A new set of clinical guidelines published in the Journal of Clinical Endocrinology & Metabolism is reshaping how physicians diagnose and treat hirsutism, a condition that causes excessive male-pattern hair growth in women. Affecting roughly 10% of women worldwide, hirsutism has long been viewed through a primarily cosmetic lens. But the updated recommendations emphasize a broader, more nuanced approach — one that accounts for hormonal causes, treatment options, and the significant psychological toll the condition can take.
Hirsutism most often arises from elevated levels of androgens — commonly referred to as “male” hormones—or an increased sensitivity to these hormones at the level of the hair follicle. The most frequent culprit is polycystic ovary syndrome (PCOS), a complex hormonal disorder also associated with irregular menstrual cycles, acne, and infertility. Other causes include adrenal disorders, certain medications, and in rare cases, androgen-secreting tumors. In some instances, no identifiable cause is found, termed idiopathic hirsutism.
“For many women, hirsutism is more than a medical issue. It impacts how they see themselves, how they interact socially, and their overall quality of life,” said one of the lead authors of the guideline update.
The guidelines encourage physicians to adopt a more individualized approach to diagnosis. The Ferriman-Gallwey scoring system — used to rate hair growth in nine body areas — remains a cornerstone of clinical evaluation. However, experts now urge practitioners to consider ethnic differences in hair distribution, as some populations naturally have more body hair than others.
Blood tests to measure total and free testosterone are recommended in nearly all cases, along with additional hormone testing when symptoms point to more serious underlying conditions such as late-onset congenital adrenal hyperplasia (CAH) or Cushing’s syndrome.
First-line treatment still includes combined oral contraceptives (COCs), which lower free testosterone levels by suppressing ovarian hormone production and increasing sex hormone-binding globulin. But when COCs are not enough, the guidelines support the use of anti-androgen medications like spironolactone — though they stress the importance of contraception due to the risk of birth defects.
Equally emphasized are cosmetic solutions, such as laser hair removal and electrolysis. These can provide immediate relief while medical treatments work on the root hormonal causes. Experts say a dual approach — combining medical and cosmetic strategies — offers the most effective long-term outcomes.
Perhaps the most notable shift in the new guidelines is the inclusion of mental health as a core component of care. Studies have shown that women with hirsutism are at a higher risk of anxiety, depression, and body dysmorphia and decreased self-esteem.
“Too often, these patients are told it’s ‘just hair,’” said one clinician involved in drafting the recommendations. “But for many, it affects every part of their lives. That needs to be acknowledged and addressed.” The guidelines represent a modern, patient-centered approach to a condition that is often misunderstood or dismissed. By incorporating mental health screening, nuanced diagnostics, and tailored treatment strategies, experts hope to improve outcomes for the millions of women living with hirsutism today.
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