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Hirsutism - Management
How should I assess for an underlying cause of hirsutism?

  • Ask about, and look for, features of polycystic ovary syndrome (PCOS) — oligomenorrhoea or amenorrhoea, infertility, acne, hair loss from the scalp, central obesity, acanthosis nigricans.
  • Ask about, and look for, features of an androgen secreting tumour — sudden onset or rapid progression of hair growth, severe hirsutism, signs of virilization (hair loss from the scalp, voice deepening, increased muscle bulk, clitoromegaly), a pelvic or abdominal mass.
    • Urgently refer the woman if an androgen-secreting tumour is clinically suspected.
  • Ask about, and look for, features of Cushing's syndrome — for example: weight gain in the face (moon face), neck region, upper back, and torso; stretch marks; easy bruising; and proximal muscle weakness.
    • Refer the woman if Cushing's syndrome is suspected.
    • Consider checking free cortisol levels (using a 24-hour urine collection) or performing a dexamethasone suppression test before the outpatient appointment.
  • Ask about current medication, including any use of anabolic steroids.
  • In women with mild hirsutism and no other signs of PCOS or other underlying condition:
    • Investigations are not usually necessary.
  • In women with moderate-to-severe hirsutism and no other signs of PCOS or other underlying condition:
    • Measure plasma testosterone.
    • If the testosterone level is greater than 5 nanomol/L, seek specialist advice.
  • Consider screening for late-onset congenital adrenal hyperplasia in women who are at high risk (for example those with a positive family history, or from a high-risk ethnic group [such as Ashkenazi Jewish, Hispanic, and Slavic people]), especially if they wish to conceive.
    • Measurement of early morning 17-hydroxyprogesterone is recommended — check with the local laboratory for details of when and how this test should be performed.
    • Refer the woman to an endocrinologist if 17-hydroxyprogesterone levels are elevated.

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