Hirsutism is a disease affecting only women, characterized by an increase in the hairiness of the beard, torso… a source of often major psychological suffering for affected women.

Definition of hirsutism

This is the exaggerated development of hair growth in male areas (beard, torso, back, etc.) from adolescence or suddenly in an adult woman.

Hirsutism or excessive hairiness?

We distinguish hirsutism from an increase in normal hair growth (arms, legs, etc.) called hypertrichosis. The hair from hypertrichosis therefore only affects normal areas in women, but the hairs are longer, thicker and thicker than usual. 

Unlike hirsutism, this hyperpilosity most often already exists in childhood and affects both sexes. Hypertrichosis is most often familial and it is common around the Mediterranean basin and in browns. Hormonal treatments are therefore not effective and laser hair removal is generally offered.

Hirsutism is the reflection of an effect of male hormones on the female organism. There are three main types of hormones that can impact hair growth in male areas in women:

Male hormones from the ovary (testosterone and Delta 4 Androstenedione):

Their increase may be the reflection of an ovarian tumor secreting these male hormones or more frequently of microcysts on the ovaries secreting these hormones (micropolycystic ovary syndrome). In the event of an elevation in serum testosterone or Delta 4-androstenedione levels, the doctor prescribes an endovaginal ultrasound to look for these two pathologies (micropolycystic ovaries or ovarian tumor).

Male hormones from the adrenal gland

This is SDHA for De Hydroepi Androsterone Sulfate secreted by an adrenal tumor and more frequently it is a functional adrenal hyperandrogenism by moderate increase in the secretion of 17 hydroxyprogesterone (17-OHP) then requiring a stimulation test with Synacthène® to confirm the diagnosis. More rarely, because it is systematically screened at birth by a blood sample from the heel on the 3rd day of life by measuring the level of 17 hydroxyprogesterone (17-OHP) in the blood, the anomaly can be congenital: it is acts of congenital adrenal hyperplasia by 21-hydroxylase deficiency linked to the mutation of its gene on chromosome 6.

קאָרטיסאָל

The increase in cortisol in the blood (Cushing’s syndrome) may be due to prolonged use of corticosteroids, an adrenal tumor secreting cortisol, or a tumor secreting ACTH (a hormone that secretes cortisol from the adrenal gland).

Tumor causes are often sudden onset in an adult woman, while the hirsutism present in adolescence is most often due to functional ovarian or adrenal hyperandrogenism.

With normal hormonal dosages and normal ovarian ultrasound, it is called idiopathic hirsutism.

In practice, therefore, in the presence of hirsutism, the doctor asks for a blood dosage of testosterone, Delta 4-androstenedione, SDHA and 17-hydroxyprogesterone (with Synacthène® test if it is moderately high), cortisoluria in the event of suspected Cushing and an ovarian ultrasound.

The dosages should be requested without taking cortisone, without hormonal contraception for three months. They should be done in the morning around 8 a.m. and on one of the first six days of the cycle (they should not be requested during the first three years of a teenage period as they are irrelevant).

Hard hairs on the face, thorax, back… in women.

The doctor looks for other signs linked to hyperandrogenism (increase in male hormones): hyperseborrhea, acne, androgenetic alopecia or baldness, menstruation disorders… or virilization (clitoral hypertrophy, deep and hoarse voice). These signs are suggestive of increased hormone levels in the blood and therefore do not argue in favor of idiopathic hirsutism.

The sudden onset of these signs rather points to a tumor while their gradual installation from adolescence is more in favor of functional ovarian or adrenal hyperandrogenism, or even idiopathic hirsutism if the examinations are normal.

ריזיקירן סיבות

The risk factors for hirsutism in women include:

• taking cortisone for several months (Cushing’s syndrome)
• obesity: it can reflect a cortisol problem or be part of a polycystic ovary syndrome. But we also know that fat has a tendency to promote the metabolization of male hormones.
• family history of hirsutism

עוואַלושאַן און קאַמפּלאַקיישאַנז מעגלעך

Hirsutism linked to a tumor exposes people to risks linked to the tumor itself, especially if it is malignant (risk of metastases, etc.)

Hirsutism, whether tumoral or functional, in addition to its aesthetic inconvenience, is often complicated by acne, folliculitis, baldness in women …

The treatment of hirsutism is based on the treatment of the cause and the combination of taking anti-androgens and hair removal or depilation techniques

באַהאַנדלונג פון די סיבה

Removal of an ovarian or adrenal tumor, ACTH-secreting tumor (often located in the lung)… if necessary.

Combination of a depilation or depilation technique and an anti-androgen

Hair removal or depilation techniques must be combined with anti-androgen hormonal treatment to limit the risk of coarse hair regrowth

Hair removal and depilation

Many techniques can be used such as bleaching the hair, shaving, depilatory creams, waxing or even electric hair removal in the dermatologist’s office which is painful and tedious.

There is a cream based on eflornithine, an antiparasitic molecule which, applied locally, inhibits ornithine decarboxylase, an enzyme involved in the production of hair by the hair follicle. This is Vaniqa® which, applied twice a day, reduces hair growth.

Laser hair removal is indicated in cases of extensive hirsutism. It is combined with anti-androgen therapy to prevent recurrence.

Anti androgens

The term anti-androgen means that the molecule inhibits the binding of testosterone (to be precise 5-dihydrotestosterone) to its receptor. As testosterone no longer has access to its receptors in the hair, it can no longer have a stimulating effect.

There are two used in current practice:

• cyproterone acetate (Androcur®) is reimbursed in France for the indication of hirsutism. In addition to its anti-androgen receptor blocking activity, it also has an antigonadotropic effect (it decreases the production of androgens by reducing pituitary stimulation) and inhibition of the 5-dihydrotestosterone / receptor complex at the level of the androgen binding protein. .

It is a progestogen which must therefore most often be combined with estrogen to mimic the natural hormonal cycle of women: the doctor most often prescribes a tablet of Androcur® 50 mg / day combined with a natural estrogen in tablet, gel or patch, twenty days out of twenty-eight.

Improvement in hirsutism is only seen after about 6 months of treatment.

• spironolactone (Aldactone®), a diuretic, can be offered off-label. Besides its anti-androgenic receptor blocking effect, it inhibits testosterone synthesis. The doctor prescribes two tablets per day of 50 or 75 mg to achieve the daily dose of 100 to 150 mg / day, in combination, fifteen days per month, with a non-androgenic progestogen to avoid cycle disorders. As with cyproterone acetate, the effect begins to be observed only after 6 months of treatment, sometimes a year.