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by Geoffrey Redmond, MD


Quick Reference
How Much Hair Is Normal
Medical Terms For Extra Hair
Ethnic Variations In Facial And Body Hair
What Causes Increased Hair
Lab Tests For Increased Hair
I Have Too Much Hair But My Hormone Tests Are Normal – How Can This Be?
Other Reasons For Hirsutism With Normal Testosterone
Treatments For Increased Hair
Medications For Increased Hair
Hope For Women With Unwanted Hair

Women and Hair
Though recent decades have seen many changes in our concepts of masculinity and femininity, one thing has not changed: women still are not supposed to have hair on their face or body. That this is not biologically accurate – most women do have at least some extra hair somewhere – has not changed fashion.

Indeed our society seems to have grown more “trichophobic” -  phobic about body hair. Even pubic hair is now often shaved or waxed. This dislike of hair is not confined to women  -- more and more men are opting to have chest or back hair removed. In the past, ideals of beauty were more realistic. In ancient India, a band of hair in the middle of a woman’s chest was considered a sign of great beauty. That body hair was more accepted in earlier times does not help much now since we have to be comfortable in the culture in which we find ourselves.

Despite the assumption that women do not have facial and body hair, many do. How bothersome this extra hair is depends on the amount and consistency. Having to tweeze a light chin hair once in awhile can be taken in stride. But if you need to spend more than a few minutes each morning removing hair, or if your extra hair is dark and stiff, it tends to be more distressing because it is harder to conceal.

Unfortunately, women with hirsutism are often not believed when they turn to health care providers for help. Some doctors fail to notice the extra hair. Or, if they do, they may tell women that the condition is hereditary with the implication that nothing can be done about it. While there is no question that some families and ethnic groups have a tendency to more hair, this does not mean that they cannot benefit from treatment. There are other excuses doctors give for not treating hirsutism but women with increased hair should not be put off by them. There are effective treatments for hirsutism, and women troubled by this condition are entitled to seek help.

How Much Hair is Normal
Testosterone is thought of as the male hormone but this is not strictly accurate because it is present in active levels in women as well as men. Women’s levels however are only 5 to 10% of men’s levels.

In both sexes, testosterone levels rise at puberty, causing increased oiliness of the skin and the appearance of pubic and underarm hair. While we think of these as the only places a woman has body hair, most have some on other areas as well: lower legs, upper thighs, between the navel and pubic region, around the nipples and on the chin and upper lip. Some women experience increases in hair on other regions as well: chest and abdomen, lower back, neck and cheeks.

Because I see many women with increased hair growth in my practice, I am often asked how much hair is normal for a woman. There is no absolute answer. Half of American women remove facial hair at least once in a while and ten percent remove it two or more times a week. Many of the women I see in my practice remove even more often. Some even use a razor once or twice a day because their facial hair grows as quickly as a man’s. Heavy hair growth on women is not as rare as people think because women with this unfortunate problem do all they can to hide it. Most never discuss this problem with friends because they feel so embarrassed about it.  Women on TV or in movies or magazines never seem to have any extra hair. The reality is different. There are some well known actresses who have considerable growth of facial or body hair but they either wax it off or the camera is kept slightly out of focus – a trick also routinely used to hide wrinkles. Retouching is the rule also.

There is no sharp dividing line between normal and abnormal amounts of hair. Facial and body hair is a very personal matter and so a personal definition is appropriate: hair that is enough to make a woman afraid that it will show is too much. However this does not mean that a medical problem is present.  A few hairs in the following locations are normal for a woman: outer corners of the upper lip, the chin, around the nipples, between the navel and pubic region and the tops of the thighs. If a woman has more than light growth of hair in these places or if there is wider coverage of face and body, then the condition of hirsutism can be said to be present. This degree of extra hair is reason for medical evaluation, especially if accompanied by irregular periods or weight problems.

Treatments For Increased Hair
There are basically three approaches: self-removal at home, use of electrolysis or laser and prescription medication.

Home removal All sorts of methods are in use, but the most common one, tweezing, is the worst -- because it pulls the hair out by the root, which injures the skin. Done for a long time it can give a bumpy look to the skin over the jaw. Snipping with a scissors is better than plucking though it does not last as long. Bleaches and depilatories are OK too; but with depilatories, be sure not to leave them on longer than the instructions say otherwise there can be considerable irritation. A razor is an effective way to remove hair but many women understandably do not like to use one. Despite widespread belief to the contrary, removing hair by a razor or other means does not make it grow in faster or darker.

Electrolysis is a well-established method which is permanent. Continuing treatment is often needed for women with substantial hair growth because new follicles become active. I particularly familiar with this method because I have been an advisor to one of the major electrolysis organizations. To get a good result, electrolysis needs to be done by a skilled professional using proper equipment. A good place to start is the Worldwide Registry of Professional Electrologists WROPE or the directories of two national professional associations: The International Guild of Professional Electrologists, Inc. and American Electrolysis Association. Many electrologists are highly committed to their profession and have an excellent understanding of the problems of women with increased hair growth.

Laser has been heavily promoted. It is said to offer “permanent hair reduction” though how much the hair is actually reduced in the long term is difficult to tell. Current laser technology is not suitable for those with very light or very dark skin. Some get pigmentary changes from it. Long term studies are lacking so that it is hard to tell how happy people will be with the results later on.   

Ethnic Variations in Facial and Body Hair
Asians, both men and women, have relatively little body hair. However, many women in Japan find even slight extra hair growth disturbing. Sometimes it is assumed that women from Mediterranean countries (Italy, Greece, etc.) will not be bothered by extra hair since it is more common in those parts of the world. However in the media there, as everywhere, photographs of women do not show how much facial and body hair they really have. The result is that women with average or slightly more than average amounts of hair think they are abnormal. Sadly, this tends to create a feeling of isolation. If you are reading this article because you have extra hair, be reassured, there are millions of other women like you.

Blacks have fewer hairs than whites but the hair tends to be equally noticeable because it is curly and dark, so the incidence of visible hirsutism is similar in whites and blacks.

African-Americans have another problem when they develop excessive hair. The curliness makes the hairs more likely to become ingrown after they are removed. This can result in a pimple-like breakout termed PFB (pseudofolliculitis barbae). As these lesions heal, they often leave dark patches do not fade completely. Proper treatment of the hirsutism to reduce ingrown hairs is important to maintain smooth skin coloring.

What Causes Increased Hair
With only the rarest of exceptions, facial and body hair are due to the action of androgens, the family of hormones that includes testosterone. Though androgens are loosely called “male hormones,” this is misleading. All adult males and females have biologically active levels of testosterone in their blood. The levels in men are about 10 times higher than the levels in women. In childhood, androgen levels are unmeasurably low in both boys and girls.

At puberty testosterone levels begin to rise in both sexes, but of course much more sharply in boys. Some of the normal events produced by androgens at puberty are: the appearance of pubic and underarm hair, increased oiliness of the face and darkening of the genital skin. In males, androgens stimulate sexual feelings, but their role in this regard is far less clear in women.

As androgen levels increase, more areas of the skin start to respond by showing hair growth. The genital area is most sensitive, followed by the underarms, chin, middle of the upper lip, around the edge of the nipples and the midline of the abdomen. Many women have some hair in these latter four locations and in small amounts it is certainly not abnormal. For a few the amounts are greater, and embarrassment and self-consciousness result.

Lab Tests for Increased Hair
The most important lab test is testosterone. The so-called free testosterone should also be measured. This is the portion of the hormone which is not attached to protein in the blood and therefore can actually travel into the tissues. DHEA-S can be converted to testosterone and so should also be measured. Another androgen, androstenedione is useful occasionally. If one or more of these androgens is more than mildly elevated, more tests need to be done to determine the cause and find out which gland the extra testosterone is coming from – ovary or adrenal or both.

If periods are irregular, FSH and prolactin should be checked to find out if there is a problem in the ovary or pituitary.

The most common underlying condition causing increased hair growth is PCOS (polycystic ovary syndrome). This is discussed in detail in a separate article on this site. With PCOS, there are often changes in metabolism and other tests are needed to identify these so that they can be treated.

A variety of rare conditions such as late-onset adrenal hyperplasia require more elaborate work-up by an endocrinologist.

I Have Too Much Hair But My Hormone Tests Are Normal – How Can This Be?
Many of the women I see in my practice for increased hair growth have normal hormone levels; they, and often their doctors, find this baffling. If your testosterone is normal, but you shave daily, does this mean that hormones are not involved? This question is one I am asked over and over. The answer is clearly “no.” Hirsutism is always due to testosterone stimulating the hair follicles. Why then do many women with hirsutism have normal levels of this hormone? The answer is that some people have hair follicles which are extremely sensitive to testosterone. Think about body hair on men. Some have a little and others have a lot even though their testosterone levels are similar. In women the situation is the same; whatever their testosterone levels, those with more sensitive follicles have more hair. Hair follicle sensitivity to testosterone is the single most important factor in increased hair growth. As I will discuss below, hair follicle sensitivity is highly treatable.

Some women have the opposite situation: hair follicles which are insensitive to testosterone and so have hardly any body hair. This is usual in Asians but is uncommon in whites or blacks.

Lab tests are important in medical evaluation of hirsutism but they have their limitations, too. The laboratory does not tell us what is wrong with someone, rather it aids in doing so. Tests are ordered when there are symptoms or other reasons to suspect a disease. But a negative test does not mean there is no problem, simply that the test has failed to tell us the cause. 

Other Reasons For Hirsutism With Normal Testosterone
Women’s levels of testosterone are at their highest in the late teens and early 20s. After that levels decline until after menopause when they are usually very low. But here’s the unfair part: once stimulated by testosterone, hair follicles stay over-active. A woman might have slightly high testosterone levels when she is in her 20s, but by the time she has a workup some years later, the elevations are already long gone. However the follicles haven’t forgotten and keep on producing thick, dark hairs.

Another cause of misleading test results is that testosterone is released into the blood episodically. Levels fluctuate and so testosterone may be high only sometimes. But hair follicles are stimulated every time the testosterone level goes up. A single blood draw may miss the peaks.

A sudden or large increase in hair makes it important to see if hormone levels are high. If they are, a hormonal disorder is present and more work-up may be needed. If levels are normal, there is usually no hormonal disorder, just a problem with sensitive follicles.

Increased hair can be treated whether testosterone levels are normal or elevated. Medications which block androgens such as spironolactone (Aldactone®) work in both situations because they protect the hair follicles against the testosterone.

If you have increased hair but normal hormones, don’t believe it if you are told that nothing can be done. There are several treatments which can greatly reduce the amount of hair. If your testosterone is high, or there are other abnormal hormone levels, treatment can significantly reduce hair but more medications may be needed in order to help with other effects of the hormonal abnormality.  

Medical Terms for Extra Hair
Hirsutism refers to increased hair in the so-called sexual distribution. Sexual distribution simply means skin areas on which men and women have different amounts of hair. Hair growth on these areas is due to the effect of testosterone on the hair follicle. As I have just mentioned, hirsutism can affect chin, upper lip, sideburn area, neck, chest, abdomen and pubic region as well as upper thighs.

Hypertrichosis refers to extra hair on other areas and which is not caused by testosterone.  Areas which can be affected by hypertrichosis include the forehead, upper cheeks or, in the case of prepubertal children, anywhere on the body. Hair on the forearms and lower legs can be hormonal or non-hormonal. More than mild hypertrichosis is uncommon.  Certain infrequently used drugs can cause it, for example, cyclosporin, used to prevent transplant rejection.

The dark, stiff opaque hairs found with hirsutism are called terminal hairs. Very light, fine hairs which are barely visible are termed vellus. With testosterone stimulation vellus hairs develop into terminal ones. Sometimes the vellus hairs start to become more noticeable but are still fine – a situation colloquially referred to as “peach fuzz.” This sort of hair can appear at or after menopause.

Almost all women concerned about increased hair growth have hirsutism, not hypertrichosis.

Hope For Women With Unwanted Hair
If you have increased facial or body hair, I’m sure you have heard a lot of discouraging messages. Ignore them. Whatever you have been told, it is possible to find out what is causing unwanted hair growth and to get effective treatment. Treatment will not necessarily remove every unwanted hair but can reduce it considerably, making removal less of a burden and reducing insecurity that others will discover the secret. 

Medications For Increased Hair
Although hirsutism shows on the skin, it is started by hormones in the blood. It is therefore as much an internal as external condition. Treatment directed at the hormonal cause can be quite effective. Several of these treatments have been in use for many years but are not widely known. Most of the prescription medications are FDA approved for other indications but not for hirsutism. They can be prescribed for hirsutism however.

The following is meant as general information. What treatment is suitable for an individual must be worked out with a physician.

Proper treatment depends on hormone levels. It generally involves two components:
1) Lowering the level of free testosterone. Oral contraceptives (OCs) are often used for this since some will lower free testosterone by about half. However by themselves, OCs help only slightly. They slow hair growth rates but not down to normal. Some specific oral contraceptives seem to be better than others for hirsutism and related problems. OCs work best when combined with the next form of medical treatment: 

2) Blocking the effect of testosterone on the hair follicle. Several medications have this effect. Here are some of the most often used:

Spironolactone  The medication most commonly used to block testosterone is spironolactone (Aldactone®) but it must be used in the proper dose. Originally introduced for treatment of high blood pressure, spironolactone is probably now more often used for hirsutism. Doses for hirsutism are higher than those for high blood pressure. Spironolactone can cause menstrual periods to come closer together but combined use with an OC will usually keep the cycle regulated. Because it is a diuretic (water pill) spironolactone can cause slight dehydration. Signs of this include mild fatigue and dizziness but this can be almost always be prevented by adequate water intake.

Finasteride (Proscar® and Propecia®)  Finasteride is sold in different doses under the brand names Proscar ® and Propecia® for prostate enlargement and male pattern baldness respectively. This medication blocks the enzyme 5 alpha-reductase which converts testosterone to its more active form, DHT (dihydrotestosterone). DHT is the hormone responsible for the gradual enlargement of the prostate which occurs in most men beyond the age of fifty. A form of this same enzyme is active in the hair follicle and plays a role in both increased hair and loss of hair from the scalp. We know this because people with a rare inherited condition of deficiency of this enzyme have scant body hair. Unfortunately, the males with this rare condition also have abnormal genital development.

Finasteride seems to have some effectiveness for hirsutism though it may not be quite as effective as spironolactone. (It probably can also help alopecia but this is discussed in the article on hair loss.) However it does not have the common spironolactone side effects of increased water loss and more frequent periods.

Risks of finasteride There is a major problem which greatly limits use of finasteride in women. I pointed out that men with a genetic defect in 5a-reductase — the same situation as finasteride creates — are born with abnormalities in their genitalia. This is because the a male baby needs full levels of DHT for his genitalia to form properly during fetal development. The fear is that if a woman takes finasteride when pregnant with a male child, genital abnormalities may occur. This has not been reported in humans but remains a grave concern nonetheless. The labeling for finasteride includes warnings that it should not be taken by women. This is because of the birth defect concern.

Finasteride has been used for hirsutism and alopecia in women, usually those who cannot become pregnant — because they have gone through menopause or had a tubal ligation or hysterectomy. Use of finasteride by women is a decision which needs to be thought through carefully with the input of a knowledgeable physician and reliable means for prevention of pregnancy.

Actually, there are similar concerns about any anti-androgen and any women who takes such medications must be aware of this and take suitable precautions not to become pregnant.

The Cream for Facial Hair There is a new medication, Vaniqa® (eflornithine) which is FDA approved for treatment of facial hair. It is applied twice a day and works by slowing the metabolism of the hair follicle. It does not eliminate the hair but simply slows its growth. I was involved in its development and many women are happy with it. The thing to remember is that it is basically for women who are removing hair. By slowing down how quickly it regrows, Vaniqa can decrease how often hair needs to be removed and make a woman more confident that her secret will not be apparent a few hours after removal. It can be combined with other medications.

How long does it take to see improvement? Because hair growth changes slowly, treatments to alter it work gradually. Though improvement can begin to show within the first 3 or 4 months, it is after that the difference starts to become more and more apparent. It does take patience but most women are happy with the result if treatment is done properly. A regimen customized to a woman’s individual hormonal pattern is much more likely to produce a satisfying result.

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