Hirsutism: causes, tests and treatment for excess facial and body hair in women

The BAD says that where there is an underlying hormonal disorder, the doctor may suggest treating that first. Where there is no underlying cause, or hirsutism comes with PCOS, treatment falls into three groups: self-help hair removal, physical treatments that aim to destroy the hair root, and medical treatments that slow or reduce hair growth.

NICE CKS lists what a GP can offer premenopausal women: advice on weight loss if overweight or obese, advice on hair reduction and removal, eflornithine cream for facial hirsutism in women aged 19 and over, and a combined oral contraceptive pill if there are no contraindications. For postmenopausal women it lists cosmetic hair removal, eflornithine cream and weight-loss advice. Referral to a specialist is recommended if treatment has not worked after at least a 6 month trial.

The BAD sets out the choices. Shaving does not encourage more growth, though regrowth stubble can be undesirable and frequent shaving can irritate. Waxing works for some but can irritate and needs caution on the face. Depilatory creams dissolve hair shafts; do a skin test first. Bleaching makes dark hairs pale but may irritate and can temporarily lighten darker skin tones. Pseudofolliculitis (razor bumps) can follow shaving and waxing, and may leave discolouration or scarring.

Electrolysis uses an electric current through a needle to destroy the hair root and usually needs multiple treatments; the BAD says it is relatively expensive, time-consuming and not normally available on the NHS, advises checking the operator is registered with the British Institute and Association of Electrolysis, and does not recommend home electrolysis machines. Laser and IPL aim to destroy the root permanently, need several sessions over months, are not normally available on the NHS, and can cause redness, discolouration or scarring. The BAD suggests checking practitioners are registered with the Care Quality Commission or British Medical Laser Association.

The BAD says eflornithine cream slows hair growth, needs at least 4 to 8 weeks of regular use to see an effect and continued use to maintain it, and can cause burning, stinging, folliculitis and acne. The combined pill may take 6 to 12 months to show an effect. Anti-androgens such as finasteride, cyproterone acetate and spironolactone block androgen action; they take several months, hirsutism tends to return when they are stopped, and they can harm an unborn male baby, so effective contraception is needed. The BAD notes they are not formally approved for hirsutism in the UK and may be used off-licence with informed consent. Insulin sensitisers such as metformin have unconvincing evidence for hirsutism. NICE CKS says referral to a specialist is recommended if treatment has not worked after at least a 6 month trial.

NICE CKS defines hirsutism as the growth of excess terminal hair in androgen-dependent areas in women, such as the face, chest, linea alba (the midline of the abdomen), lower back, buttocks and thighs. Terminal hair is the thick, pigmented hair, as opposed to fine vellus hair. The pattern matters: hair growth that is generalised and not in a male-like pattern is called hypertrichosis, which the BAD says is a different condition.

Many women notice a little extra facial or body hair as they get older, particularly after the menopause, and the BAD says this is common. The concern in hirsutism is hair that is noticeable, progressing or accompanied by other changes.

Androgens are often thought of as male hormones, but the BAD notes both men and women produce them, men usually in greater amounts. Hirsutism arises from higher androgen production, greater skin sensitivity to androgens, or both. NICE CKS also lists peripheral metabolism of androgens as a mechanism.

In premenopausal women, polycystic ovary syndrome is the most common cause. The NHS now calls PCOS polyendocrine metabolic ovarian syndrome (PMOS), says it can affect hair growth, periods, fertility and mood, and lists excessive hair growth or hair loss among its symptoms. Less common causes listed by NICE CKS are androgen-secreting tumours, adrenal hyperplasia, Cushing's syndrome, acromegaly, raised prolactin, thyroid disorders and some medicines. The BAD says rarely steroids or hormonal disorders are the cause, and extremely rarely an androgen-secreting tumour, in which case the hirsutism is severe and appears over a few years. The BAD says that in 5 to 20% of affected women no apparent cause is found, and NICE CKS puts it at about half for mild hirsutism.

The main sign is thick, dark hair where it is more typical in men. The NHS lists excessive hair growth (hirsutism) or hair loss among the symptoms of polyendocrine metabolic ovarian syndrome (PMOS, formerly PCOS), alongside irregular periods, weight gain, acne and difficulty getting pregnant. Hair that is only slightly more noticeable is common, but the BAD says it is important to see a doctor if hirsutism is associated with any of the following.

• It develops quickly (over 1 to 2 years), or before puberty.

• It comes with menstrual problems.

• It comes with thinning of scalp hair, baldness or deepening of the voice, which suggest raised androgens.

• It comes with obesity or diabetes.

NICE CKS says that in women with isolated, local hair growth, a normal hirsutism score and no other signs of a hormonal disorder, tests are not usually needed unless the hair growth progresses despite treatment. In women with an abnormal hirsutism score, or local growth together with signs of a hormonal disorder, a total testosterone level should be checked, and if it is above 4 nanomol/L referral to endocrinology is arranged. The BAD adds that a dermatologist may request hormone tests, possibly an ultrasound of the pelvis to assess for PCOS, and refer to an endocrinologist.

Urgent referral is recommended by NICE CKS if features suggest an adrenal or ovarian tumour: sudden onset and rapid progression of hair growth, signs of virilisation or an abdominal or pelvic mass.

NICE CKS includes weight-loss advice among the primary care options for women with hirsutism who are overweight or obese. The NHS page on PMOS lists eating a healthy, balanced diet, exercising regularly and trying to lose weight if you are overweight among the things that can help symptoms, and suggests talking therapy if symptoms are causing low mood or anxiety.

The BAD does not describe any food or supplement as a treatment for hirsutism. Home measures in its leaflet are the hair removal methods above. It advises a skin test before using depilatory creams, and warns that shaving and waxing can cause razor bumps (pseudofolliculitis) that sometimes leave discolouration or scarring.

A GP can examine you, arrange hormone blood tests and prescribe eflornithine cream or the combined pill, and refer to endocrinology or dermatology where needed. The BAD says electrolysis, laser and IPL are not normally available on the NHS and are usually arranged privately, so it advises checking that practitioners are registered with the British Institute and Association of Electrolysis, the Care Quality Commission or the British Medical Laser Association as appropriate.

A private dermatology or endocrinology appointment can be quicker, and the tests and treatments are the same. Ask for a letter to your GP so your records stay complete.