Excess Body Hair

Differential Diagnosis

Common Diagnoses

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

ConstitutionalPCOSAnorexiaMenopauseDrugs
Excess Vellous HairNoNoYesNoPossible
Facial HirsutismPossiblePossibleNoYesPossible
Oligo/AmenorrhoeaNoYesYesYesNo
Otherwise WellYesYesNoPossiblePossible
Weight LossNoNoYesNoNo

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.
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