Unwanted or excessive hair that grows on a woman’s face and body is the result of a condition called hirsutism; though all women have facial and body hair, but the hair is usually very fine and light in color.
Hirsutism is defined as the presence of terminal (coarse) hairs in females in a male-like pattern. It affects 5-10% of women. It is the most common cosmetic problem in women.
Hypertrichosis is a term applied to excessive hair growth developed all over the body or can be in small patches. It can present at any age, sex, and race. Hypertrichosis may be congenital (present at birth) or acquired (arises later in life).
Hirsutism is often a sign of underlying disorders. Hirsutism is usually due to increased androgen (testosterone) levels in females. The increased production of androgens is called hyperandrogenism, either due to adrenals or to an ovarian. Hirsutism is attributed either to increased production or increased sensitivity of the hair follicles to circulating androgen (testosterone).
Causes of Hirsutism: The causes of hirsutism can be divided into:
1.Non-androgenic factor, normal androgen levels,
2.Androgenetic factors due to androgen excess.
3.Idiopathic hirsutism-normal androgen level but related to disorders in peripheral androgen activity
1. Non-androgenic causes of hirsutism are relatively rare like acromegaly, the excess hair growth. Non-androgenic anabolic drugs will cause a generalized growth of many tissues, particularly vellus hair. It is called value hypertrichosis and not hirsutism. However, coarsening of the hairs may develop with chronic skin irritation.
2. Androgenic causes: the most common cause of hirsutism, accounting for approximately 70-85% of such patients. Androgen disorders include:
Ovarian disorders: Polycystic ovarian syndrome (PCOS).and ovarian tumors.
Adrenal disorders: Cushing’s syndrome, congenital adrenal hyperplasia (CAH), most commonly due to 21-hydroxylase deficiency.
Hyperandrogenic-insulin resistant-acanthosis nigricans syndrome (HAIRAN).
Hyperprolactinemia by increasing adrenal dehydroepiandrosterone sulfate (DHEA-S) production may cause hirsutism.
Rare causes: Ovarian or adrenal androgen-secreting tumors.
Drugs: Androgenic drugs are also an important cause of hirsutism
Hirsutism can also occur in some premenopausal women and continue for a few years after menopause. This is due to a decrease in ovarian estrogen secretion with continuous androgen production.
5α-reductase activity in the body is increased by local growth factors and circulating androgens. This enzyme helps in the conversion of testosterone to dihydrotestosterone (DHT). In body hair, DHT stimulates.
Polycystic ovary syndrome (PCOS) is one of the most common (3 out of 4) causes of hirsutism. Benign ovarian cysts cause increase hormone production, leading to irregular menstrual cycles, moderate to severe acne, and overweight. Other symptoms such as fatigue, mood changes, pelvic pain, headaches, sleep problems, and infertility. About 50% of PCOS patients demonstrate insulin resistance and secondary hyperinsulinemia, this increases the risk for type 2 diabetes mellitus.
Adrenal gland disorders: The other causes of unwanted hair are due to hormonal imbalance related to adrenal gland disorders such as:
Congenital adrenal hyperplasia
adrenal tumors or cancer
The adrenal glands are located just above the kidneys, are responsible for hormone production. Cushing’s disease has high levels of cortisol. Cortisol is also called the stress hormone. Congenital adrenal hyperplasia is born without an enzyme, which is necessary for hormone production. These conditions can affect the way your body produces androgens. The usual symptoms of adrenal gland disorders are excess weight in the upper half of body, headaches, high blood pressure, bone and muscle weakness, and high or low blood sugar levels
Drugs: Excessive facial or body hair growth can be due to any of the following medications:
anabolic steroids, a synthetic variation of testosterone
minoxidil used to promote hair growth
cyclosporine, an immunosuppressant drug for organ transplants
3. Idiopathic Hirsutism: in about 20% of the patient, present with normal androgen levels and ovarian function and called Idiopathic hirsutism (IH). The cause of unwanted hair in these women could be related to disorders in peripheral androgen activity. Idiopathic hirsutism occurs shortly after puberty with slow progression. The 5α reductase activity in the skin and hair follicle is overactive, leading to hirsutism in the face with normal circulating androgen levels. It’s usually chronic and may be harder to treat.
Treatment for unwanted or excessive hair: Most of the women adopt hair removal techniques to manage unwanted or excessive hair.
Waxing, shaving, plucking, and depilatories: Though simple and inexpensive, these methods are temporary. They have side effects like physical discomfort, scarring, folliculitis, irritant dermatitis, or discoloration. These methods are adopted by many women to keep their legs, bikini line, and underarms free of hair.
Electrolysis: This is an older day’s technique to remove each hair follicle permanently; hence the sessions can take a long time. Here the electric current is used to remove the hair. The disadvantage being difficult to treat large areas like hairs on the chest or upper back, time-consuming, painful, and cause pigmentation or scarring.
Laser hair removal: Laser hair removal has gained wide popularity in the past two decades and can achieve a permanent reduction of hair. Laser hair removal is most ideal for idiopathic hirsutism with normal androgen levels. Lasers work on the principle of selective photo thermolysis where the laser energy acts specifically to destroy the target (melanin). The laser energy works only on growing or anagen hair follicles. Therefore, multiple treatments are required to get significant results. With sufficient treatments, laser hair removal can provide permanent or near-permanent results.
Lifestyle changes: play an important role, maintaining a healthy weight can correct the androgen levels without the use of medication. Diet and exercise are primarily required for women with PCOS. Weight loss should be advised for all obese women.
Eflornithine hydrochloride is the commonly used topical cream to reduce the growth of facial hair. It takes one to two months to show the result and should be used twice a day. Side effects such as skin rash and irritation can happen. A new topical antiandrogen 2% fluridil gel has shown to be a safe and effective treatment method of hirsutism.
Drugs: Oral medical treatment is required if excessive hair growth is a symptom of PCOS or adrenal disorders. Hence the drugs are indicated if there is an increase in androgens, and the hyperandrogenism is confirmed by various laboratory tests. The following drugs can be used:
1.Oral contraceptives (OCP) are first-line treatment for hirsutism, particularly in those women desiring contraception. These pills, which have both estrogen and progesterone, may help shrink the cysts from PCOS. The estrogen can also help reduce excess hair. These drugs are usually a long-term solution for hirsutism and notice improvement after three to six months.
1.Treatment of insulin resistance, primarily by weight loss and by using metformin or thiazolidinediones has been shown to improve hyperandrogenemia and ovulatory function in many women with PCOS.
Antiandrogen medications: Steroidal androgens and nonsteroidal (or pure) antiandrogens can block androgen receptors and reduce androgen production from the adrenal glands, ovaries, and pituitary gland. Androgen receptor blocker spironolactone is an androgen blocker and has an inhibitory effect on 5 alpha-reductase activity (5-RA) and competes with androgens (DHT) for binding to the androgen receptor It also has variable progestational activity and decreases the production of ovarian androgens. The starting dose is 50 mg twice daily and may be increased to a total daily dose of 200 mg. It takes at least six months to have any beneficial effect
Cyproterone Acetate (CA) has strong progestogenic and antiandrogen properties. It produces a decrease in circulating testosterone and androstenedione levels through a reduction in circulating LH and has been used as an effective treatment for hirsutism. CPA is available in combination with Ethinyl estradiol (EE) (2 mg CPA and 35 μg EE/tablet).
Finasteride, a 5-alpha reductase inhibitor has been found to be effective in the treatment of idiopathic hirsutism. This compound effectively inhibits DHT production. 5-RA agents have the potential of feminizing a male fetus. Hence, effective contraception must be used by patients on these drugs.
Adrenal suppression: Glucocorticoid: The main use of corticosteroids has been to treat hirsutism associated with congenital
1.adrenal hyperplasia (CAH). They are given at bedtime in low doses like dexamethasone.
2.Gonadotrophin-releasing hormone (GnRH agonists)
This drug is therapy is given for women with severe hirsutism and who do not respond to the OC and antiandrogens. Long-acting GnRH analogs are decreased gonadotrophin secretion, reduces ovarian stimulation and hence testosterone.