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Hirsutism and hypertrichosis

14 June 2019, by ROCHA M. F.


Chapter written with the help of the EADV, the Fondation René Touraine and the Therapeutics in Dermatology


Hirsutism is the excessive growth of hair in women, following a pattern of male distribution, as a result of the increased activity or sensitivity to normal levels of male hormones called androgens (such as testosterone).

Hypertrichosis is an increase in the amount of hair in any part of the body, in both sexes. Excess hair can appear all over the body or only in specific places that are not sensitive to androgens. This disorder may be present at birth or develop later.


In hirsutism we can find the so-called virilization effects produced by androgens:

  • Increase sebum production, which results in a greasy skin and acne.
  • Irregularity of ovulation and menstruation, sub - or infertility.
  • Baldness as in men.
  • Thick voice.
  • Increase in muscle mass.
  • Enlargement of the clitoris and reduction in breast size. 

Hair growth areas sensitive to androgens:

More common: upper lip, beard area, breasts, lower abdomen, internal thighs, and lower back.

Less common: thorax and sternum, upper abdomen, upper back.

The clinical forms of hypertrichosis will depend on their classification in congenital or acquired, or according to a pattern of generalized or localized growth.


Hair growth depends on the balance between male and female hormones. Male hormones stimulate the growth of thick and dark hair. Female hormones (such as estrogen) slow down hair growth making it thinner and lighter in color. Women normally produce small amounts of male hormones, while men produce small amounts of female hormones.

The disorders that tilt the hormonal balance in favor of male hormones cause hirsutism.

The most frequent cause of hirsutism is polycystic ovary syndrome.

Other less frequent causes are:

– Androgen-secreting tumors of adrenal glands, ovaries, lungs or digestive tract.

– Disorders of hypophysis (pituitary gland) that cause an excessive androgen production.

– Functional androgen excess:

  • Deficiencies of the adrenal enzymes: the main hormones of the adrenal gland are not synthesized (cortisol and aldosterone) and these are diverted by another metabolic route to become androgens.
  • Cushing’s syndrome: there is a chronic excess of cortisol that produces obesity, hypertension, diabetes and masculine characteristics.

– Idiopathic hirsutism (women’s hair follicles are simply more sensitive to normal levels of male hormones).

– Use of certain medications, such as anabolic steroids, danazol, oral contraceptives.

There are multiple causes of hypertrichosis according to its form of presentation (localized or generalized):


  • Drugs (Minoxidil, Phenytoin, Cyclosporine, Latanoprost, topical steroids...)
  • Porphyria.
  • Dermatomyositis.
  • Paraneoplastic syndromes (malignancy).
  • Traumatic brain injury, postviral encephalitis, alterations of hypophysis (pituitary gland) or hypothalamus.
  • Malnutrition, anorexia, bulimia.
  • Human immunodeficiency virus (AIDS).
  • Repeated trauma (lichen simplex chronicus, insect bites…)

Congenital: in these cases hypertrichosis is present from birth.

  • Congenital hypertrichosis lanuginosa (Ambras syndrome).
  • Hereditary gingival fibromatosis with generalized hypertrichosis.
  • Becker’s Nevus.
  • Hemihypertrophy (half of the body, or a part, presents a generalized hypertrophy of the soft tissues and skeleton).
  • Gingival fibromatosis with hypertrichosis.


The clinical history and physical examination of the patient can suggest the origin of the disorder and discern between a case of hirsutism or hypertrichosis. It is important to know about the timing and initial location of excessive hair growth, the regularity of menstrual cycle, family history, and about medications and products used.

During the physical examination, the pattern of hair growth and the presence of masculine features or other characteristics that help to guide the cause are observed.

Sometimes it is necessary to perform blood and urine tests to determine some hormone levels, and depending on the diagnostic suspicion, an ultrasound or computed tomography (CT) may be indicated.

The treatment will be based mainly on four pillars:

  • Treat the underlying disease or change medication.
  • Weight loss (may be useful in Polycystic ovary syndrome and obese patients, since obesity increases testosterone levels).
  • Hormonotherapy.
  • Discoloration or waxing for aesthetic improvement.

The treatment of excess hair is not necessary unless women want to minimize or eliminate for aesthetic reasons. If excessive hair growth is not related to an increase in male hormone levels, physical methods (waxing, laser, depilatory creams and shaver) will be used. But if the cause it is due an increase in androgen levels, hormone therapy will also be necessary.

Hormone therapy includes oral contraceptives and drugs that block the effects of male hormones, such as Finasteride, Flutamide and Spironolactone.

Metformin, a drug used to treat diabetes, reduces testosterone levels, but is less effective than other drugs.

Gonadotropin-releasing hormone agonists (such as Leuprorelin) can be used if the ovaries produce extremely high levels of male hormones, but the use of these drugs requires strict supervision by a gynecologist or endocrinologist. In addition, corticosteroids can be used to reduce the levels of androgens produced by tumors of the adrenal glands.

Discoloration is an alternative to hair removal. It is a cheap method and works well when you only have a slight excess of hair. Most products contain hydrogen peroxide.

Eflornithine cream decreases the speed of hair growth, and with its long-term use, can lengthen the time between hair removal treatments.


It is important to know that excess body hair can be hereditary, and the idea of excess varies according to culture.

The first thing that has to be determined in the face of an excess of body hair is whether it is due to a disorder (congenital or acquired) or simply is an aesthetic problem.

There are several alarm signs that may indicate the need an immediate medical evaluation, such as:

  • Development of male characteristics mentioned previously (virilization).
  • Appearance of excessive hair localized or generalized at birth.
  • Rapid start of excessive hair growth (during weeks or months).
  • Notice a bulge in abdomen or pelvis.

In general, women do not need to see a doctor if they have always had excess hair, feel well, have regular menstrual periods, do not have masculine characteristics and have relatives with excess hair.

Pregnant women or women who may become pregnant should not take medications that block male hormones, as they can cause the development of female characteristics in a male fetus.

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