The appearance of some excess hair can be normal in many women. However, when the hair becomes thicker, darker, and more coarse and appears in areas such as the chin, upper lip, chest, or abdomen, it may be referred to as hirsutism. The condition is not only a cosmetic concern; in some cases, it may indicate an underlying hormonal imbalance or another health condition that requires medical evaluation.The causes of hirsutism vary from one woman to another. It may be associated with polycystic ovary syndrome (PCOS), elevated androgen levels, certain medications, or genetic factors. In some cases, hirsutism may occur without an identifiable underlying cause. It can also affect a woman's self-confidence and emotional well-being, particularly when the excess hair is noticeable or becomes more pronounced over time.So, what causes hirsutism? How can it be distinguished from normal excess hair growth? What symptoms and complications may accompany it? And how is hirsutism diagnosed and treated? In this article on Dalili Medical, we will explore the causes and symptoms of hirsutism, its potential complications, as well as the most important methods of diagnosis, treatment, and prevention.

1. What is hirsutism?

Hirsutism is a condition characterized by the growth of dark, coarse hair in women in areas of the body that are typically influenced by male hormones, such as the face, chin, upper lip, chest, and abdomen.

2. Does hirsutism mean that male hormone levels are elevated?

Not necessarily. Hirsutism may result from elevated levels of male hormones (androgens), but it can also occur when hormone levels are normal due to increased sensitivity of the hair follicles to androgens.

3. Is hirsutism a hereditary condition?

Genetic factors may play a role in the development of hirsutism, particularly when there is a family history of the condition. However, hirsutism may also result from hormonal disorders or certain medications.

4. Can polycystic ovary syndrome (PCOS) cause hirsutism?

Yes. Polycystic ovary syndrome (PCOS) is one of the most common causes of hirsutism in women. It may also be associated with irregular menstrual periods, acne, weight gain, or difficulty losing weight.

5. Can hirsutism occur in children?

Yes, hirsutism can occur in children. However, the appearance of coarse, male-pattern hair before puberty requires medical evaluation to determine the underlying cause, especially if it is accompanied by signs of early puberty or increased androgen levels.

6. Is congenital hypertrichosis the same as hirsutism?

No. They are two different conditions. Congenital hypertrichosis may be present from birth or develop during early childhood and can cause excessive hair growth over large areas of the body. It does not necessarily involve increased levels of male hormones or androgens.

7. Does shaving make hair grow back thicker?

No. Shaving does not increase the number of hair follicles or cause a true increase in hair thickness. However, hair may appear coarser or thicker as it grows back because shaving cuts the hair at the surface, leaving a blunt tip.

8. Can hirsutism be treated permanently?

Hirsutism can often be significantly reduced and controlled, but the possibility of complete resolution depends on the underlying cause. Treatment may include hormonal medications when appropriate, along with hair-removal methods such as laser hair removal or electrolysis.

9. Does laser hair removal treat the underlying cause of hirsutism?

No. Laser hair removal is designed to reduce hair growth and remove unwanted hair, but it does not treat the underlying hormonal disorder or medical condition that may be causing hirsutism. Therefore, treatment of the underlying cause may be needed alongside hair removal.

10. Does hirsutism affect fertility or the chances of becoming pregnant?

Hirsutism itself does not prevent pregnancy. However, if it is caused by an underlying hormonal disorder, such as polycystic ovary syndrome (PCOS), the underlying condition may affect ovulation and fertility.

11. What tests and laboratory investigations may be needed?

The tests required vary depending on the individual case and associated symptoms. A doctor may measure certain hormone levels, including total and free testosterone, DHEA-S, and 17-hydroxyprogesterone (17-OHP). Additional blood tests or imaging studies, such as an ultrasound, may also be recommended when necessary.

12. When is hirsutism a cause for concern?

Hirsutism requires medical evaluation, particularly when excessive hair growth appears suddenly and progresses rapidly, or when it is accompanied by signs of significantly increased androgen levels, such as a deeper or coarser voice, enlargement of the clitoris, increased muscle mass, male-pattern hair loss on the scalp, or significant menstrual irregularities.

13. Can menstrual periods remain regular despite having hirsutism?

Yes. Some women may have hirsutism despite having regular menstrual cycles. This can occur in cases of idiopathic hirsutism or increased sensitivity of the hair follicles to androgens, even when androgen levels are not clearly elevated.

14. Does being overweight cause hirsutism?

Being overweight is not a direct cause of hirsutism in every case. However, excess weight may be associated with increased insulin resistance and altered androgen levels, particularly in women with polycystic ovary syndrome (PCOS), which may contribute to increased hair growth.

15. Do medications remove existing hair?

Hormonal medications generally do not remove existing hair directly. Instead, they help reduce the growth of new hair and slow the rate of hair growth. Therefore, they may be used alongside hair-removal methods such as laser hair removal or electrolysis.

16. Does hirsutism in children require treatment?

Not every case of excess hair growth in children requires treatment. However, if the hair is dark, coarse, and male-patterned, appears at an unusually young age, or begins to increase rapidly, medical evaluation is important to determine the underlying cause before selecting an appropriate treatment.

17. Is hirsutism a serious condition?

In most cases, hirsutism is not dangerous in itself. However, its significance lies in the underlying cause. It may be associated with hormonal disorders that require diagnosis and treatment, while in other cases it may be idiopathic and not indicate a serious health problem.

Where Does Hirsutism Appear, and What Does It Look and Feel Like?

Hirsutism in women typically occurs in areas of the body where hair growth is influenced by male hormones (androgens). The hair differs in appearance and texture from the fine, soft vellus hair that normally covers most areas of the body.

Common Areas Where Hirsutism Appears

Hirsutism most commonly appears in the following areas:

• Face: particularly the upper lip, chin, jawline, and sides of the face.

• Chest: especially around the nipples or along the middle of the chest.

• Abdomen: particularly the lower abdomen and the line extending from the navel toward the pubic area.

• Back: especially the lower back.

• Buttocks.

• Thighs: in some women.

• It may also appear, to a lesser extent, in other areas of the body that are sensitive to the effects of androgens.

What Does Hirsutism Look Like?

Hair associated with hirsutism typically has the following characteristics:

• Dark in color: usually black or dark brown.

• Noticeable and visible: compared with normal fine body hair.

• Thick and coarse: thicker than ordinary vellus hair.

• Relatively long: particularly when it is not removed.

• It resembles terminal hair, which is the thick, pigmented hair that naturally grows in areas such as the beard and chest in men.

What Does Hirsutism Feel Like?

Hirsutism-related hair is usually:

• Coarse and thick to the touch.

• Firmer than the soft, fine vellus hair found on most areas of the body.

• Variable in density from one woman to another, depending on the severity and underlying cause.

Difference Between Normal Vellus Hair and Hirsutism

Normal Vellus Hair	Hirsutism
Fine and soft	Thick and coarse
Usually light-colored or minimally pigmented	Usually dark-colored
Short and fine	Longer and more noticeable
Covers broad areas of the body	Appears in areas influenced by androgens

Note: The presence of a few dark or coarse hairs on the face does not necessarily mean that a woman has hirsutism. Diagnosis depends on the amount of hair, where it appears, its degree of coarseness, and other associated symptoms.

What Causes Hirsutism in Women, Children, and Adolescents?

Hirsutism is characterized by the growth of dark, coarse hair in women in areas of the body that are typically influenced by male hormones (androgens), such as the upper lip, chin, chest, and lower abdomen. The causes of hirsutism vary depending on age, stage of puberty, how quickly the hair develops, and any associated symptoms.

First: Common Causes of Hirsutism in Women

1. Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome is one of the most common causes of hirsutism in women. It may be accompanied by:

• Irregular menstrual periods.

• Increased facial and body hair growth.

• Acne.

• Weight gain or difficulty losing weight.

• Difficulty becoming pregnant due to irregular ovulation.

• Elevated levels of male hormones, such as testosterone, in some women.

2. Increased Androgen Production from the Ovaries or Adrenal Glands

Hirsutism may occur when androgen levels become elevated, including testosterone or DHEA-S. The increase may be mild, while a significant elevation or rapidly developing symptoms may, in rare cases, indicate an androgen-producing tumor.

3. Congenital Adrenal Hyperplasia (CAH)

Congenital adrenal hyperplasia is a genetic disorder that affects the adrenal glands' ability to produce certain hormones. This may result in increased androgen production. Some forms may become apparent during childhood, while others may not appear until adolescence or adulthood.

4. Cushing Syndrome

Cushing syndrome occurs when the body is exposed to high levels of cortisol for a prolonged period. It may be associated with:

• Weight gain, particularly around the abdomen and face.

• Muscle weakness.

• High blood pressure.

• Easy bruising.

• Prominent stretch marks on the skin.

5. Thyroid Disorders

Some thyroid disorders may be associated with changes in hair growth. However, thyroid disorders are not among the most common causes of hirsutism.

6. Certain Medications

Some medications may increase hair growth or contribute to hirsutism, particularly medications with androgenic effects or those that influence hormone levels. The risk depends on the type of medication, dosage, and duration of use.

7. Idiopathic Hirsutism

In some women, hirsutism occurs without an identifiable underlying cause or a noticeable increase in androgen levels. In such cases, the hair follicles may be more sensitive to androgens, while menstrual cycles and hormone tests remain within normal ranges.

8. Ovarian or Adrenal Tumors

These are rare causes of hirsutism. However, they should be considered when coarse hair appears suddenly and progresses rapidly, particularly when accompanied by signs of significant androgen excess, such as a deeper voice, increased muscle mass, enlargement of the clitoris, or male-pattern hair loss on the scalp.

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Second: Causes of Hirsutism in Children and Adolescents

The causes of hirsutism in children and adolescents vary according to age and stage of puberty. Common possibilities include:

1. Normal Changes During Puberty

As puberty begins, androgen levels naturally increase, leading to the development of hair in the armpits and pubic area. This does not necessarily indicate an underlying health problem.

2. Polycystic Ovary Syndrome (PCOS)

PCOS becomes a possible cause in adolescents after menstruation begins, particularly when there is significant menstrual irregularity, severe acne, increased male-pattern hair growth, or weight gain.

3. Congenital Adrenal Hyperplasia (CAH)

This inherited disorder can lead to increased androgen production, which may cause excessive hair growth or other signs of early puberty.

4. Disorders of the Ovaries or Adrenal Glands

These conditions are less common but require evaluation, particularly when hair growth develops rapidly or when there are clear signs of increased androgen levels.

5. Exposure to Androgens from External Sources

A child may be unintentionally exposed to hormones such as testosterone, for example, through contact with topical products containing hormones that are being used by another household member. Such exposure may lead to signs of androgen excess.

6. Certain Medications

Some medications may cause increased hair growth. The effect depends on the type of medication, its dosage, and the duration of use.

7. Hypertrichosis

It is important to distinguish between hypertrichosis and hirsutism. In hypertrichosis, excessive hair growth may occur in different areas of the body. It may be present from birth or develop during childhood and is not necessarily associated with increased male hormone levels.

When Does Hirsutism in a Child or Woman Require Attention?

Medical evaluation is recommended when coarse, dark hair appears suddenly or grows rapidly, when it develops before puberty, or when it is accompanied by signs such as a deepening voice, clitoral enlargement, severe acne, menstrual irregularities, or signs of early puberty.

Medical evaluation can help determine the underlying cause and identify the appropriate treatment.

Symptoms of Hirsutism in Women and Children

The symptoms of hirsutism vary depending on age, severity, and the underlying cause. The main sign is the appearance of dark, coarse hair in areas of the body that are normally sensitive to male hormones (androgens).

First: Symptoms of Hirsutism in Women

1. Appearance of Coarse, Dark Hair in Unusual Areas

Hirsutism most commonly appears in the following areas:

• The upper lip and mustache area.

• The chin, jawline, and sides of the face.

• The chest, especially around the nipples.

• The upper and lower abdomen.

• The back, particularly the lower back.

• The buttocks and thighs in some cases.

This hair is typically thicker, coarser, and more noticeable than the fine, soft vellus hair that normally covers most areas of the body.

2. Associated Symptoms That May Indicate Increased Androgen Levels

Hirsutism may be accompanied by other signs, including:

• Acne, especially if it is severe or has appeared recently.

• Increased skin oiliness.

• Male-pattern hair loss from the scalp, particularly at the front or top of the head.

• Menstrual irregularities, such as irregular, infrequent, or absent periods.

• Difficulty becoming pregnant in some cases due to ovulation problems.

• Weight gain, particularly around the abdomen, which may be associated with insulin resistance.

3. Severe Signs That Require Evaluation for a Hormonal Cause

When androgen levels are significantly elevated, signs of virilization may occur, including:

• Deepening of the voice.

• Noticeable increase in muscle mass.

• Enlargement of the clitoris.

• Severe menstrual irregularities or absence of menstruation.

• Rapid and marked development of coarse hair.

• Increased male-pattern hair loss from the scalp.

The presence of these signs, particularly when they develop suddenly and rapidly, requires medical evaluation. They may be associated with significantly elevated androgen levels, and in rare cases, the cause may be an androgen-producing tumor.

Second: Symptoms of Hirsutism in Children and Adolescent Girls

Symptoms vary depending on the child's age and stage of puberty.

Before Puberty

Coarse, dark hair may appear in areas such as:

• The face.

• The chin or upper lip.

• The chest.

• The abdomen.

The condition is more concerning when the hair appears at a very young age or increases noticeably and rapidly.

It may also be accompanied by other signs of increased androgen levels or early puberty, such as:

• Acne appearing at an unusually early age and being particularly severe.

• Strong adult-like body odor.

• Early development of underarm and pubic hair.

• Rapid growth in height over a short period.

• Clitoral enlargement.

• Deepening of the voice.

• Increased muscle mass.

These signs may indicate early puberty or increased androgen levels and therefore warrant medical evaluation to determine the underlying cause.

During Adolescence

Adolescent girls may experience symptoms such as:

• Increased hair growth on the face, chin, and upper lip.

• Excess hair around the nipples, on the chest, or on the abdomen.

• Acne.

• Increased skin oiliness.

• Irregular menstrual cycles after menstruation begins.

• Weight gain or difficulty losing weight.

• Scalp hair loss in some cases.

Polycystic ovary syndrome (PCOS) may be one possible cause of hirsutism in adolescent girls. However, its diagnosis should not be based on hirsutism alone and requires a comprehensive assessment of symptoms, clinical signs, and appropriate tests.

Diagnosis of Hirsutism

The diagnosis of hirsutism does not depend solely on the presence of excess hair. It is based on evaluating the appearance of the hair, its distribution, the rate at which it develops, associated symptoms, and the underlying cause.

1. Clinical Examination and Assessment

The doctor begins by taking a medical history and performing a physical examination. They may ask about:

• When the excess hair first appeared.

• How quickly the hair has increased and whether the change was gradual or sudden.

• The areas where the hair appears, such as the face, chin, chest, abdomen, and back.

• Menstrual regularity.

• The presence of acne or scalp hair loss.

• Weight gain or signs suggestive of insulin resistance.

• Medications and products being used.

• A family history of similar conditions.

The doctor may use the Ferriman–Gallwey score to assess the severity of hirsutism by evaluating hair growth in several androgen-sensitive areas of the body.

2. Looking for Signs of Increased Androgen Levels

The doctor assesses for signs that may indicate elevated male hormone levels, including:

• Severe acne.

• Male-pattern scalp hair loss.

• Irregular or absent menstrual periods.

• Rapid and noticeable hair growth.

• Deepening of the voice.

• Clitoral enlargement.

The latter signs, particularly when they develop suddenly, are indicators that require evaluation for significantly elevated androgen levels.

3. Blood Tests

Not every woman with hirsutism requires all hormonal tests. The doctor determines which tests are appropriate based on age, symptoms, and the physical examination.

Commonly requested tests may include:

Test	Purpose
Total Testosterone	Measures total testosterone levels and helps detect elevated levels.
Free Testosterone	Evaluates the biologically active portion of testosterone.
DHEA-S	Helps assess androgen production by the adrenal glands.
17-OH Progesterone	Helps detect certain forms of congenital adrenal hyperplasia.
TSH	Evaluates thyroid function when clinically indicated.
Prolactin	May be requested when menstrual irregularities or symptoms associated with elevated prolactin are present.

The doctor may request additional tests, such as cortisol testing, when symptoms suggest Cushing syndrome.

4. Imaging Tests

Imaging may be used when symptoms or laboratory results suggest a problem involving the ovaries or adrenal glands.

Common imaging studies include:

• Pelvic ultrasound: May be used when polycystic ovary syndrome or another ovarian problem is suspected.

• CT scan or MRI: May be requested in selected cases when an ovarian or adrenal tumor is suspected, particularly when androgen levels are markedly elevated or signs of virilization develop rapidly.

When Does the Diagnosis Require Special Attention?

Medical evaluation becomes particularly important when hirsutism develops suddenly or rapidly, or when it is accompanied by signs such as deepening of the voice, clitoral enlargement, increased muscle mass, or severe menstrual irregularities. These symptoms may indicate a significant increase in male hormone levels and require investigation to determine the cause.

When Should Hirsutism Be Evaluated by a Doctor?

It is recommended to consult a doctor when coarse, dark hair appears suddenly or increases rapidly, or when it is accompanied by deepening of the voice, clitoral enlargement, severe menstrual irregularities, or other signs of increased androgen levels.

Medical Treatment of Hirsutism

Common Medications Used to Treat Hirsutism

Medication	Role in Treating Hirsutism	Important Notes
Combined Oral Contraceptives	Help reduce the effects of androgens and limit excessive hair growth.	Used in some women who are not trying to become pregnant, based on medical evaluation.
Spironolactone	An anti-androgen that reduces the effects of male hormones on hair follicles.	Requires medical supervision and should not be used during pregnancy.
Finasteride	Reduces the conversion of testosterone to DHT, one of the more active forms of androgen.	Used in selected cases under medical supervision and is contraindicated during pregnancy.
Other Anti-androgens	May be used in certain cases when initial treatment is insufficient.	The appropriate medication is determined by the doctor based on the individual case.
Eflornithine	A topical cream that helps slow facial hair growth.	Does not reduce androgen levels and is applied directly to the skin.

Treatment of Hirsutism Associated with Polycystic Ovary Syndrome

When hirsutism is associated with polycystic ovary syndrome (PCOS), treatment may involve a combination of approaches depending on the patient's condition, such as:

• Appropriate combined oral contraceptives.

• An anti-androgen such as spironolactone when needed.

• Lifestyle improvement and maintaining a healthy weight when overweight.

• Treatment of insulin resistance when present.

Metformin may be used in some cases of PCOS, particularly when insulin resistance or metabolic abnormalities are present. However, it is not considered the primary treatment for hirsutism itself.

Procedural and Surgical Treatment of Hirsutism

1. Laser Hair Removal

Laser hair removal is one of the most commonly used procedures for reducing unwanted hair. It works by:

• Directing laser energy toward the hair follicles.

• The pigment in the hair absorbs the energy and converts it into heat, which weakens the follicle.

• Multiple sessions are usually required because hair grows in different phases.

The response is generally better with dark hair than with white or blond hair.

Temporary redness or skin irritation may occur after treatment. In some cases, changes in skin pigmentation may also develop.

2. Electrolysis

Electrolysis directly targets individual hair follicles. It involves:

• Inserting a very fine probe or needle into the hair follicle.

• Applying an electrical current to destroy the cells responsible for hair growth.

• Repeating treatment over multiple sessions depending on the number of hairs and the area being treated.

Electrolysis can be used with different hair colors, including light-colored hair, making it a potential option when laser treatment is not sufficiently effective.

3. Surgery When a Tumor Is the Cause of Hirsutism

In rare cases, hirsutism may be caused by an androgen-producing tumor of the ovary or adrenal gland. In such cases, treating the underlying cause is essential and may require surgical removal of the tumor.

• Ovarian tumors: May require surgery depending on the type, size, and characteristics of the tumor.

• Adrenal tumors: Some may require removal of the tumor or the affected adrenal gland, depending on the diagnosis and medical assessment.

Important Note

The appropriate treatment varies from one person to another. Hormonal medications or anti-androgens should not be used without a medical prescription, particularly in children, adolescents, and women who are planning pregnancy or who may become pregnant.

Tips for Managing Hirsutism

Hirsutism can be managed and its effects reduced by combining treatment of the underlying cause with appropriate skin care and suitable hair-removal methods.

1. Identify and Treat the Underlying Cause

Identifying the cause of hirsutism is the first step toward appropriate treatment. It is recommended to:

• Consult a gynecologist or endocrinologist when excessive hair growth becomes noticeable.

• Undergo the tests and laboratory investigations recommended by the doctor when a hormonal disorder or elevated androgen levels are suspected.

• Treat the underlying condition, such as PCOS or adrenal gland disorders, when diagnosed.

2. Choose an Appropriate Hair-Removal Method

Several methods can be used to remove unwanted hair or reduce its appearance, including:

• Laser hair removal: Helps reduce hair growth over the long term and usually requires multiple sessions.

• Electrolysis: Directly targets hair follicles and can be used with different hair colors.

• Shaving: A simple and safe method when performed correctly.

• Waxing or threading: May be used depending on skin sensitivity and individual preference.

• Depilatory creams: May be used if suitable for the individual's skin type and if they do not cause irritation.

Important: Shaving does not increase the number of hair follicles or cause the hair to become truly thicker. However, regrowing hair may appear coarser because of the way the hair shaft is cut.

3. Skin Care

Proper skin care can help reduce irritation and problems caused by hair removal. Helpful measures include:

• Using a gentle cleanser suitable for your skin type.

• Moisturizing the skin regularly.

• Avoiding squeezing or scratching hair follicles after hair removal.

• Using sunscreen, especially when pigmentation is present or after certain hair-removal procedures.

• Avoiding methods that cause severe irritation or recurrent skin inflammation.

4. Follow a Healthy Lifestyle

If hirsutism is associated with PCOS or excess weight, improving lifestyle habits may help control some of the hormonal and metabolic factors associated with the condition. This may include:

• Maintaining a healthy weight.

• Engaging in regular physical activity.

• Following a balanced and varied diet.

• Limiting highly processed foods and added sugars.

• Monitoring blood sugar and lipid levels according to your doctor's recommendations.

It is important to emphasize that a healthy lifestyle may help improve some factors associated with PCOS and insulin resistance, but it is not a direct treatment for hirsutism in every case.