TL;DR…What’s the lowdown?
- Excess hair growth (hirsutism) is pretty common, affecting 5-10% of women
- Hirsutism refers to hair growth in androgen sensitive areas such as face, chest and back
- It’s associated with the hormonal imbalances of Polycystic Ovary Syndrome (PCOS)
- Medications including the combined oral contraceptive pill can help treat symptoms
- The pill affects hair cycles so this can be why growth or loss may appear to change initially on the pill (but these symptoms settle with time)
- Electrolysis and laser hair removal can help to manage excess hair growth
Watching any razor or hair removal advert would have you believe that we should exist with Barbie doll smooth skin, where any hint of stubble calls for imminent removal faster than you can shout ‘Brazilian Wax.’
We still remember the PE room chatter, feeling mortified at a frighteningly young age about leg hair, or god forbid some armpit fuzz. Growing up against this backdrop, it’s hard to see what is normal and what isn’t…
In this piece we explore hirsutism and the various treatment options, including the combined pill.
Hirsutism: what is it?
Affecting around 5-10% of women, hirsutism is where coarse terminal hairs appear in a male-type distribution (like the face, back or stomach). Terminal hairs include pubic hairs and eyebrows (different to the softer, shorter vellus hairs that appear over the body).
Hypertrichosis (generalised hair increase) has other causes and isn’t discussed within this piece.
There are ways to diagnose hirsutism. After observing whether the hair growth is in male pattern areas, tests are:
- Ferriman-Gallwey scoring system: this looks at 9 key androgen sensitive areas which are each scored from 0 to 4 (excessive hair growth). A total score of 8 or more is used to determine hirsutism in black or white women of reproductive age. This score can be lower for some Asian and South American populations and higher for some Mediterrean, Middle Eastern or Hispanic populations.
- Elevated Androgens: If associated with PCOS, a blood sample showing elevated androgens (e.g. testosterone) could be a marker of diagnosis. However, diagnosis of PCOS requires further tests including a pelvic ultrasound to detect ovarian cysts and investigation into menstrual irregularities.
What causes hirsutism?
Polycystic Ovary Syndrome (PCOS)
Hirsutism is most commonly associated with PCOS (there’ll be more on this later). Studies suggest 72-82% of all hirsutism cases are due to PCOS.
In PCOS, some women may have small cyst-like follicles on their ovaries. These immature follicles often fail to ovulate and can be caused by hormonal imbalances such as excess androgens e.g. testosterone. To find out more about PCOS, we have a brilliant talk by PCOS expert Professor Colin Duncan on our website. Watch the recording here and check out this brilliant blog on contraception and PCOS.
Idiopathic Hirsutism (IH)
Sometimes hormone levels and ovarian function (e.g. ovulation and menstrual cycles) can be completely normal, this is known as Idiopathic Hirsutism with no other underlying cause identified. Less than 20% of cases of hirsutism are down to IH, but interestingly one half of women with mild hirsutism have IH (scores 8-15).
- Androgen secreting tumour: produces hormones such as testosterone
- Adrenal Hyperplasia: enlarged adrenal glands
- Cushing’s syndrome: an excess of the hormone cortisol
- Thyroid dysfunction: underactive thyroid gland
- Certain medications: including sodium valproate and anabolic steroids
Okay, some of the above sound pretty sinister but just to reassure you that these are much less common – most likely causes are PCOS or IH.
What’s the deal: PCOS and body/facial hair growth
So, to understand this connection we need to think about normal hair growth. Our bodies are covered with hair follicles, containing vellus or terminal hairs. In women, vellus areas are the fine, soft hairs on your face or back. You might not be able to see them unless you look closely. Terminal hairs are darker and thicker (typically covering the face and body in men), but in women cover the scalp, pubic areas and armpits.
Androgens (produced by the ovaries) can be elevated in women with PCOS causing excessive hair growth. This makes sense as men have a higher level of androgens and much more terminal hair spread throughout their bodies.
Your hair follicles may be sensitive to increased androgens which can be present with PCOS – this can cause the softer vellus hairs to change to thicker, faster growing terminal hairs. Usually, once a vellus hair has changed to a terminal hair it will not change back again.
The pill and hair growth
Normal hair growth occurs in cycles, whilst some follicles grow, others rest or shed. When taking the contraceptive pill, the hormonal changes can synchronise these cycles. This can make it look like your hair is growing or shedding more than normal. Don’t worry though, these patterns seem to regulate after 6-12 months. In fact, the pill is a popular treatment for hirsutism.
Remember to log a review if you see any changes to body or facial hair growth whilst on different forms of hormonal contraception! We also have a fab blog specifically on how the pill can affect hair.
Does PCOS hair disappear?
Given the link to excess androgens, the more that can be done (including lifestyle changes), to normalise testosterone levels, the more likely improvement is. Medications such as the combined pill or topical creams can be super effective in managing excess hair.
If overweight, losing weight can help as the hormonal imbalance in PCOS improves.
Does chin hair mean PCOS?
Plucking the odd straggly chin hair is normal and nothing to worry about – particularly if it’s finer hair. However, if you notice that there are repeated, thick, dark hairs, this could be due to the hormone imbalances seen in PCOS. However, diagnosing PCOS requires other tests and hallmarks. Remember some hair growth can be unexplained (evidence suggests it is genetic), so chin hairs alone are not enough to determine PCOS.
Natural treatments for excess hair
It is perfectly fine to use regular hair removal methods such as shaving and bleaching to manage excess hair. Waxing is not recommended as it can cause skin damage and ingrown hairs. However, a few longer-lasting non-medical solutions are:
- Laser hair removal: this inhibits hair follicle growth. Most effective with dark hair and fair skin – but repeated sessions are needed. Also, it can induce terminal hairs to minimise into vellus hairs, so any hair within that site should appear thinner and lighter. Plus, it’s less painful than electrolysis!
- Electrolysis: Disrupts hair growth using heat or chemical energy. Usually more effective than laser hair removal but can cause scarring.
Medical treatments for excess hair:
- The combined pill: Progestogen inhibits the ovarian production of androgens and oestrogen inhibits Sex Hormone Binding Globulin (SHBG), a hormone that controls testosterone production, to prevent excess hair growth.
- Eflornithine: This prescription cream can be applied to the skin twice a day and works best on facial hair growth.
- Anti-androgen medications:
- Spironolactone: This blocks androgen receptors and can be used alongside the combined pill.
- Finasteride: This drug influences enzymes that affect testosterone. However, it cannot be used for women who may want to get pregnant.
- Sachdeva, S. Hirsutism: Evaluation and Treatment 2010
- Clue Hirsutism and the menstrual cycle 2018
- NICE How should I assess for an underlying cause of hirsutism? 2020
- Bode, D., Seehusen, D., Baird, D. Hirsutism in Women 2012
- Khomami, M.B., Tehrani, F.R., Hashemi, S., Farahmand, M., Azizi, F. Of PCOS Symptoms, Hirsutism Has the Most Significant Impact on the Quality of Life of Iranian Women 2015
- British Association of Dermatologists. Hirsutism 2019
- Martin, K.A., Anderson, R.R., Chang, R.J., Ehrmann, D.A., Lobo, R.A., Murad, M.H., Pugeat, M.M., Rosenfield, R.L Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society* Clinical Practice Guideline 2018
- ASRM Hirsutism and Polycystic Ovary Syndrome 2016
- NHS UK Excessive Hair Growth (Hirsutism)
- Agrawal, N.K Management of hirsutism 2013
- Pasquali, R., Gambineri, A. THERAPY OF ENDOCRINE DISEASE: Treatment of hirsutism in the polycystic ovary syndrome 2014
- Gainder, S., Sharma, B., Update on Management of Polycystic Ovarian Syndrome for Dermatologists 2019