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Skin and nail Women's health

Hirsutism

Last revised in October 2024

Hirsutism is the growth of excess terminal hair on the face, chest, linea alba, lower back, buttocks, and anterior thighs in women.

Hirsutism: Summary

  • Hirsutism is the growth of excess terminal hair in androgen-dependent areas (for example face, chest, abdomen, lower back, upper arms, and thighs) in women.
  • Hirsutism occurs because of the effect of increased androgens on the pilosebaceous unit (from which the hair shaft appears), increased pilosebaceous unit sensitivity to androgens, or the peripheral metabolism of androgens.
    • Polycystic ovary syndrome (PCOS) is the most common cause of hirsutism (more than 70% of cases). No apparent underlying cause is found in about half of women with mild hirsutism. Androgen-secreting tumours, adrenal hyperplasia, Cushing’s syndrome, acromegaly, hyperprolactinaemia, thyroid disorders, and some drugs are less common causes of hirsutism.
    • In menopausal women, reduction in oestrogen and progesterone production can result in hair and skin disorders. The reduction of progesterone can increase the influence of androgens on the sebaceous glands and hair follicles.  
  • An underlying cause should be looked for.
    • In women with local, isolated sexual hair growth, a normal hirsutism score, and no other signs of a hyperandrogenic endocrine disorder, investigations are not usually necessary unless hair growth progresses despite treatment.
    • In all women with an abnormal hirsutism score, or local sexual hair growth with clinical evidence of a hyperandrogenic endocrine disorder, elevated androgen levels (serum total testosterone level) should be tested for. If the testosterone level is greater than 4 nanomol/L, referral to endocrinology should be arranged.
  • Management options in primary care for premenopausal women include offering:
    • Advice on weight loss (if obese or overweight).
    • Advice on hair reduction and removal treatments (such as shaving, waxing, electrolysis, or laser treatment).
    • Eflornithine cream (for facial hirsutism in women aged 19 years and older).
    • A combined oral contraceptive (COC), provided there are no contraindications.
  • Management options in primary care for postmenopausal women include offering:
    • Advice on cosmetic hair reduction and removal.
    • Eflornithine cream (for facial hirsutism).
    • Advice on weight loss (if obese or overweight).
  • Referral to a specialist is recommended if:
    • There are clinical features suggestive of an underlying adrenal or ovarian neoplasm (urgent referral). Features of androgen-secreting tumours include sudden onset and rapid progression of hair growth, signs of virilization, or an abdominal or pelvic mass.
    • Another underlying endocrine condition is suspected that requires secondary care diagnosis and/or management.
    • Treatment has not been effective after at least 6 month trial.
  • Treatments that may be offered by specialists include:
    • Anti-androgens (such as cyproterone acetate, finasteride, spironolactone, and flutamide).
    • Insulin-sensitizing drugs.
    • Gonadotrophin-releasing hormone analogues.

Have I got the right topic?

From age 18 years onwards (Female).

This CKS topic covers the primary care management of women with hirsutism.

This CKS topic does not cover the management of excess hair growth in children or men. It also does not cover in detail the secondary care treatments for hirsutism.

There are separate CKS topics on Acne vulgaris, Female pattern hair loss (female androgenetic alopecia), Menopause, and Polycystic ovary syndrome.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

October 2024 — reviewed. A literature search was conducted in October 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

Previous changes

July 2020 — minor update. New advice on cyproterone acetate added to the management of hirsutism in premenopausal women section.

October 2019 to February 2020 — reviewed. Literature searches were conducted in September 2019 and updated in January 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic.

Discussion of the use of a scoring system for diagnosis has been added. The section on assessing for underlying causes has been expanded and minor changes made to the recommendations on further investigations. Changes have been made to to the referral section. In the management section, recommendations on choice of combined oral contraceptive to treat hirsutism in a premenopausal woman have undergone an update and links to patient information are included. The structure of the prescribing information section has been altered.

December 2014 — reviewed. A literature search was conducted in September 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made. However, the Medicines and Healthcare products Regulatory Agency (MHRA) warning that the venous thromboembolism risk with Dianette® is likely to be similar to that with Yasmin® has been included in the topic. A prescribing information section for eflornithine cream has also been added.

May 2013 — minor update. Eflornithine cream is now only licensed for women over 18 years of age. The text and the prescriptions have been amended to reflect this.

June 2011 — minor update. Broken link fixed. 

September 2009 to January 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 October 2024.

HTAs (Health Technology Assessments)

No new HTAs since 1 October 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 October 2024.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 October 2024.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 October 2024.

New policies

No new national policies or guidelines since 1 October 2024.

New safety alerts

No new safety alerts since 1 October 2024.

Changes in product availability

No changes in product availability since 1 October 2024.

Goals and outcome measures

Goals

To support primary health care professionals to:

  • Make a diagnosis of hirsutism.
  • Identify any underlying cause of hirsutism.
  • Refer for investigation and treatment of an underlying cause, if appropriate.
  • Offer advice on treatment and self-care measures in primary care.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Hirsutism is the growth of excess terminal hair in androgen-dependent areas in women (for example face, chest, abdomen, lower back, upper arms, and thighs) [DermNet NZ, 2016; Martin, 2018; Elliott, 2023]. 
  • Hirsutism occurs because of the effect of increased androgens on the pilosebaceous unit (from which the hair shaft appears), increased pilosebaceous unit sensitivity to androgens, or the peripheral metabolism of androgens [Elliott, 2023].  

What causes it?

  • Polycystic ovary syndrome is the most common cause of hirsutism (more than 70% of cases) [Rothman, 2011; Kini, 2018; BAD, 2021; Elliott, 2023]. 
  • Idiopathic hirsutism (a diagnosis of exclusion where there is no apparent underlying cause, normal serum androgen concentrations, normal ovulatory and menstrual cycles, and normal ovarian morphology) is also common, accounting for around half of women with mild hirsutism. Idiopathic hirsutism may be a result of increased sensitivity to androgens in the pilosebaceous unit, enhanced local conversion of testosterone to dihydrotestosterone by 5-alpha-reductase, or altered function of androgen receptors [Blume-Peytavi, 2012; Mihailidis, 2017; Kini, 2018; BMJ Best Practice, 2024]. 
  • Less commonly, hirsutism may be caused by [Rothman, 2011; Escobar-Morreale, 2012; Kini, 2018; Matheson, 2019; BAD, 2021; Elliott, 2023]:
    • Non-classical congenital adrenal hyperplasia.
    • An androgen-secreting tumour. 
    • Cushing's syndrome.
    • Acromegaly.
    • Hyperprolactinaemia.
    • Thyroid disorders.
    • Drugs (for example anabolic steroids, ciclosporin, danazol,  phenytoin, sodium valproate, and tamoxifen). 
  • In menopausal women, reduction in oestrogen and progesterone production can result in hair and skin disorders. The reduction of progesterone can increase the influence of androgens on the sebaceous glands and hair follicles [Blume-Peytavi, 2012].

How common is it?

What are the complications?

Diagnosis of hirsutism

How do I know my patient has it?

  • Look for excessive terminal hair in androgen-dependent areas, including the face, chest, abdomen, lower back, upper arms, and thighs.
    • Terminal hairs can be clinically distinguished from vellus hairs (soft, short, lightly pigmented) because they are longer, stiff, and pigmented. 
    • Pictures of hirsutism are available from DermNetNZ.
  • The Ferriman-Gallwey scoring system is the gold standard for evaluating hirsutism, and includes nine androgen-sensitive body areas. Each area is scored from 0 (no hair) to 4 (extensive hair growth). A score of 8 or above is considered to define hirsutism in UK black or white women of reproductive age. Normal scores are lower in some Asian and South American populations, and higher in some Mediterranean, Middle Eastern, or Hispanic populations.
    • However, the Ferriman-Gallwey scoring system has limitations because it is subjective, does not include some androgen-sensitive areas (such as the sides of the face), can be affected by previous cosmetic treatments, and does not account for locally high scores. An individual score may not correlate with the level of distress excess hair causes the woman, and it has not been carefully validated in postmenopausal women.
    • Be aware that Lower Ferriman-Gallwey total scores than those defining hirsutism in women of reproductive age may also be clinically important. Treatment decisions also depend on the importance of the hirsutism to the woman. 

Basis for recommendation

The recommendations on clinical diagnosis of hirsutism are based on an Endocrine Society Clinical Practice Guideline Evaluation and treatment of hirsutism in premenopausal women [Martin, 2018], the Society of Obstetricians and Gynaecologists of Canada guideline Hirsutism: Evaluation and Treatment [Elliott, 2023], the BMJ Best Practice guideline Assessment of hirsutism [BMJ Best Practice, 2024], and information in expert review articles [Rothman, 2011; Matheson, 2019].

How should I assess for an underlying cause of hirsutism?

  • Ask about, and be alert for, features of underlying conditions, such as:
    • Polycystic ovary syndrome (PCOS), including oligomenorrhoea or amenorrhoea, infertility, acne, central obesity, and acanthosis nigricans.
    • An androgen-secreting tumour, including sudden onset or rapid progression of hair growth, progression despite treatment, signs of virilization (hair loss from the scalp, voice deepening, increased muscle bulk, clitoromegaly), and a pelvic or abdominal mass.
    • Endocrine conditions (uncommonly cause hirsutism), including: 
      • Cushing's syndrome — facial weight gain (moon face); central obesity; fat deposition on the upper back and between the shoulders; stretch marks; easy bruising; and proximal muscle weakness.
      • Non-classical congenital adrenal hyperplasia — family history of adrenal hyperplasia, menstrual dysfunction, or infertility. 
      • Thyroid dysfunction — abnormal thyroid function tests. Hypothyroidism and hyperthyroidism are uncommonly associated with isolated hirsutism.
      • Hyperprolactinaemia — galactorrhoea, amenorrhoea, and infertility; infrequently presents with hirsutism.
      • Acromegaly — increased size of hands or feet and mandible, frontal bossing, deepening of voice; a rare cause of isolated hirsutism.
  • Ask about current medication(s)
    • Certain drugs, including danazol, sodium valproate, and anabolic steroids, can cause hirsutism.
  • Ask about family history of hirsutism or hyperandrogenism.
  • In all women with an abnormal hirsutism score, or local sexual hair growth with clinical evidence of a hyperandrogenic endocrine disorder (suggested by sudden-onset or rapidly progressing hirsutism, irregular menses, infertility, galactorrhoea, features of hypothyroidism or Cushing's syndrome, acromegaly, or central obesity), test for elevated androgen levels (serum total testosterone level) using a reliable specialty assay.
    • If serum total testosterone levels are normal and sexual hair growth is moderate/severe, or sexual hair growth is mild with clinical signs of a hyperandrogenic endocrine disorder (for example menstrual disturbance), measure an early morning serum total and free testosterone by a reliable specialty assay.
  • In women with local, isolated sexual hair growth, a normal hirsutism score, and no other signs of a hyperandrogenic endocrine disorder, investigations are not usually necessary unless hair growth progresses despite treatment.
  • Consider screening for non-classical congenital adrenal hyperplasia in hyperandrogenemic women, and hirsute women at high risk (even if serum total and free testosterone levels are normal), for example, those with a positive family history, or from a high-risk ethnic group (such as Ashkenazi Jewish, Hispanic, and Eastern European people). 
    • Measurement of early morning 17-hydroxyprogesterone levels in the follicular phase is recommended — check with the local laboratory for details on when and how this test should be performed. 

Basis for recommendation

The recommendations on assessing women with hirsutism are largely based on expert opinion in the Endocrine Society Clinical Practice Guideline Evaluation and treatment of hirsutism in premenopausal women [Martin, 2018], the Society of Obstetricians and Gynaecologists of Canada guideline Hirsutism: Evaluation and Treatment  [Elliott, 2023], and the BMJ Best Practice guideline Assessment of hirsutism [BMJ Best Practice, 2024]. 

Underlying causes

  • The recommendations on identification of potential underlying causes for hirsutism are based on guidance from the Endocrine Society [Martin, 2018] and the approach suggested by experts in review articles on the management of androgen excess and hair disorders in postmenopausal women [Rothman, 2011; Blume-Peytavi, 2012]. 
    • Clinical features suggestive of polycystic ovary syndrome (PCOS), androgen-secreting tumours, Cushing's syndrome, and other endocrine conditions are described in the Canadian guidelines  [Elliott, 2023], the DermNet NZ page on Hirsutism [DermNet NZ, 2016], and review articles [Kini, 2018; Matheson, 2019]. 

Medication use

  • Experts state that certain drugs, including danazol, sodium valproate, and anabolic steroids, can cause hirsutism [Elliott, 2023; Kini, 2018] and a medication review is therefore recommended for women with hirsutism.

Family history 

  • The recommendation to enquire about family history of hirsutism or hyperandrogenism is derived from the Canadian guidelines [Elliott, 2023] as well as information in review articles [Lui, 2017; Matheson, 2019], which state that family history of hyperandrogenism is common in women with hirsutism and may be consistent with a benign or idiopathic cause

Testosterone levels

  • This recommendation on checking total testosterone blood levels in women with an abnormal hirsutism score, or local sexual hair growth with clinical evidence of a hyperandrogenic endocrine disorder, is based on guidance from the Endocrine Society [Martin, 2018].
    • The Endocrine Society suggests checking for increased serum total testosterone levels in women with an abnormal hirsutism score because they are more likely to have excess androgen production. It also advises ruling out raised androgen levels in women with any degree of sexual hair growth and clinical evidence of a hyperandrogenic endocrine disorder [Martin, 2018].
    • The Canadian guideline also advises laboratory investigations (including total testosterone) for women with moderate to severe hirsutism [Elliott, 2023]. 

When to not investigate

  • This recommendation that no investigations are required if there is local, isolated hair growth, a normal hirsutism score, and no other signs of a hyperandrogenic endocrine disorder is based on guidance from the Endocrine Society [Martin, 2018]. 
    • If a woman has unwanted hair growth and regular periods, but does not have an abnormal hirsutism score, the Endocrine Society recommends against testing for increased androgen levels because it is unlikely an underlying medical disorder with an impact on management or outcome will be identified [Martin, 2018].  
    • The Canadian guidelines also note the questionable benefit of laboratory investigations for mild hirsutism [Elliott, 2023].  

Non-classical congenital adrenal hyperplasia

  • The recommendation to screen screening selected women for non-classical congenital adrenal hyperplasia reflects guidance from the Endocrine Society  [Martin, 2018]. The Canadian and BMJ Best Practice guidelines also advise assessing serum 17-hydroxyprogesterone in women with hyperandrogenic hirsutism [Elliott, 2023; BMJ Best Practice, 2024].

What else might it be?

  • Hirsutism should be differentiated from hypertrichosis — excessive hair growth distributed in a generalized, nonsexual pattern, commonly affecting the limbs, trunk and back. It is not caused by excess androgen, although it may be aggravated by hyperandrogenaemia. It can be:
    • Congenital, for example, Hurler's syndrome, trisomy 18 syndrome, or fetal alcohol syndrome.
    • Associated with certain conditions, for example, hypothyroidism, porphyrias, epidermolysis bullosa, anorexia nervosa, malnutrition, dermatomyositis, or following a severe head injury.
    • Induced by drugs such as minoxidil, ciclosporin, glucocorticoids, and phenytoin.

Basis for recommendation

The information on the differential diagnoses of hirsutism are based on expert opinion in the Endocrine Society Clinical Practice Guideline Evaluation and treatment of hirsutism in premenopausal women [Martin, 2018], the Society of Obstetricians and Gynaecologists of Canada guideline Hirsutism: Evaluation and Treatment  [Elliott, 2023], and the BMJ Best Practice guideline Assessment of hirsutism [BMJ Best Practice, 2024], a consensus statement [Escobar-Morreale, 2012], and review articles on hirsutism and its diagnosis and management [Hunter, 2003; Kini, 2018; Matheson, 2019]. 

Management

Scenario: Management of hirsutism

From age 18 years onwards (Female).

When should I refer a woman with hirsutism?

  • Refer urgently (within 2 weeks) to endocrinology if there is a possibility of an underlying adrenal or ovarian neoplasm. Features of androgen-secreting tumours include:
    • Sudden onset or rapid progression of hair growth.
    • Signs of virilization (such as voice deepening, increased muscle bulk, and clitoromegaly).
    • A pelvic or abdominal mass.
  • Consider referral to endocrinology (with urgency dependent on clinical judgement) if another underlying endocrine condition is suspected that requires secondary care diagnosis and/or management.
  • Where further investigations returned abnormal results, refer to endocrinology as appropriate. This includes women with:
    • Raised testosterone level of greater than 4 nanomol/L (urgent referral is required if there is a possibility of an underlying adrenal or ovarian neoplasm or testosterone level is above 6–7 nanomol/L). 
    • Elevated 17-hydroxyprogesterone levels.

Basis for recommendation

The information on when to refer a woman with hirsutism is largely based on expert opinion in the Endocrine Society Clinical Practice Guideline Evaluation and treatment of hirsutism in premenopausal women [Martin, 2018], the Primary Care Dermatology Society guidance on Hyperandrogenism [PCDS, 2022b], the Society of Obstetricians and Gynaecologists of Canada guideline Hirsutism: Evaluation and Treatment  [Elliott, 2023], the BMJ Best Practice guideline Assessment of hirsutism [BMJ Best Practice, 2024], and a review article on hirsutism and its diagnosis and management [Kini, 2018].

Urgent referral 
  • The recommendation on urgent referral if there are clinical features suggestive of an androgen-secreting tumour is extrapolated from Primary Care Dermatology Society guidance on Hyperandrogenism [PCDS, 2022b]. 
    • The information on the clinical features of androgen-secreting tumours derives from the Endocrine Society and Canadian guidelines [Martin, 2018; Elliott, 2023], the Royal College of Obstetricians and Gynaecologists (RCOG) guidance on the long-term consequences of polycystic ovary syndrome [RCOG, 2014], and expert opinion in a review article that notes virilisation is a red flag symptom which requires urgent referral to an endocrinologist [Kini, 2018]. 
Referral if an underlying endocrine condition is suspected
  • This recommendation is pragmatic and is based on what CKS considers to be good clinical practice, reflecting expert opinion that in women with hirsutism not related to medication use, one focus of the evaluation is testing for endocrinopathies such as adrenal hyperplasia, Cushing syndrome, and androgen-secreting tumours [Kini, 2018]. 
Elevated serum total testosterone
  • High testosterone levels warrant investigation to exclude conditions such as late-onset congenital adrenal hyperplasia or an androgen-secreting tumour [RCOG, 2014]. However, the values and thresholds will depend upon the assay methodology and the normal range for that particular assay. 
    • Expert opinion in a guideline issued by the Royal College of Obstetricians and Gynaecologists on the long-term consequences of polycystic ovary syndrome suggests further investigation of high testosterone levels (greater than 5.0 nanomol/L or more than twice the upper limit of the normal reference range) [RCOG, 2014]. Guidance on hyperandrogenism from the Primary Care Dermatology Society advises that women with a confirmed testosterone level above 4.8 nanomol/L should be referred to an endocrinologist [PCDS, 2022b]. However, previous expert reviewers of this CKS topic suggested that a value of 4.0 nanomol/L should trigger a referral. CKS therefore recommends this lower value as a precautionary measure. 
    • A previous expert reviewer of this CKS topic recommended urgent referral if testosterone level is above 6–7 nanomol/L, to exclude an androgen-secreting tumour.
Elevated 17-hydroxyprogesterone levels
  • The recommendation to refer women with elevated 17-hydroxyprogesterone levels is based on expert opinion in the Canadian guidelines, which focus on women of reproductive age [Elliott, 2023]. 
    • Levels of 17-hydroxyprogesterone of more than 6 nanomol/L are indicative of non-classical congenital adrenal hyperplasia (NCCAH) and require further investigation [BMJ Best Practice, 2024]. 

How should I assess the severity of hirsutism?

  • Assess the severity of hair growth and the impact on the woman's quality of life, as this may guide treatment.
  • A subjective approach is generally appropriate in primary care, using the woman's own perception of her condition and the extent it impacts on her quality of life.

Basis for recommendation

The recommendations on assessment of severity of hirsutism are based on expert opinion in the Endocrine Society Clinical Practice Guideline Evaluation and treatment of hirsutism in premenopausal women [Martin, 2018] and the Society of Obstetricians and Gynaecologists of Canada guideline Hirsutism: Evaluation and Treatment  [Elliott, 2023].

Severity measures
  • Using the modified Ferriman-Gallwey score, a cut-off of 8 indicates excessive hair growth; mild hirsutism has been diagnosed in women with a score of less than 15, moderate hirsutism with a score of 16 to 25, and severe hirsutism with a score of more than 25 [Elliott, 2023]. 
  • However, the scoring system has a number of limitations including that clinicians may not be familiar with its use, and that use of cosmetic measures makes the calculation of an accurate score difficult. It also has not been carefully validated in postmenopausal women. In addition, the effect of the excess hair on the woman in terms of distress caused needs to be taken into account when planning treatment as some women with low scores may have higher levels of distress than other women with higher scores [Rothman, 2011; Martin, 2018].  
    • In a prospective observational study of 633 women, a Ferriman–Gallwey score of 2 or less was recorded in approximately 75% of women. 16% of these women considered themselves to be hirsute [DeUgarte, 2006]. 
    • Of the women with a Ferriman–Gallwey score of three or more, 69% considered themselves to be hirsute.
      • Similarly, 70% of women with a Ferriman–Gallwey score of 8 or more considered themselves to be hirsute.

How should I manage hirsutism in premenopausal women?

If referral is not indicated:

  • Encourage, and offer advice on, weight loss in women who are overweight or obese. See the CKS topic on Obesity for more information.
  • Discuss methods of hair reduction and removal (such as shaving and waxing), as these will remain an important part of management.
  • If hirsutism is mild and does not significantly impact the woman's quality of life, reassure and advise that no additional treatment is required.
  • If additional treatment is required:
    • For women with facial hirsutism, offer topical eflornithine (depending on local prescribing policies).
      • Advise that noticeable results take 6–8 weeks.
      • If no benefit is seen within 4 months of starting treatment, discontinue treatment and refer the woman to secondary care.
      • If improvement is seen, continued treatment is necessary to maintain the benefits. If the cream is discontinued, hair growth will return to pretreatment levels within about 8 weeks.
      • Do not prescribe topical eflornithine to pregnant or breastfeeding women, or women younger than 19 years of age.
      • For information on what advice to offer, contraindications, cautions, adverse effects, and drug interactions, see the section on Prescribing information. 
    • For all other women with hirsutism, offer a combined oral contraceptive (COC) containing ethinylestradiol as initial treatment, provided there are no contraindications. If the woman is at higher risk of venous thromboembolism (for example over the age of 39 years, or obese) consider a COC with the lowest effective dose of ethinylestradiol (usually 20 micrograms) and a low-risk progestogen. Discuss the risks associated with the use of the COC. 
      • See the CKS topic on Contraception - combined hormonal methods for detailed information on the contraindications and cautions of combined oral contraceptives (COCs) and the risks associated with their use.
      • The use of oral contraceptives for hirsutism is an off-label indication, except for Dianette® (cyproterone acetate and ethinylestradiol), which is licensed for the treatment of moderate to severe hirsutism in women of reproductive age.
        • Any woman with a history of meningioma should not take any cyproterone-containing medications.
  • If COCs are contraindicated or have been ineffective (after treatment for 6 months or more), refer the woman to secondary care for consideration of specialist treatment.
  • Offer information on hirsutism, such as:

Methods of hair removal

  • Treatments in a domestic setting which offer temporary hair removal include:
    • Shaving — an easily available technique. However, it needs to be repeated frequently and leads to stubble; the blunt tip of shaved hair may give the illusion of thicker hair.
    • Waxing and plucking — these are effective techniques but can be painful and may cause scarring, folliculitis, and hyperpigmentation. 
    • Chemical depilatory agents — dissolve hair, but may be associated with irritant dermatitis and hyperpigmentation.
    • Bleaching — this can mask the appearance of unwanted hair especially on the face, but it may also lead to skin irritation and skin discolouration.
  • Treatments carried out in specialist clinics may offer permanent hair reduction. They include:
    • Electrolysis — this uses a small current of electricity to destroy the hair follicle. It is effective, but is time-consuming, can be painful, and is impractical for hair removal over large areas. 
    • Laser hair removal — can be used over larger areas. It can be painful and time-consuming. It is most effective in women with lighter skin and darker hair.

Basis for recommendation

The recommendations on management of premenopausal women with hirsutism are largely based on expert opinion in the Endocrine Society Clinical Practice Guideline Evaluation and treatment of hirsutism in premenopausal women [Martin, 2018] and the Society of Obstetricians and Gynaecologists of Canada guideline Hirsutism: Evaluation and Treatment  [Elliott, 2023], from the Primary Care Dermatology Society [PCDS, 2022a; PCDS, 2022b], and within narrative review articles [Kini, 2018; Matheson, 2019].

Weight loss
  • The recommendation to encourage lifestyle modifications including weight loss for women who are overweight or obese, especially those with polycystic ovary syndrome (PCOS), is supported by an Endocrine Society guideline [Martin, 2018], and a number of experts [Mihailidis, 2017; Kini, 2018; Matheson, 2019]. 
Methods of hair removal
Mild hirsutism
  • The advice to consider offering reassurance (rather than intervention) to women with mild hirsutism that is not significantly affecting their quality of life is extrapolated from the Endocrine Society guidelines on hirsutis who acknowledge that treatment decisions should reflect the extent that excessive hair impacts the woman [Martin, 2018]
  • The authors of a systematic review also suggest that treatment may not be needed in women with mild hirsutism and no evidence of an endocrine disorder [Barrionuevo, 2018].
Topical eflornithine
  • There is limited published evidence on the use of topical eflornithine for facial hirsutism.
    • Evidence from open-label and randomized studies suggests that topical eflornithine may improve the appearance and reduce the growth of facial hair  [van Zuuren, 2015; Martin, 2018].
  • Topical eflornithine is licensed for the treatment of facial hirsutism in women aged 19 years and older [EMC, 2022], and is recommended in clinical guidelines on the treatment of hirsutism [Martin, 2018; Elliott, 2023] and expert review articles  [Mihailidis, 2017; Kini, 2018]. 
  • Information on advice to give women regarding eflornithine treatment is based on guidelines from the Endocrine Society [Martin, 2018], the British National Formulary [BNF, 2024], and the manufacturer's Summary of Product Characteristics [EMC, 2022]. 
Combined oral contraceptives (COCs)
  • The recommendation to offer a COC first-line for premenopausal women with hirsutism is largely based on expert opinion in the Endocrine Society guideline [Martin, 2018], the Canadian guideline  [Elliott, 2023], guidance from the Primary Care Dermatology Society [PCDS, 2022b], and expert opinion in review articles [Kini, 2018; Matheson, 2019]. 
    • Evidence in a systematic review and network meta-analysis has demonstrated efficacy of COCs compared with placebo for improving hirsutism [Barrionuevo, 2018], although the effectiveness of a COC depends on the ethinylestradiol content and the progestogen it contains [PCDS, 2022b]. 
  • COCs reduce hyperandrogenism by suppression of luteinizing hormone secretion (thereby reducing ovarian androgen secretion) and by increasing the production of sex hormone-binding globulin (thereby increasing androgen binding and reducing free androgen levels) [Elliott, 2023; Martin, 2018]. 
  • Data from a French cohort study indicates that use of high dose cyproterone acetate containing 50–100 mg per tablet is associated with significantly increased risk of meningioma. Co-cyprindiol/Dianette® tablets containing cyproterone acetate with ethinylestradiol which are used for treatment of hirsutism in women of reproductive age contain only 2 mg of cyproterone acetate. The annual cumulative exposure to cyproterone acetate is therefore about 0.8 g. The MHRA advises that although exposure to this is low dose of cyproterone acetate has not been shown to increase risk of meningioma, an association is plausible and cannot be excluded [CoSRH, 2020].
    • MHRA advice is therefore that women who have had a meningioma should not use any product containing cyproterone acetate. Women without a history of meningioma may use Co-cyprindiol/Dianette® for management of acne/hirsutism although they advise that clinicians should be vigilant for symptoms and signs of meningioma [CoSRH, 2020]. 
Choice of COC
  • Guidance from the Primary Care Dermatology Society and Society of Obstetricians and Gynaecologists of Canada suggest that COCs containing non-androgenic progestogens (for example desogestrel or norgestimate) or antiandrogenic progestogens (for example cyproterone acetate, drospirenone) may be more effective [PCDS, 2022b; Elliott, 2023]. However, a specific oral contraceptive formulation is not recommended by the Endocrine Society for treating hirsutism in most women [Martin, 2018].
    • Although oral contraceptives containing cyproterone acetate or drospirenone were found to be associated with a slightly lower hirsutism severity score than other COCs, the Endocrine Society concluded that the differences were probably not clinically important [Martin, 2018]. A systematic review and network meta-analysis on treatment options for hirsutism also found similar effectiveness or trivial differences between COCs containing levonorgestrel, cyproterone acetate, or drospirenone and other COCs [Barrionuevo, 2018].
  • Cyproterone acetate and drospirenone act as weak androgen receptor antagonists. Progestogens with low androgenicity include norgestimate, desogestrel, and gestodene [Martin, 2018]. COCs containing levonorgestrel or norethisterone are more androgenic [PCDS, 2022b; Kini, 2018]. Levonorgestrel is the most androgenic progestogen but concerns regarding the effectiveness of levonorgestrel-containing COCs containing this for treating hirsutism have not been supported by a meta-analysis. However, levonorgestrel is generally avoided in women with PCOS due to concerns about its adverse effects on metabolic biomarkers [Martin, 2018]. 
  • The pragmatic recommendation to discuss the risks associated with COC use aims to ensure that the woman is fully informed. COCs are associated with a small increased risk of certain conditions, including venous thromboembolism (VTE) [CoSRH, 2023]. Risk is further increased in women aged over 39 years and in women with obesity [Martin, 2018]. 
    • The incidence of VTE is 1.5–2 times higher in women using Dianette® (which contains cyproterone acetate) than in women using COCs containing levonorgestrel, and the VTE risk with Dianette® may be similar to that with COCs containing desogestrel, gestodene, or drospirenone [BNF, 2024].
  • Licensing information for COCs is derived from the British National Formulary [BNF, 2024] and the manufacturer's Summary of Product Characteristics for Dianette® [EMC, 2023]. 
Referral
  • The recommendation on when to refer for specialist treatment is based on expert opinion in a review article stating that, for intractable cases, dermatology referral may be considered [Matheson, 2019]. The recommended timescale is based on information within the Endocrine Society  guideline, which recommends a trial of 6 months of a pharmacological treatment before switching, changing the dose, or adding medication [Martin, 2018]. 
  • Other systemic treatments which have been suggested for the treatment of hirsutism include anti-androgens (for example cyproterone acetate, finasteride, flutamide, spironolactone), insulin-sensitizing drugs, and gonadotrophin-releasing hormone analogues [Mihailidis, 2017; Martin, 2018; PCDS, 2022b]. CKS recommends referral to secondary care if COCs are contraindicated or have been ineffective, because alternative treatments are not licensed for the treatment of hirsutism and some may have potentially serious adverse effects [Elliott, 2023; BNF, 2024].  

How should I manage hirsutism in postmenopausal women?

If referral is not indicated:

  • Discuss methods of hair reduction and removal (such as shaving and waxing), as these will remain an important part of management.
  • If hirsutism is mild and does not significantly impact the woman's quality of life, reassure and advise that no additional treatment is required.
  • Encourage weight loss in women who are overweight or obese. See the CKS topic on Obesity for more information.
  • If additional treatment is required:
    • For women with facial hirsutism, offer topical eflornithine (depending on local prescribing policies).
      • Advise that noticeable results take 6–8 weeks.
      • If no benefit is seen within 4 months of starting treatment, discontinue treatment and refer the woman to secondary care.
      • If improvement is seen, continued treatment is necessary to maintain the benefits. Once the cream is discontinued, hair growth returns to pretreatment levels within about 8 weeks.
      • For information on what advice to give, contraindications, cautions, adverse effects, and drug interactions, see Prescribing information. 
    • For all other women with hirsutism, refer for initiation of specialist treatment.

Basis for recommendation

There is very limited evidence about the specific treatment of hirsutism in post-menopausal women [Blume-Peytavi, 2012]. Recommendations are therefore largely based on the opinion of previous expert reviewers of this CKS topic and what is considered to be good clinical practice. In addition, advice on general management has been extrapolated from guidelines on hirsutism in premenopausal women [Martin, 2018; Elliott, 2023; PCDS, 2022a; PCDS, 2022b] and expert review articles [Kini, 2018; Matheson, 2019].

Weight loss
  • The recommendation to encourage lifestyle modifications including weight loss for women who are overweight or obese, especially those with polycystic ovary syndrome (PCOS), is supported by an Endocrine Society guideline [Martin, 2018], and a number of experts [Mihailidis, 2017; Kini, 2018; Matheson, 2019]. 
Methods of hair removal
Mild hirsutism
  • The advice to consider offering reassurance (rather than intervention) to women with mild hirsutism that is not significantly affecting their quality of life is extrapolated from the Endocrine Society guidelines on hirsutism. These acknowledge that treatment decisions should reflect the extent that excessive hair affects the woman [Martin, 2018]
  • The authors of a systematic review also suggest that treatment may not be needed in women with mild hirsutism and no evidence of an endocrine disorder [Barrionuevo, 2018].
Topical eflornithine
  • There is limited published evidence on the use of topical eflornithine for facial hirsutism. 
    • Evidence from open-label and randomized studies suggests that topical eflornithine may improve the appearance and reduce the growth of facial hair  [van Zuuren, 2015; Martin, 2018].
  • Topical eflornithine is licensed for the treatment of facial hirsutism in women aged 19 years and older [EMC, 2022], and is recommended in clinical guidelines on the treatment of hirsutism [Martin, 2018; Elliott, 2023] and and a review article on hair disorders in postmenopausal women [Blume-Peytavi, 2012].
  • Information on advice to give women regarding eflornithine treatment is based on guidelines from the Endocrine Society [Martin, 2018], the British National Formulary [BNF, 2024], and the manufacturer's Summary of Product Characteristics [EMC, 2022]. 
Referral
  • The recommendation on when to refer for specialist treatment is based on expert opinion in a review article stating that, for intractable cases, dermatology referral may be considered [Matheson, 2019].
  • Other systemic treatments which have been suggested for the treatment of hirsutism include anti-androgens (for example cyproterone acetate, finasteride, flutamide, spironolactone), insulin-sensitizing drugs, and gonadotrophin-releasing hormone analogues [Rothman, 2011; Blume-Peytavi, 2012; Mihailidis, 2017; Martin, 2018; PCDS, 2022b]. CKS recommends referral to secondary care if hirsutism has failed to respond to treatment in primary care, because alternative treatments are not licensed for the treatment of hirsutism and some may have potentially serious adverse effects [Elliott, 2023; BNF, 2024].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF) .

Topical eflornithine

What should I advise a person using eflornithine?

  • Topical eflornithine (Vaniqa® 11.5% cream) is licensed for the treatment of facial hirsutism. 
  • Advise that:
    • A thin layer of topical eflornithine should be applied to the affected area two times a day, at least 8 hours apart. The manufacturer advises that application should be limited to the face and under the chin because efficacy has only been demonstrated for these areas. 
    • Topical eflornithine should be rubbed in thoroughly; contact with eyes or mucous membranes (for example nose or mouth) should be avoided.
    • Cosmetics may be applied over the treated area 5 minutes after applying topical eflornithine, and the treated area should not be washed for 4 hours after application.
    • Other hair removal methods (such as shaving or waxing) may be used in conjunction with topical eflornithine. In such cases, the cream should be applied no sooner than 5 minutes after the use of the hair removal method because increased stinging or burning may otherwise occur.

[EMC, 2022; BNF, 2024]

What are the contraindications and cautions for eflornithine?

  • The manufacturer advises that topical eflornithine should not be used in:
    • Pregnant women — the potential risk of topical eflornithine to human pregnancy is unknown.
    • Breastfeeding women — it is not known if topical eflornithine is excreted in human milk.
    • People under the age of 19 years — there are no data available to support the use of topical eflornithine in this age group.

[EMC, 2022]

What are the adverse effects of eflornithine?

  • Adverse effects are mostly skin-related, mild in intensity, and resolve without discontinuation of topical eflornithine or initiation of medical treatment.
    • The most frequently reported adverse effect is mild acne.
    • Other common adverse effects include pseudofolliculitis barbae, alopecia, stinging, burning, tingling, dry skin, pruritus, erythema, skin irritation, rash, and folliculitis.
    • If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. Stop treatment if irritation continues. 

[EMC, 2022; BNF, 2024]

What drug interactions occur with eflornithine?

  • There are no known drug interactions with topical eflornithine — no interaction studies have been carried out.

[EMC, 2022]

Supporting evidence

This CKS topic is largely based on Endocrine Society Clinical Practice Guideline Evaluation and treatment of hirsutism in premenopausal women [Martin, 2018] and the Society of Obstetricians and Gynaecologists of Canada guideline Hirsutism: Evaluation and Treatment  [Elliott, 2023], guidance from the Primary Care Dermatology Society on Hirsutism [PCDS, 2022a] and Hyperandrogenism [PCDS, 2022b]. The rationale for the primary care diagnosis, management, and referral of women with hirsutism is discussed in the relevant basis for recommendation sections. 

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of hirsutism.

Search dates

January 2020 - October 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 20th September 2019, update searches completed on 28th January 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S4     S1 OR S2 OR S3 
S3    AB excessive hair growth OR TI excessive hair growth 
S2    AB hirsutism OR TI hirsutism 
S1    (MH "Hirsutism") 
 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • BAD (2021) Hirsutism. British Association of Dermatologists. https://www.bad.org.uk [Free Full-text]
  • Barrionuevo, P., Nabhan, M. and Altayar, O. (2018) Treatment options for hirsutism: A systematic review and network meta-analysis. Journal of Clinical Endocrinology and Metabolism 103(4), 1258-1264. [Abstract]
  • Blume-Peytavi, U., Atkin, S. and Gieler, U. (2012) Skin academy: hair, skin, hormones and menopause - current status/knowledge on the management of hair disorders in menopausal women. European Journal of Dermatology 22(3), 310-318. [Abstract]
  • BMJ Best Practice (2024) Assessment of hirsutism. BMJ Publishing Group.
  • BNF (2024) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • CoSRH (2020) FSRH CEU Statement : New advice from the MHRA regarding cyproterone acetate: how does this affect prescribing of Co-cyprindiol/Dianette® for acne/hirsutism? College of Sexual and Reproductive Healthcare. http://www.cosrh.org [Free Full-text]
  • CoSRH (2023) Combined Hormonal Contraception. College of Sexual and Reproductive Healthcare. https://www.cosrh.org [Free Full-text]
  • DermNet NZ (2016) Hirsutism. DermNet NZ. https://dermnetnz.org [Free Full-text]
  • DeUgarte, C.M., Woods, K.S., Bartolucci, A.A. and Azziz, R. (2006) Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. Journal of Clinical Endocrinology and Metabolism 91(4), 1345-1350. [Abstract]
  • Elliott, J., Liu, K. and Motan, T. (2023) Guideline No. 444: Hirsutism: Evaluation and Treatment. Journal of Obstetrics and Gynaecology Canada 45(12), 102272. [Abstract]
  • EMC (2022) SPC for Vaniqa 11.5% cream. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2023) SPC for Dianette. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Escobar-Morreale, H.F., Carmina, E. and Dewailly, D. (2012) Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society. Human Reproduction Update 18(2), 146-170. [Abstract]
  • Hunter, M. and Carek, P. (2003) Evaluation and treatment of women with hirsutism. American Family Physician 67(12), 2565-2572. [Abstract]
  • Kim, A.B., Cheng, B.T. and Hassan, S. (2023) Hirsutism is associated with increased hospitalization for mental health disorders. Archives of Dermatology Research 315(5), 1277-1286. [Abstract]
  • Kini, S. and Ramalingam, M. (2018) Hirsutism. Obstetrics, Gynaecology and Reproductive Medicine 28(5), 129-135. [Free Full-text]
  • Lui, K., Motan, T. and Claman, P. (2017) No. 350-Hirsutism: Evaluation and Treatment. Journal of Obstetrics and Gynaecology Canada 39(11), 1054-1068. [Abstract]
  • Martin, K.A., Anderson, R.R. and Chang, R.J. (2018) Evaluation and treatment of hirsutism in premenopausal women: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism 103(4), 1233-1257. [Abstract]
  • Matheson, E. and Bain, J. (2019) Hirsutism in women. American Family Physician 100(3), 168-175. [Abstract]
  • Mihailidis, J., Dermesropian, R. and Taxel, P. (2017) Endocrine evaluation of hirsutism. International Journal of Women's Dermatology 3(1 Suppl), S6-S10. [Abstract]
  • PCDS (2022a) Hirsutism. Primary Care Dermatology Society. https://www.pcds.org.uk [Free Full-text]
  • PCDS (2022b) Hyperandrogenism. Primary Care Dermatology Society. https://www.pcds.org.uk [Free Full-text]
  • RCOG (2014) Long-term consequences of polycystic ovary syndrome. Royal College of Obstetricians and Gynaecologists. http://www.rcog.org.uk [Free Full-text]
  • Rothman, M.S. and Wierman, M.E. (2011) How should postmenopausal androgen excess be evaluated? Clinical Endocrinology 75(2), 160-164. [Abstract]
  • van Zuuren, E.J., Fedorowicz, Z. and Carter, B. (2015) Interventions for hirsutism (excluding laser and photoepilation therapy alone) (Cochrane Review). Issue 2. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
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