Evaluation of hirsutism

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Last reviewed: 1 Apr 2025

Last updated: 13 Feb 2024

Hirsutism is a condition seen in women that is associated with development of androgen-dependent terminal hair (coarse, pigmented) following a male-pattern distribution (face, chest, abdomen, back).

Pathophysiology

Hair in different areas of the body demonstrates varying levels of androgen sensitivity, depending mostly on local sensitivity of androgen receptors and 5-alpha-reductase activity levels. Terminal hair, also known as sexual hair, is dependent on androgens for development and maintenance.[1] Hair response to androgens varies from person to person and includes increase in follicle size, fiber diameter, and the amount of time spent in anagen (the growth-cycle phase of a hair follicle).[2][3]

Around 70% to 80% of women with androgen excess manifest hirsutism.[4] Excessive sexual hair may be accompanied by signs of virilization: male-pattern alopecia, deepening of the voice, clitoromegaly, increased muscle bulk. When present, virilization indicates an underlying condition associated with moderately to severely elevated androgen levels.

Epidemiology

The extent of terminal hair varies by ethnic background and the method used to evaluate it.[4] Women of Asian ethnicity have less body hair compared with southern European women. Among white and black American women, the prevalence of hirsutism, as assessed by a standard score, is 20%.[5]

Differentials

Common

Polycystic ovary syndrome
Idiopathic hirsutism

Full details

Uncommon

Hyperprolactinemia
Nonclassic congenital adrenal hyperplasia
Cushing syndrome (benign)
Androgenic medications
Androgen-secreting ovarian tumor
Ovarian hyperthecosis
Adrenocortical carcinoma

Full details

Contributors

Authors

Stephen L. Atkin, PhD, FRCP

Professor of Medicine

Head of School of Postgraduate Studies & Research

The Royal College of Surgeons in Ireland - Bahrain

Busaiteen

Bahrain

Disclosures

SLA has received funds for an investigator-initiated study and delivered educational lectures for Novo Nordisk.

Thozhukat Sathyapalan, MD, MRCP FRCPE

Professor of Endocrinology/Honorary Consultant Endocrinologist

Academic Endocrinology, Diabetes and Metabolism

Hull York Medical School

Michael White Diabetes Centre

Hull Royal Infirmary

Hull

Disclosures

TS declares that he has no competing interests.

Acknowledgements

Dr Stephen L. Atkin and Dr Thozhukat Sathyapalan would like to gratefully acknowledge Dr Shehzad Basaria and Dr Milena Braga-Basaria, the previous contributors to this topic.

Disclosures

SB and MBB declared that they had no competing interests.

Peer reviewers

Joe McKenna, MD

Professor of Investigative Endocrinology

University College

Dublin

Ireland

Disclosures

JM declares that he has no competing interests.

Udaya Kabadi, MD, FRCP(C), FACP, FACE

Director

Endocrinology

Department of Internal Medicine

VA Medical Center

University of Iowa

Iowa City

Disclosures

UK declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Martin KA, Anderson RR, Chang RJ, et al. Evaluation and treatment of hirsutism in premenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018 Apr 1;103(4):1233-57.Full text Abstract

Legro RS, Arslanian SA, Ehrmann DA, et al; Endocrine Society. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013 Dec;98(12):4565-92.Full text Abstract

Teede HJ, Tay CT, Laven J, et al. Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril. 2023 Oct;120(4):767-93.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Patient information
Polycystic ovary syndrome
Ovarian cancer
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Evaluation of hirsutism

Summary

Pathophysiology

Epidemiology

Differentials

Common

Uncommon

Contributors

Authors

Stephen L. Atkin, PhD, FRCP

Disclosures

Thozhukat Sathyapalan, MD, MRCP FRCPE

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Joe McKenna, MD

Disclosures

Udaya Kabadi, MD, FRCP(C), FACP, FACE

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice