Excessive Body Hair In Women
Many women feel the need to shave their legs regularly. This is especially the case for white women and those from central Asia. Women of black African and oriental ancestry do not need to do this as much as hair growth in these parts of the body is much less pronounced. However, hairy legs (in isolation), real or imagined, is not what is referred to when we talk about hirsutism. Presence of hair on the chin, abdomen, chest, upper thighs and the back is what constitute hirsutism. This is what is regarded as medically abnormal.
Androgens and hirsutism
In all cases of excessive body hair in women, the underlying physiological process is an excess of circulating androgens, also known as ‘male sex hormones’. A brief clarification is in order here: The term ‘male sex hormones’ is somewhat misleading as it appears to suggest that females are not supposed to have these hormones. That is not the case. Women are supposed to have these hormones, the more appropriate term of which is ‘androgens’. The most common androgen is testosterone. Testosterone is essential for women. We will discuss this shortly. As stated, if levels of androgens in circulations are higher than normal, in the long run this produces virilising effects, one of which is appearance of hair in areas which are not normal (for a woman) as detailed above. There are several conditions which lead to excessive testosterone and other androgens but, by far, the commonest is polycystic ovarian syndrome (PCOS).
Total and free testosterone levels
Describing testosterone as a male sex hormone is, unfortunately, misleading as it is just as essential in women. Testosterone is produced by testes and adrenal glands in men. In women it is produced by ovaries (the equivalent of testes) and adrenal glands. The major difference is in the amount. Men produce about 10 to 20 times the amount of testosterone produced by women. However, even that relatively low amount plays vital roles in a woman’s wellbeing.
In both men and women, the normal range is wide and change with age, with a slow and steady decline with age. Levels in men range from 11 – 35nmol/litre (320 – 1005ng/dl in old style units), the highest levels seen in the 20s and early 30s age range. In women in child-bearing age, the range is 1.03 – 2.4nmol/litre (30 -70ng/dl) with much lower levels in young pre-pubescent girls and levels declining, sometimes drastically, after the menopause. Please note: Your local lab’s reference ranges may differ slightly from those quoted above.
Just to confuse you a bit more; there is a difference between the total testosterone and what is described as free testosterone. This is an extremely vital difference and an important one to be aware of. The total testosterone gives us an idea of how much is being produced in the body but it is the free component that is biologically important. You see, most of the testosterone produced in the body is immediately bound to a special protein (aptly named ‘sex hormone binding globulin [SHBG]). The bound hormone is biologically inactive. It does not have any effect. It is the unbound or ‘free’ component that is active and can have the various biological effects in the body including stimulating hair growth. Normally, only around 2% of the total testosterone is free. Why is this important? Well; it is because in Polycystic Ovarian Syndrome (the chief culprit in hirsutism), the blood concentrations of this vital binding protein (SHBG) tend to be low. It means therefore that, even if you have normal levels of total testosterone, you may still suffer from excessive body hair because, as a result of the deficiency of the binding protein, the proportion of free and therefore active testosterone is high.
Role of testosterone in women
On this I intend to be brief. Testosterone is vital for both men and women. In women, levels rise significantly after puberty. They are at their peak when a woman is in her 20s. They start declining after menopause. Testosterone is vital for:
- Sex drive: Loss of libido is associated with low testosterone levels. In the old days, it was common for gynaecological surgeons to remove ovaries when performing a hysterectomy. This was done even for women in their early or mid-30s. Apart from inducing instant menopause, this tended to have a catastrophic effect on a woman’s sex drive bearing in mind that ovaries are the chief source of testosterone. Mercifully, this sort of practice is rarely seen nowadays.
- Bone health: Testosterone, alongside estrogen, is vital for maintaining bone health
- Muscle mass and strength: Testosterone is important for maintenance of the health of our muscles.
- Mood: Low testosterone levels are associated with low mood as well as mood swings. Conversely, normal testosterone levels are strongly associated with a sense of wellbeing and energy.
Causes of Hirsutism
As discussed above, for hirsutism to occur there has to be an excess of free androgens, mainly testosterone, in circulation. Causes of excess androgens (and therefore hirsutism) include:
- Polycystic ovarian syndrome (PCOS): This is thought to affect around 25% of all women. The degree of expression of polycystic ovaries varies enormously, from those where there is hardly any sign to those with typical textbook features of excessive body hair, erratic or absent menstrual periods, excessive weight, sub-fertility and skin problems. Most will fall somewhere within the spectrum. Hirsutism is a very common feature of polycystic ovarian syndrome.
- Congenital adrenal hyperplasia (CAH) is an uncommon condition which can present with hirsutism. It is an inherited condition, the underlying problem being deficiency of a vital enzyme.
- Tumours: Some tumours of the ovaries and adrenal glands can lead to an over-production of androgens. These tumours are rare and the typical presentation is a rather sudden development of body hair which wasn’t there before. Typically, there will be change in the pattern of the menstrual periods whereby they become erratic, light or disappear altogether. This is, unless the woman in question is on the combined pill in which case this effect will not be apparent. A sudden development of hirsutism ought to be investigated actively and promptly because some of these tumours are malignant.
- Some drugs used for common conditions can lead to hirsutism, usually mild. These include Penicillamine used in rheumatoid arthritis; phenytoin, which is used in epilepsy and Minoxidil which is now mainly used to try to combat male baldness but was originally an anti-hypertensive.
- Anabolic steroids which are usually used by body builders are androgenic and one of the effects in women who use them over a prolonged period is hirsutism
- Acanthosis nigricans is a rare condition characterised by severe insulin resistance, an indirect effect of which is increased free testosterone and therefore hirsutism.
- Idiopathic (no identifiable cause): In 1 in every 16 women affected by hirsutism, no cause can be identified.
Treating excessive hair
Like all conditions, the mainstay of dealing with hirsutism is to treat the underlying cause. Treating the conditions listed above will effectively banish excessive hair.
When it comes to the PCOS where most affected women will fall, weight is the main issue. The complex interplay of hormone imbalances seen in polycystic ovaries can be largely corrected by getting back to normal weight. If a woman suffering from polycystic ovaries manages to achieve a normal body mass index (BMI), most of the associated problems, including hirsutism, will disappear. Of course this can be a formidable challenge as losing weight in PCOS can and often is exceptionally difficult.
Medication tends to have a modest effect on body hair and should primarily be utilised for preventing increase rather than in expectation of a complete resolution. These include Cyproterone, Finasteride, Spironolactone and topical preparations such as Vaniqa cream (Eflornithine). None of these should ever be taken without a doctor’s prescription.
Waxing and sugaring: These need to be done on a regular basis. Hair always grows back.
Depilatory creams: Only ever suitable for mild/moderate hirsutism. Hair on the face may be resistant and occasionally there is skin irritation with repeated use
Bleaching: Only suitable for light-skinned individuals and where the amount (on the upper lip) is not excessive.
Electrolysis: Each individual hair is treated separately. It is effective but quite laborious. Because of the way it is done, it is not practical in severe hirsutism where large areas need treating. Repeated treatments are always required and in a clinic setting, dozens of sessions spanning many months could be required. Electrolysis is painful.
Laser therapy: This is the most effective form of treatment for hirsutism. Full and permanent hair removal may require several sessions which can turn out quite expensive and probably beyond many pockets. Problems associated with this include skin depigmentation especially in those with dark skin. It is important that the correct type of laser is used to ensure this does not occur.