Excess Body Hair
Differential Diagnosis
Common Diagnoses
- Constitutional (Physiological)
- Polycystic Ovary Syndrome (PCOS): 50% of Cases
- Anorexia Nervosa
- Menopause and Perimenopause
- Iatrogenic (e.g. Phenytoin, Minoxidil, Danazol, Glucocorticoids)
Occasional Diagnoses
- Congenital Adrenal Hyperplasia (1 in 5000)
- Anabolic Steroid Abuse
- Ovarian Tumours: Arrhenoblastoma, Hilus Cell Tumour, Luteoma
- Adrenal Tumours: Carcinoma and Adenoma
- Congenital (1 in 5000 Live Births) and Juvenile Hypothyroidism
Rare Diagnoses
- Acromegaly (Incidence 3 Per Million)
- Porphyria Cutanea Tarda
- Cushing’s Syndrome (Incidence 1–2 Per Million)
- Hypertrichosis Lanuginosa
- Cornelia De Lange Syndrome (Amsterdam Dwarfism)
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Constitutional | PCOS | Anorexia | Menopause | Drugs | |
|---|---|---|---|---|---|
| Excess Vellous Hair | No | No | Yes | No | Possible |
| Facial Hirsutism | Possible | Possible | No | Yes | Possible |
| Oligo/Amenorrhoea | No | Yes | Yes | Yes | No |
| Otherwise Well | Yes | Yes | No | Possible | Possible |
| Weight Loss | No | No | Yes | No | No |
Possible Investigations
Likely:None.
Possible:Serum testosterone, SHBG, pelvic ultrasound, FBC, U&E, TFT.
Small Print:FSH/LH, other tests of endocrine function and specialised imaging techniques (for adrenal/pituitary disorders), urinary porphyrins.
- Serum testosterone and SHBG: Probably the most useful investigation. Mild elevation (up to three times the normal value) and normal or low SHBG suggests PCOS; testosterone levels above this indicate a possible tumour.
- FBC, U&E: Possible iron deficiency anaemia and electrolyte disturbance in anorexia; U&E may be deranged in adrenal disorders.
- FSH/LH and TFT: The former may help to confirm menopause and may point towards PCOS (elevated LH, normal FSH); the latter reveals hypothyroidism.
- Other tests of endocrine function and imaging techniques: To investigate possible adrenal and pituitary disorders (usually undertaken in secondary care).
- Pelvic ultrasound: Multiple ovarian cysts characteristic of PCOS; may also reveal ovarian tumour.
- Urinary porphyrins: For porphyria.
Top Tips
- Mild, long-standing hirsutism does not require investigation.
- Enquire about self-medication, especially in athletes – anabolic steroids may occasionally be the cause.
- Take the problem seriously and be prepared for questions about cosmetic treatments such as bleaching, depilatory creams and electrolysis.
Red Flags
- Sudden and severe hirsutism is the most important marker for serious underlying pathology.
- Other clues suggesting a possible hormone-secreting tumour include amenorrhoea, onset of baldness at the same time as hirsutism and a patient who seems generally unwell.
- Consider psychological factors: Hirsutism can cause – or be the presenting complaint in – significant depression.
- Recent onset of significant headache and visual field defect raise the possibility of a pituitary adenoma.