Hirsutism in Women


Hirsutism is defined as the presence of excessive terminal hair in androgen-dependent areas of a woman's body. The disorder is a sign of increased androgen action on hair follicles, from increased circulating levels of androgens (endogenous or exogenous) or increased sensitivity of hair follicles to normal levels of circulating androgens.

 

Hirsutism can develop at any age, but most patients begin experiencing symptoms during their childbearing years. In young girls who have not yet reached puberty, hirsutism is serious and could be a sign of a hormone-secreting tumor. During menopause, hirsutism is characterized by the thinning of underarm and pubic hair with gradual hair growth in other parts of the body. In post-menopausal women, sudden or severe hirsutism could be caused by an androgen-secreting tumor.
 

Hirsutism is a sign of increased androgen action on hair follicles, from increased circulating levels of androgens or increased sensitivity of hair follicles to normal levels of circulating androgens.

 

Commonly affected sites are the face , neck, extremities, trunk, breasts, linea alba, lower back, upper pubic triangle, and upper inner thighs . Unwanted hair is coarse, long and, often, pigmented.

Type

Hirsutism can be either androgen-dependent or nonandrogen-dependent (Drug-induced hirsutism).

Androgen-dependent Hirsutism

  • Hirsutism is caused by the overproduction of androgens, which are the hormones responsible for masculine qualities in either sex. While all women normally have some facial hair, hirsutism is characterized by excessive or rapidly growing hair in traditionally male areas of the body. If hirsutism is accompanied by other symptoms such as acne, amenorrhea, deepening of the voice, increased muscle mass or loss of breast tissue, this may signal a hormonal abnormality. Androgen-excess syndrome has several major features: seborrhea, acne, hirsutism, alopecia, obesity, and acanthosis nigricans. When hirsutism is associated with obesity and menstrual abnormalities, the source of androgen excess is often ovarian, typically polycystic ovary syndrome. When it is associated with average weight and normal menses, the source is often adrenal and rarely (in <5% of cases) pituitary.
     

  • Decreased androgen binding in the circulation - only free androgen is biologically active. Estrogens increase liver manufacture of SHBG. Androgens decrease it. Thus lack of estrogens can effectively increase available blood androgens. Also any ingestion of androgens by mouth will further decrease SHBG and make those ingested androgens even more available to stimulate hair growth.
     

  • Altered androgen metabolism (conversion from weak to potent androgens) - this is the most common cause of hirsutism and it appears to be the result of an increased conversion in the skin of testosterone to DHT.

Nonandrogen-dependent (Drug-induced hirsutism)

Many drugs can induce hirsutism, both generalized and localized. These agents, too, are divided into those that have androgenic activity and those that have nonandrogenic activity .

 

Commonly used drugs that have androgenic activity are testosterone, dehydroepiandrosterone sulfate (DHEAS), danazol (Danocrine), corticotropin, high-dose corticosteroids, metyrapone (Metopirone), phenothiazine derivatives, anabolic steroids, androgenic progestin, and acetazolamide (Dazamide, Diamox).

 

Common nonandrogenic drugs that can cause hirsutism include cyclosporine (Neoral, Sandimmune, SangCya), phenytoin (Dilantin), diazoxide (Hyperstat IV), triamterene-hydrochlorothiazide (Dyazide, Maxzide), minoxidil (Loniten, Rogaine), hexachlorobenzene, penicillamine (Cuprimine, Depen), and psoralens.

 


Hirsutism can present with a broad spectrum of symptoms including the following:

  • Excessive hair growth - individuals with hirsutism will often present with excess hair on areas of the body where hair follicles are sensitive to androgens including: face, chest, breast, lower back, midline region of the lower abdomen, inner thigh, arms, legs, etc.
     

  • Acne - excess androgen associated with hirsutism can also contribute to the development of acne, which may occur on the face, chest and/or upper-back.
     

  • Irregular menstrual cycle - increased androgen levels can also disrupt the normal menstrual cycles. In severe cases may cause women to be anovulatory.
     

  • Some major presenting complaints may occasionally include: nipple discharge, emotional dysfunction, recurrent miscarriage rate, pelvic pains


Doctors usually order blood levels of testosterone, to check out an ovarian source and DHEA-S to check out an adrenal source of excess androgens. If both studies show levels in normal range, treatment is directed toward reducing the available androgens in blood circulation.

 

Two other hormonal tests, prolactin and 17-OH progesterone may also be ordered especially if the excess hair growth has been present since puberty, there is a strong family history of hirsutism, ethnic background is Ashkenazi Jewish, a woman is shorter than other family members or there is evidence of defeminization such as a decrease in breast size. These risk factors can be associated with genetic causes of adrenal hirsutism that do not always result in elevated DHEA-S levels.

 

Treatment options for patients who have hirsutism can be divided into

  • Measures targeting local manifestations of hirsutism and

  • pharmacologic therapy aimed at the underlying causes.

Therapy that targets local manifestations includes physical methods of hair removal ranging from shaving to laser therapy, topical treatment, and weight loss.

Measures targeting local manifestations of hirsutism

Local measures such as shaving, bleaching, depilatories, and electrolysis may be used for hair removal. Shaving is the easiest and safest method, but is often unacceptable to patients. Bleaching products are often ineffective for dark hair growth, and may cause skin irritation . Chemical depilatories produce results similar to shaving, but skin irritation is common. Electrolysis is one of the most effective and permanent methods of hair removal, and may be an adjunct to hormonal treatment. However, electrolysis is costly and time consuming, and  has been replaced by use of laser techniques.

The need for rapid methods of hair removal has led to the development of laser therapy for hirsutism. Several different lasers exist, including ruby, alexandrite, pulsed diode, and Q-switched yttrium-aluminum-garnet (YAG) lasers. Pulsed diode lasers are generally less expensive and more reliable than other laser sources for hair removal. Q-switched YAG lasers work well in patients with darker skin; however, these lasers are ineffective for long-term hair removal. Most patients experience a two- to six-month growth delay after a single treatment, and some have permanent hair removal after multiple treatments. Laser therapy works best on dark hair.

Each of these methods has associated pros and cons which any consumer should consider. Temporary methods which remove hairs by the roots (waxing, sugaring, threading) are considered risky by some professionals due to the possible induction of bacteria into the blood stream. Sanitary procedures should always be followed to avoid infection.

 

Vaniqa - is a new FDA approved prescription medication applied to the skin for the reduction of unwanted facial hair. Vaniqa is prescribed for the treatment of unwanted facial hair around the lips and under the chin. The fragrance-free medication is applied similar to a moisturizing cream twice a day.

 Vaniqa works by actively inhibiting an enzyme located in the root of the hair follicle, which is responsible for hair growth. The medical breakthrough, Vaniqa, is proven to stop and prevent the growth of unwanted facial hair.

 

Note: If permanent hair removal is your goal, do not purchase equipment or services that do not have clearance unless you personally know someone who has had successful results. Ask the manufacturer to mail you a copy of their 510(k) clearance letter from the FDA or to supply you with their 510(k) number so you can look it up at the FDA website
 

Pharmacologic Treatment

Pharmacologic treatment for hirsutism should be aimed at blocking androgen action at hair follicles or suppression of androgen production

 

Medications Commonly Used in the Treatment of Hirsutism
 

Class of drug

Drug

Dosage

side effect and warning *

Comments

Cost (generic)

Oral contraceptives

Ethinyl estradiol with norgestimate, desogestrel, norethindrone, ethynodiol diacetate

One tablet per day for 21 days, followed byseven-day pill- free interval

GI distress, breast tenderness, headache, intolerance tocontact lenses

Pregnancy category X No FDA labeling for treatment of hirsutism
Least androgenic progestin component preferred

$31.00 per month

 

Ethinyl estradiol with drospirenone

 

Hyperkalemia may occur.
Contraindicated with hepatic dysfunction, renal insufficiency, adrenal disease

Monitor serum potassium during first cycle with concurrent use of NSAIDs, ACE inhibitors, angiotensin-II receptor blockers, heparin, potassium supplements, potassium sparing diuretics.

29.00 per month

Antiandrogens (no FDA labeling for treatment of hirsutism)

Spironolactone (Aldactone)

50 to 200 mg per day

Hyperkalemia (rare), theoretic feminization of male fetus, gynecomastia

Pregnancy category D
Irregular bleeding may occur, monitor electrolytes.

29.00 per month (22.00 to 25.00)

 

Flutamide (Eulexin)

250 mg two to three times daily

Monitor liver function.

Combine with other method of contraception.
Pregnancy category D

144.00 per month (125.00)

 

Finasteride (Proscar)

5 mg daily

Monitor liver function.

Pregnancy category X

70.00 per month

Glucocorticoids (no FDA labeling for treatment of hirsutism)

Dexamethasone

0.5 mg nightly

Weight gain, hypokalemia, decreased bone density, immune suppression

Pregnancy category C. May be combined with oral contraceptives or Gn-RH agonists for severe hirsutism.

20.00 per month (2.00 to 10.00)

 

Prednisone

5 to 10 mg daily

 

Pregnancy category C

1.50 per month (2.00 to 3.00)

Gn-RH agonists (no FDA labeling for treatment of hirsutism)

Leuprolide (Lupron)

3.75 mg IM per month for up to six months

Hot flushes, decreased bone mineral density, atrophic vaginitis

Pregnancy category X. Use with caution for short periods because of hypoestrogenic effect.

535.00 per month

 

 

11.25 mg IM every three months (depot form)

May need add-back HT.

Use nonhormonal contraception during treatment.

1,605.00 for three months

Antifungal agents (no FDA labelingfor treatment of hirsutism)

Ketoconazole (Nizoral)

400 mg daily

Scalp hair loss, dry skin, abdominal pain, fatigue, headache, vaginal spotting, hepatotoxicity

Pregnancy category C Use as last resort.

231.00 per month (182.00 to 190.00)

 

 

 

Monitoring of hepatic function necessary

 

 

Topical hair growthretardant

Eflornithine HCI(Vaniqa)

Apply to face twice daily at least eight hours apart.

Skin adverse effects include acne, erythema, stinging/burning, dry skin.
FDA approval for reduction of unwanted facial hair

Pregnancy category C
May cause mild elevations in transaminase levels.
No significant drug interaction known

42.00 for 30-g tube

Insulin-sensitizing agents (not FDA approved for treatment of hirsutism)

Metformin (Glucophage)

500 mg twice daily 1,000 mg twicedaily (maximaldosage 2.0 to 2.5 g per day)`
850 mg three times daily

GI distress, lactic acidosis (rare with mortality nearly 50 percent), numerous drug interactions
Monitor liver function, confirm normal renal function before starting,and monitor.

Pregnancy category B
Resumption of ovulation may occur.
No FDA labeling for treatment of PCOS

47.00 per month (42.00)

 

GI = gastrointestinal;
FDA = U.S. Food and Drug Administration;
NSAIDs = nonsteroidal anti-inflammatory drugs;
ACE = angiotensin-converting enzyme;
Gn-RH = gonadotropin-releasing hormone;
IM = intramuscular;
HT = hormone therapy;
PCOS = polycystic ovary syndrome.

*--For more detailed information, consult the package insert provided by the manufacturer of each drug.

--Estimated cost to the pharmacies (rounded to the nearest dollar) based on average wholesale prices in Red book, Montvale, N.J.: Medical Economics Data, 2002. Cost to the patient will be higher, depending on prescription filling fee.
 

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