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Management of female excessive body hair (hirsutism)

A doctor seeing a woman with this problem needs to take a careful detailed history, including family history. This will help give pointers to possible causes. This will be followed by a physical examination.

Investigations, which tend to include various hormone assays, will depend on the suspected underlying cause garnered from the history and examination. This is important because timing of the test may be crucial in reaching the correct diagnosis. For instance, in suspected Non-classic congenital adrenal hyperplasia (discussed above), raised 7-hydroxyprogesterone is diagnostic but this needs to be checked in an early morning sample. Overall, free androgen index is regarded as the most sensitive test to diagnose elevated androgen activity of whatever origin.

Pelvic and abdominal ultrasound scan will help in the diagnosis of conditions such as polycystic ovaries or adrenal tumours.

Weight Loss:

The majority of women with excessive body hair will be so because of polycystic ovarian syndrome (PCOS). The commonest hallmark of PCOS is excessive weight.  Many are surprised and some can be quite sceptical when advised that losing weight to as close to the ideal body weight tends to have dramatic effect on the excessive hair as well. However, this is certainly true and the one measure that is within the individual woman’s power to directly influence. There is a reduction of around 50% of the excess hair within months of achieving a normal body mass index (BMI). It is therefore the single most effective remedial measure for women with polycystic ovaries and hirsutism. This is, apart from the other long term health benefits of shedding the excess weight.

Medication for hirsutism

The Combined Pill: The standard oral contraceptive pill is beneficial in this regard. It tends to stop further hair growth but hair that is already present is not affected. The benefit will be noted if this is combined with cosmetic measures used for hair removal. These are discussed below. There are a number of contraceptive pill types which are specifically aimed at individuals with hirsutism and/or other hyperandrogenic skin problems such as severe acne or a greasy skin. These include Dianette and the relatively new Yasmin. Dianette contains Cyproterone which has anti-androgenic effect. It therefore has the effect of blocking the effect of androgens on hair follicles. Yasmin contains Drospirenone which too has anti-androgenic effect. The pill is ideal for women requiring acontraception and those who may want to have regular periods.

Cyproterone: As mentioned above, this is an anti-androgen. In fact, it reduces the production of androgens such as Testosterone and also antagonises their effect on, among others, the hair follicles. It is a constituent of the pill Dianette but it can also be used in isolation at a higher dose of 50 mg per day. Its effect is modest and response varies among women. There is also the issue of potential side-effects which include weight gain, the last thing a woman with polycystic ovaries would want to contend with. Other potential side effects include feeling lethargic, loss of libido and mood changes. It also increases the risk of thrombo-embolism similar to the second generation contraceptive pill.

Metformin: This is an insulin sensitizer which has been used in Type 2 diabetes for many years. It reduces the level of circulating insulin by increasing the number of insulin receptors and inhibiting liver production of glucose. The reduction in insulin concentration has a knock on effect of reduced androgen production by the ovaries.

Finasteride: This is an enzyme inhibitor which has similar effectiveness to Cyproterone (discussed above). It has very few side effects but a woman taking this medication should ensure she has reliable contraception in place. Conception during the use of Finasteride could lead to feminization of a male fetus.

Vaniqa cream: This relatively new product consists of Eflornithine as the active ingredient. Eflonirthine is an enzyme inhibitor which has the effect of arresting hair growth. The effect continues for as long as it is used. Application is twice a day and results can be seen within a few months of starting the application. It is currently licensed for use on the face only.

Spironolactone: This can be employed to combat hirsutism because of its anti-androgenic effect. Whilst it is mainly used as a diuretic especially for patients with heart failure, it has been shown to have a good effect when used to combat hirsutism and may even be superior to Finasteride and Cyproterone (discussed above). A woman should avoid pregnancy during its use.

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Successful weight loss is the single most effective solution for many of the problems associated with PCOS including hirsutism