Definition of hirsutism
This is the exaggerated development of hair in the male areas (beard, torso, back …) from adolescence or brutally in an adult woman.
Hirsutism or excessive hair?
We distinguish hirsutism from an increase in normal hair (arms, legs …) called hypertrichosis. The hairiness of hypertrichosis therefore affects only normal areas in women, but the hair is longer, thicker and provided than usual.
Unlike hirsutism, this hyperpilosity most often exists in childhood and affects both sexes. Hypertrichosis is most often familial and is frequent around the Mediterranean basin and among browns. Hormonal treatments are therefore not effective and so we generally propose laser hair removal.
Hirsutism is a reflection of an effect of male hormones on the body of women. There are three main types of hormones that can affect hair growth in male areas in women:
Male hormones from the ovary (testosterone and Delta 4 Androstenedione):
Their increase may be a reflection of an ovarian tumor secreting these male hormones or more frequently micro-cysts on the ovaries secreting these hormones (micropolycystic ovary syndrome). In case of elevated testosterone or Delta 4-androstenedione serum levels, the doctor prescribes an endovaginal ultrasound in search of these two pathologies (micropolycystic ovaries or ovarian tumor).
Male hormones from the adrenal gland
It is the SDHA for Hydroepi Dehydrate and Androsterone secreted by an adrenal tumor and more frequently it is a functional adrenal hyperandrogenism by moderate increase in the secretion of 17 hydroxyprogesterone (17-OHP) then requiring a stimulation test Synacthene to confirm the diagnosis. More rarely, because it is systematically detected at birth by a blood sample in the heel at the 3rd day of life by measuring the level of 17 hydroxyprogesterone (17-OHP) in the blood, the anomaly can be congenital: it is acts of congenital hyperplasia of the adrenal glands by 21-hydroxylase deficiency linked to the mutation of its gene on chromosome .
The increase in cortisol in the blood (Cushing’s syndrome) may be due to prolonged corticosteroids, an adrenal tumor secreting cortisol or a tumor secreting ACTH (a hormone that secretes cortisol from the adrenal gland).
The tumoral causes are often of brutal appearance in an adult woman whereas the hirsutism present since adolescence is most often due to an ovarian or adrenal functional hyperandrogenism.
In normal hormonal assays and normal ovarian ultrasound, idiopathic hirsutism is used.
In practice, therefore, the doctor asks a hirsutism blood testosterone, Delta 4-androstenedione, SDHA and 17-hydroxyprogesterone (with Synacthene test if it is moderately high), cortisoluria in case of suspicion of Cushing and an ovarian ultrasound.
Dosages must be requested without taking cortisone, without hormonal contraception for three months. They must be performed in the morning around 8am and one of the first six days of the cycle (they should not be asked for the first three years of adolescent menstruation because they are irrelevant).
Hard hair on the face, chest, back … at the woman.
The doctor is looking for other signs related to hyperandrogenism (increase of male hormones): hyperseborrhoea, acne, androgenetic alopecia or baldness, menstruation disorders … or virilization (clitoral hypertrophy, deep and hoarse voice). These signs are suggestive of an increase in hormone levels in the blood and therefore do not advocate idiopathic hirsutism.
The abrupt onset of these signs tends to lead to a tumor whereas their gradual onset from adolescence is more in favor of ovarian or adrenal functional hyperandrogenism, or even idiopathic hirsutism if the examinations are normal.
Risk factors for hirsutism in women include:
- taking cortisone for several months ( Cushing’s syndrome )
- obesity: it can translate a problem of cortisol or to register in a syndrome of the polycystic ovaries. But we also know that fat has a tendency to promote the metabolism of male hormones.
- family history of hirsutism
Evolution and possible complications
The hirsutism linked to a tumor exposes to the risks related to the tumor itself, especially if it is malignant (risk of metastases …)
The hirsutism that is tumoral or functional, besides its aesthetic inconveniences, is often complicated by acne, folliculitis, baldness of the woman …
|The opinion of Ludovic Rousseau, dermatologist
Hirsutism is a relatively common problem that plagues the lives of affected women. Fortunately, it is most often an idiopathic hirsutism but the doctor can only assert this diagnosis when all examinations have been performed and are normal.
Laser hair removal has changed the lives of women concerned, especially since it can be reimbursed in part by the Social Security after prior agreement with the medical adviser, in the case of hirsutism with abnormal blood levels of hormones masculine.
Treatments of Hirsutism
The treatment of hirsutism is based on the treatment of the cause and the combination of taking anti-androgens and hair removal or depilation techniques
Treatment of the cause
Removal of a tumor of the ovary, adrenal, tumor secreting ACTH (often located in the lung) … if any.
Association of hair removal or depilation technique and anti-androgen
Hair removal or depilation techniques should be combined with anti-androgenic hormone therapy to reduce the risk of hair regrowth
Hair removal and depilation
Many techniques can be used such as hair discoloration, shaving, hair removal creams, waxing or even electric hair removal in the dermatologist’s office which is painful and tedious.
There is a low eflornithine cream, a locally applied pest control molecule that inhibits ornithine decarboxylase, an enzyme involved in hair production by the hair follicle. It is Vaniqa which, applied twice a day, reduces hair growth.
Laser hair removal is indicated in case of extensive hirsutism. It is combined with anti-androgen treatment to prevent recurrence.
The term anti-androgen means that the molecule inhibits the binding of testosterone (to be precise 5-dihydrotestosterone) to its receptor. Testosterone no longer has access to its receptors in the hair, it can no longer have a stimulating effect.
There are two used in common practice:
- cyproterone acetate (Androcur) is reimbursed in France for the indication of hirsutism. It has anti-androgenic receptor blocking activity, anti-gonadotropic effect (it decreases androgen production by decreasing pituitary stimulation) and inhibition of the 5-dihydrotestosterone / receptor complex at the androgen binding protein level. .
It is therefore a progestogen that must therefore most often be combined with estrogen to mimic the natural hormonal cycle of the woman: the doctor prescribes most often a tablet of Androcur 50 mg / j associated with a natural estrogen tablet, gel or patch, twenty days out of twenty-eight.
Improvement of hirsutism is observed only after approximately 6 months of treatment.
- spironolactone (Aldactone), a diuretic, can be offered off-label. In addition to its anti-androgenic receptor blocking effect, it inhibits testosterone synthesis. The doctor prescribes two tablets per day of 50 or 75 mg to reach the daily dose of 100 to 150 mg / day, in combination, fifteen days a month, to a non-androgenic progestagen to avoid the disorders of the cycle. As with cyproterone acetate, the effect begins to be observed only after 6 months of treatment, sometimes a year.