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Ten tips on hirsuitism

Consultant dermatologist Dr Olivia Stevenson outlines her key advice for managing hirsutism in women

Consultant dermatologist Dr Olivia Stevenson outlines her key advice for managing hirsutism in women

1 Be aware of the huge impact even minor hirsutism may have on a woman's wellbeing. Facial hirsutism may have a considerable impact on a woman's body image and quality of life as it goes against common perceptions of what is attractive. It is important to realise that even if a woman is able to disguise her problems by shaving or plucking, the very fact that she has to can make her feel less feminine and less attractive.

2 Consider possible underlying causes. Many patients will present with simple idiopathic hirsutism with a family or ethnic tendency. Idiopathic hirsutism accounts for 10-15% of hirsutism and is defined as hirsutism in the absence of any detectable androgen excess and with normal ovulatory function. A thorough history may identify patients with polycystic ovary syndrome (PCOS). Patients with PCOS will tend to have other signs of hyperandrogenism and/or irregular or non-existent periods.

3 Laboratory investigation should be considered if the problem is not typically idiopathic. In PCOS this should include a hormone profile – testosterone, LH, FSH and prolactin. Be sure to state day of menstrual cycle or results may be difficult to interpret. A pelvic ultrasound may be needed if there is diagnostic doubt. In any patient with sudden-onset hirsutism it is important to rule out potentially serious causes, as listed in the table (below right).

4 Don't forget drugs as a possible trigger. Ciclosporin, glucocorticoids, minoxidil, phenytoin and phenobarbital are the most common culprits.

5 The symptomatic management of excessive hair will be largely similar regardless of the underlying cause. Any pharmacological therapy should be prescribed in conjunction with appropriate lifestyle measures and self-management. In overweight or obese patients with PCOS the most important strategy is weight loss because this alone can improve metabolic and endocrine parameters as well as generally improving patients' self-esteem and quality of life.

6 It's never dangerous to pluck, wax or bleach. Many patients may have been led to believe, either through recommendation or experimentation, that various hair removal techniques may increase hair growth. This is simply not true. In fact continued physical hair removal by some methods over time leads to eventual reduction in growth. Any method of hair removal that a patient finds helpful should be encouraged.

7 Hormone therapy is first line in most cases. A combination of cyproterone acetate and ethinyloestradiol is licensed for the treatment of facial hirsutism and studies show good effect both in PCOS-related and idiopathic hirsutism. Combined therapy is not generally considered suitable on its own for use during the menopause but cyproterone can be used in conjunction with HRT. Angeliq is a combined oestradiol-drospirenone HRT preparation with anti-androgenic properties.

8 Eflornithine 11.5% cream (Vaniqa) is licensed for facial hirsutism. It is a topical therapy for twice daily application and works by inhibiting an enzyme involved in hair growth. It has been shown to reduce both the size and growth rate of terminal hairs. Effects are generally seen quite quickly, within two to three months, and should be discontinued if no benefit is seen after four months. NHS prescribing of Vaniqa is restricted to women in whom alternative drug therapy is either ineffective or inappropriate.

9 Laser treatment may be available on the NHS. Some PCTs will fund a limited amount of laser therapy and application needs to go via the PCT on a named-patient basis. Laser treatment is only effective on dark hair.

10 Unlicensed therapies tend to be reserved for secondary care use. The use of insulin-sensitising agents in PCOS is becoming more widespread and seems to have a moderate effect, although it may take several months before any benefit is seen. High-dose cyproterone is used by some, although there is little evidence that it works. Spironolactone is an aldosterone antagonist used widely as a diuretic but with anti-androgen effects, and has been shown to be effective in hirsutism in doses of 100-200mg daily. Flutamide and finasteride, licensed for the treatment of prostate cancer, are both effective but have limitations. Flutamide is potentially hepatotoxic and finasteride is teratogenic and may feminise a male fetus. Ketoconazole is a potent cytochrome P450 inducer that can increase hepatic elimination of androgens but should be a last resort in view of the considerable risk of adverse events.

Dr Olivia Stevenson is a consultant dermatologist at Kettering General Hospital, Northamptonshire.

Competing interests None declared

Laser hair removal only works on dark hair Laser hair removal only works on dark hair

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