Women with excess hair growth should be tested for PCOS, Endocrine Society says

Women who have excess dark, coarse hair on the face, chest, or back should undergo testing for polycystic ovary syndrome (PCOS), advised experts from the Endocrine Society in an updated clinical practice guideline published in The Journal of Clinical Endocrinology & Metabolism.

“Excess facial or body hair is not only distressing to women, it is often a symptom of an underlying medical problem,” said Kathryn A. Martin, MD, Massachusetts General Hospital, Boston, MA, and chair of the task force that authored the guideline.

Women who have excess hair growth, which may be hirsutism, should consult with a health-care professional to find out what’s causing it and to receive treatment, Dr. Martin advised.

Hirsutism affects 5% to 10% of women. It is described as excessive terminal hair that appears in a male pattern in women. It should not be confused with hypertrichosis, which is excessive hair growth distributed in a generalized, nonsexual pattern. Hypertrichosis is typically hereditary or caused by medications, not by excess androgen.

More than 80% of cases of hirsutism are due to excess androgen, and 70%-80% of women with hirsutism have PCOS.

“We suggest testing for elevated androgen levels in all women with an abnormal hirsutism score,” wrote the authors of the new guideline.

The previous guideline was published in 2008, and called for androgen testing in women with moderate to severe hirsutism. The authors broadened the recommendation in the new guideline to improve diagnosis rates of PCOS and other underlying conditions.

PCOS is a common condition characterized by the presence of excess androgen, infrequent or irregular ovulation (or no ovulation), and enlarged ovaries containing multiple small follicles (polycystic ovaries). PCOS contributes to infertility and metabolic health problems.

“While PCOS is the most likely diagnosis in a woman with menstrual dysfunction, hirsutism, and an elevated testosterone level, clinicians need to exclude conditions other than PCOS,” the authors advised. “The most common of these is nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency. This is particularly important to detect because of its genetic implications for those women desiring fertility.”

Treatment recommendations

“As hirsutism is common, often associated with an underlying endocrine disorder, and associated with significant personal distress, treatment is appropriate for most women who present with this problem,” the guideline states.

For most women with hirsutism who are not trying to become pregnant, the authors suggest oral contraceptives as initial therapy. As long as a woman is not at risk of developing deep vein thrombosis or a pulmonary embolism, the type of oral contraceptive is not important, since they are all equally effective for treating hirsutism.

“We suggest against antiandrogen monotherapy as initial therapy (because of the teratogenic potential of these medications) unless these women use adequate contraception,” the authors added. “However, for women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception, we suggest using either oral contraceptives or antiandrogens as initial therapy.”

Although weight loss is not a specific treatment for hirsutism, some studies have found that weight loss is associated with slight improvement in unwanted hair growth. As a result, the authors recommended women with both obesity and hirsutism to consider making lifestyle changes to improve their overall health. A healthy diet and exercise can also be beneficial for women who have PCOS, they added.

For women looking to address hirsutism, the authors recommended direct hair removal methods. “We suggest photoepilation for those whose unwanted hair is auburn, brown, or black, and we suggest electrolysis for those with white or blonde hair,” they wrote.

Women of color who choose photoepilation may require a long wavelength, long pulse-duration light source (Nd:YAG or diode laser) to avoid complications, the authors advised.

“Clinicians should warn Mediterranean and Middle Eastern women with facial hirsutism about the increased risk of developing paradoxical hypertrichosis with photoepilation therapy,” they added. “We suggest topical treatment or electrolysis over photoepilation with these patients.”

The new guideline was co-sponsored by the Androgen Excess and Polycystic Ovary Syndrome Society and the European Society of Endocrinology.