Hirsutism

Classification according to ICD-10
L68.0	Hirsutism
ICD-10 online (WHO version 2019)

Woman with hirsutism (picture from Schedel's world chronicle of 1493)

Hirsutism ( Latin hirsutus "hairy") is a male hair type in women and describes a male distribution pattern of terminal hair (long hair) in women. It is caused by the conversion of vellus hair into terminal hair and can be genetic (genetic) or disease-related (hormonal or drug-induced). The boundary to the normal state is fluid. Usually the cause of hirsutism is increased androgen formation . Hirsutism must be differentiated from hypertrichosis , which is androgen-independent, increased body and facial hair without a male distribution pattern.

In hirsutism, instead of inconspicuous vellus hairs, stronger long hairs are found in the area of ​​the sideburns (the jaw area near the ear), the upper lip (again, more often in the lateral areas) and on the chin. In the area of ​​the trunk there is hair in the upper sternum area , around the areolas and from the navel in the midline in a gusset-shaped manner to the pubic hair. The pubic hair itself expands to the thighs, so that instead of a (ideally sharply delimited) triangle shape, a rather broad rhombus shape is created. The thighs, lower legs and forearms are also hairy to varying degrees.

distribution

Hirsutism occurs in around 5–10% of women. The line between normal and hirsutism is fluid and depends on the genetic background. In a prevalence study of 633 unselected white and black American women, DeUgarte et al. Could not find any differences in terms of skin color.

causes

Hirsutism can have several causes:

• a genetic predisposition without a pathological background, especially in southern women (familial idiopathic hirsutism), see also prepuberal hypertrichosis
• a polycystic ovarian syndrome , which causes the ovaries to make more male sex hormones
• an adrenogenital syndrome (AGS), which as a rule brings with it other masculinizations in addition to hirsutism, which is why we speak of androgenization or virilization here
• an androgen- producing tumor of the ovaries or adrenal gland
• a pituitary adenoma
• taking androgens (e.g. for doping ) or some drugs such as spironolactone (an aldosterone antagonist ) or cyclosporin A (an immunosuppressant ).

Hirsutism is often associated with obesity and insulin resistance .

diagnosis

To determine the objective criteria, the Ferriman-Gallwey Index can be used, which describes the distribution of terminal hair for 9 body regions on a scale from 0 to 4. The 9 regions include the upper lip and the chest. However, this is not a measure of the patient's level of suffering . Hirsutism is diagnosed with a total of 8 or more points. The index does not apply to Asian women. In 2001 this method was changed and expanded to include 10 body regions. These included sideburns, neck and forearm, for example. Each region has its own definition of the 4-point scale.

In addition to the Ferriman-Gallwey Index, the following methods are also used to determine hirsutism:

• photographic assessment
• microscopic measurement: The diameter of the shafts is measured and counted.
• Computer based estimation
• Classification according to baron:
  • Grade I: hairline from the genital area to the navel, hairiness of the upper lip
  • Grade II: Same as Grade I plus hair on the chin and inside of the thighs
  • Grade III: Like Grade II plus hairiness of the presteral area, the back, the buttocks and the shoulders

Hirsutism and cycle irregularities occur in around 80% of women with Cushing's syndrome , so a detailed medical history and physical examination are mandatory. The determination of free testosterone and DHEA sulfate in plasma is also mandatory . Only when these are normal can the diagnosis of idiopathic hirsutism be made.

Significantly increased testosterone and DHEA sulfate levels are possible indicators of a tumor of the ovaries or adrenal glands .

acceptance

A "bearded lady" as she appeared on so-called sideshow shows in the 19th century

The women affected can suffer to different degrees from their masculine hair. In the study by DeUgarte et al., A good 70% of women with an index value of at least 3 felt they were hirsut, the same number with an index value of at least 8. In contrast, only 15.8% of women with an index value below 3 felt they were too strong hairy.

The Mexican painter Frida Kahlo always marked her “small beard” and her tightly knit eyebrows in self-portraits (often much more pronounced than they actually exist) and developed her trademark from this break with traditional ideals of beauty.

Bearded women were an important part of the so-called freak shows that roamed the country in the 19th and early 20th centuries. A well-known beard woman was Jane Barnell, who worked as Lady Olga Roderick at a circus and starred in Tod Browning's classic film Freaks in 1932 .

The portrait of Margret Halseber dates from the 16th century and was painted in several copies.

therapy

In some cases, bleaching the hair of the affected woman can already provide a cosmetically satisfactory result. Depilation and epilation are used for mechanical hair removal.

Drug treatment of an underlying hormonal disorder or tumor belongs in the hands of an endocrinologist or an oncologist .

Eflornithine irreversibly inhibits the enzyme ornithine decarboxylase , which is involved in the formation of the hair shaft by the hair follicle , and is approved for the treatment of hirsutism on the face. As a cream, it is applied twice a day. If the treatment is stopped, the effect will be lost within two months and the hair will return.

Antiandrogens

• Cyproterone acetate and chlormadinone acetate are two gestagens with antiandrogenic ability, which belong to the 17-OH progesterones . They competitively block the androgen receptor . For this treatment, people are usually prescribed oral contraceptives that contain one of these two progestogens.
• Flutamide is an antiandrogen that prevents the androgens from working on the cell nuclei.
• Finasteride , a 5α-reductase inhibitor mainly used to treat prostate hyperplasia , inhibits the conversion of testosterone to dihydrotestosterone , which is more potent than testosterone.
• Spironolactone counteracts the mineralocorticoids and androgens.
• Drospirenone has the same properties as spironolactone. It also has a gestagenic effect.

All antiandrogens are teratogenic ( teratogenic ) and may only be taken if pregnancy can be safely ruled out. Liver damage should be considered as an undesirable drug effect, whereby flutamide can cause serious liver damage. In a meta-study by Swiglo and co-workers published in February 2008, there was weak evidence for a low effectiveness of the antiandrogens. An effect on hair growth can usually only be expected after 4 to 6 months.

Insulin sensitizer

Metformin , one of the longest-running antidiabetic drugs , and other drugs that improve insulin resistance were tested for their effectiveness in treating hirsutism in a meta study by Cosma and co-workers. The evidence was described as unclear and inconsistent and the quality of the studies reviewed as poor to very poor. Metformin was found to be inferior to both spironolactone and flutamide.

literature

• P. Fritsch: Dermatology and Venereology. 2. revised Edition. Springer-Verlag, 2004, ISBN 3-540-00332-0 .
• C. Henzen: Hirsutism. (PDF; 280 kB) In: Switzerland Med Forum. No. 44-31. October 2001.
• Birgit Stammberger: Hair as a symptom. Discourses on femininity, beauty and identity. (PDF) In: Body Politics , 2, Heft 4, 2014, pp. 431–461.
• Gerald Neitzke: Hirsutism. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 603.

Web links

Wiktionary: Hirsutism  - explanations of meanings, word origins, synonyms, translations

• Hirsutism. emedicine.com (English)

Individual evidence

1. ↑ ^{a b} C. M. DeUgarte, KS Woods, AA Bartolucci, R. Azziz: Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. In: J Clin Endocrinol Metab . 2006 Apr; 91 (4), pp. 1345-1350. Epub 2006 Jan 31. PMID 16449347
2. ↑ Measurement with the Ferriman-Gallwey Index. Retrieved January 25, 2017 . 
3. ↑ Description of a version of the painting (PDF)
4. ↑ BA Swiglo, M. Cosma, DN Flynn, DM Kurtz, ML Labella, RJ Mullan, PJ Erwin, VM Montori: Clinical review: Antiandrogens for the treatment of hirsutism: a systematic review and metaanalyses of randomized controlled trials In: J. Clin . Endocrinol. Metab. 93, 2008, pp. 1153-1160. PMID 18252786 (Review).
5. ↑ M. Cosma, BA Swiglo, DN Flynn, DM Kurtz, ML Labella, RJ Mullan, MB Elamin, PJ Erwin, VM Montori: insulin sensitizer for the treatment of hirsutism: A Systematic Review and Meta-analyzes of Randomized Controlled Trials. In: J Clin Endocrinol Metab. 2008 Feb 5. PMID 18252787

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !