Hirsutism

Overview

These guidelines have been provided by the Endocrinology Team at NBT so pathways might be slightly different at UHBW

Definition

Hirsutism is defined as excessive terminal hair that appears in a male pattern (e.g. is androgen dependent) in women

Clinically diagnosed by Ferriman-Gallwey assessment of nine body areas most sensitive to androgens hair growth. Total scores that define hirsutism in women of reproductive age are as follows:

• US or UK black or white women ≥ 8
• Mediterranean, Hispanic or Middle Eastern women ≥9
• South American women ≥6
• Asian women – ranges from ≥2 to ≥7 depending upon country of origin

Important points

The majority of hirsutism is due to androgen excess (≥80%), and the majority of women who have hirsutism have PCOS (70-80%).

PCOS is defined by the presence of a combination of two or three symptoms or findings: hyperandrogenism, oligomenorrhoea and evidence of polycystic ovaries on ultrasound. For further details see PCOS page in the Gynaecology chapter.

Up to 20% of women may have idiopathic hirsutism (hirsutism without hyperandrogenism) – this rarely needs further investigation if the patient has normal periods and a normal serum testosterone

Please note: The CCG does not routinely commission treatments for permanent or semi-permanent hair removal, including electrolysis and laser therapy. Please see the Hair Removal (Including electrolysis and laser therapy, also covering complex pilonidal sinus disease and para stomal disease) Policy - Prior Approval.

Who to refer

Routine referral to Endocrinology for women with a raised testosterone level of > 4 nmol/L

If patient-important hirsutism persists despite 6 months of treatment with a contraceptive pill OR a patient does not want/is too high risk for a contraceptive pill, make a routine referral to Endocrinology to discuss alternative treatments e.g. anti-androgen therapy (non-formulary, specialist only)

Red Flags

In any patient in whom there is a clinical suggestion of rapid onset of symptoms including virilisation, refer urgently to Endocrinology. This includes a significantly elevated testosterone (≥6nmol/L in pre-menopausal and ≥3nmol/L in post-menopausal women)

Refer urgently to Endocrinology if there is a clinical history or biochemistry suggestive of active Cushing’s or acromegaly

Before referral

Further investigation

Take a history regarding the symptoms and rapidity of onset – a sudden onset of symptoms with evidence of virilisation (deepening of the voice, increased muscularity and cliteromegaly), should raise the suspicion of an androgen secreting neoplasm

Considering assessing the Ferriman-Gallwey score for hirsutism and document it at baseline_. Alternatively, assess the severity of hair growth and the impact on the woman's quality of life.

Examine all patients for rare causes of hirsutism such as Cushing’s disease (central adiposity, proximal myopathy, striae, easy bruising) and Acromegaly (frontal bossing, increased shoe size, macroglossia and macrognathia)

If amenorrhoeic, ensure a pregnancy test is negative

Measure the following:

• Prolactin, TSH
• Testosterone, SHBG
• LH/FSH, oestradiol +/- day 21 progesterone
• Cardiovascular risk factor assessment in those with suspected PCOS
  • Blood pressure
  • Lipid profile
  • HbA1c
  • Screen for obstructive sleep apnoea

In rare cases, screen for acromegaly (IGF-1) and Cushing’s disease (24 hour urinary free cortisol)

Management

• For hirsute women with obesity including PCOS, advise lifestyle measures
• Consider a 4 month trial of topical eflornithine if hirsutism affects the face
• Advise that noticeable results take 6–8 weeks and if no benefit is seen within 4 months of starting treatment, discontinue treatment
• If improvement is seen, continued treatment is necessary to maintain the benefits. (Once the cream is discontinued, hair growth returns to pre-treatment levels within about 8 weeks)
• Do not prescribe topical eflornithine to pregnant or breastfeeding women, or women younger than 19 years of age
• We recommend first line treatment with a contraceptive pill for women not seeking fertility
  • The Endocrine society guidelines 2018 do not support the use of one COC over another. However, many of these women suffer from obesity and they are at higher thromboembolic disease with the COC pill. We suggest using the UK MEC Eligibility Criteria for contraceptive use (https://www.fsrh.org/ukmec) and counsel patients about the risk/benefit
  • NICE suggest the use of Dianette® (cyproterone acetate and ethinylestradiol) for the treatment of moderate to severe hirsutism in women of reproductive age (all other COC pill use is off-license for hirsutism). Women must be counselled about the 2-fold higher risk of VTE in order to make an informed decision.
• Anti-androgen therapy is considered a 2^nd line treatment in view of its teratogenicity
• Metformin is not routinely recommended for the treatment of hirsutism in PCOS. It is reserved for women with PCOS and Type 2 diabetes who fail lifestyle measures or cannot take oral contraceptives

Services

• Endocrinology NBT

• Endocrinology UHBW

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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