Hirsutism

Hirsutism is defined as the excessive growth of terminal hair on the face and body of a female in a typical male pattern distribution. Untreated it can be associated with considerable loss of self-esteem and psychological morbidity. Hyperandrogenaemia is the key trigger for excess hair growth but the expression and severity are modified by genetic factors, such as sensitivity of the hair follicle to androgens, and metabolic factors, in particular body weight and hyperinsulinaemia. Polycystic ovary syndrome, resulting in excess ovarian androgen production, is the most common cause of hirsutism. A raised serum testosterone level of >5 nmol/l should prompt further investigations to exclude adrenal pathology or underlying androgen-secreting tumour. Treatment depends on the underlying cause. In women with polycystic ovary syndrome or idiopathic hirsutism, cyproterone acetate prescribed in a reversed sequential regimen with oestradiol is a very effective first-line treatment. Metformin is a useful second line approach in women with poor tolerance or poor response to cyproterone acetate. In all cases, weight reduction to achieve a normal body mass index is critical to achieving effective therapy.