ovulatory function)
  • menopause
    
• Less common causes:
  • drug treatment (e.g. post-menopausal androgen therapy)
    • drugs known to induce hirsutism include ciclosporin, diazoxide, glucocorticoids and minoxidil
    • drugs likely to cause excess hair growth include anti-epileptics such as phenytoin and phenobarbitone
  • congenital adrenal hyperplasia
    
• Serious underlying causes:
  • androgen-secreting adrenal or ovarian tumours
  • Cushing's syndrome
  • severe insulin resistance
  • anabolic steroid use

Diagnosis and evaluation

• Eliminate any serious underlying cause of excess hair growth (see above)
  • review clinical history
  • refer patients with rapid onset and/or severe hirsutism for specialist assessment
  • assess hormonal status:
    • total testosterone
    • thyroid function
    • prolactin
    • luteinising hormone
    • follicle-stimulating hormone
  • confirm suspected PCOS with pelvic ultrasound
  • if necessary, refer patient to secondary care for further investigations (e.g. ovarian ultrasound or assessments of androstenedione, dehydroepiandrosterone, 17-alpha hydroxy progesterone and cortisol levels) to confirm diagnosis
    
• Evaluate severity of condition based on patient's perception of symptoms and impact on their quality of life

General principles of treatment

• Prescribe any pharmacological treatment in conjunction with self-help and/or lifestyle changes:
  • weight loss in overweight or obese patients, which is likely to improve metabolic and endocrine parameters
  • methods of hair removal that are acceptable to the patient (e.g. mechanical hair removal, laser therapy, electrolytic depilation). Advise patients treated with eflornithine cream that sustained cosmetic hair removal may be required for optimum effect