Here are the facts:

  • Hirsutism affects about 8 percent of women in the United States (more than four million women).
  • There are about 50 million hair follicles covering the body.
  • Of these, 20 percent are on your scalp. There are none on your palms, the soles of your feet, or your lips.
  • Most of our hair follicles are present at birth, and we begin to lose follicles after age 40.
  • The growth cycles of individual hair follicles differ; it appears that hair grows continuously, but only some follicles are in the growth phase at any given time.

In our society the feminine ideal is hairless skin. Women get waxed, shaved, plucked, and lasered all over their bodies. They spend time and money to remove every trace of stray hair outside those on their head.  Women with hirsutism often refer to themselves as “freaks” and invest considerable time, energy, and money trying to look “normal.” They may go to great lengths to hide the truth about their bodies, avoiding situations where their secret could be revealed and concealing their daily hair removal rituals from everyone, even partners, fearful that others may discover they’re not “real women.”

Background

Hirsutism is defined as the excessive growth of terminal hair in a male distribution pattern in women. There are two types of hair on the body: vellus and terminal. Vellus hair is soft, fine, short, colorless hair on areas of the body we think of as hairless.

Terminal hair is coarse, long, and pigmented. Scalp hair, eyebrows, and eyelashes are examples of terminal hair. At puberty increased androgen levels in both girls and boys result in the growth of terminal hair in the pubic region and axilla, where hair follicles are very sensitive to androgens. Other areas, those associated with male-pattern hair growth, such as the face and chest, are not as sensitive to androgens and require much higher levels for terminal hair growth.

Although the growth of sexual hair is dependent on androgens, the degree of hirsutism is not related to the degree of androgen excess. The majority of hirsutism is associated with high androgen levels, but it can also present in women with normal androgen levels (idiopathic hirsutism). On the other hand, some women with high levels of androgens have no hirsutism at all. This suggests that other factors may contribute to the development of hirsutism. It is known that increased sensitivity of the hair follicle to androgens is one factor, and research suggests that a high level of insulin in the blood is another.

The degree of hirsutism is measured using the Ferriman-Gallwey scale. A pictorial scale is used to assign a rating from 0 (no abnormal hair growth) to 4 (extensive abnormal hair growth) for nine different areas of the body where excess hair growth occurs: above the lip and on the chin, chest, upper and lower abdomen, arms, groin/upper thigh, back, and buttocks. An overall score of 8 or more indicates hirsutism (though some providers use 6 as the cutoff ).

Management

The management of hirsutism varies according to the severity of each case. Mild hirsutism can often be treated with mechanical measures such as bleaching, shaving, electrolysis, and laser treatment.  Moderate to severe hirsutism requires both systemic and mechanical approaches. Systemic measures include oral contraceptive pills (OCPs) and antiandrogens. These stop the progression of terminal hair growth but do not reduce existing levels, so they should be combined with cosmetic measures.

There is one more effective management approach: weight loss. Weight loss lowers androgen levels and decreases hirsutism. Keep in mind that it will take time for any systemic approach to have an effect. Hair goes through three phases: an active growth phase, a dormant phase, and finally a shedding phase. Any hair already present has to go through all three phases before you see a marked change. You can use mechanical measures to manage hirsutism until systemic treatments kick in.