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Q: I've read about polycystic ovary syndrome (PCOS) but what else can cause hirsutism? I am an electrologist and many of the women I treat for unwanted hair do not have other signs of PCOS such as weight gain or irregular periods.

A: You are quite right; PCOS is not the only cause of hirsutism. PCOS has received the most attention, so medical articles often give the impression that this is the only cause. But there are several others. The best way to explain these is to review what leads to increased hair growth, and consider what can happen at each step to cause the increase.

So-called "sexual hair" grows in response to androgens -- the so-called "male hormones." This term is a little misleading because women have active levels of androgens in their blood, just as men have estrogen in theirs. Testosterone is the most active androgen, but there are several others such as androstenedione and DHEA. (DHEA is usually measured as the closely related form DHEA-S.) Androstenedione and DHEA themselves do not affect hair growth but they are converted by the body to testosterone, which does.

Both the ovary and the adrenal gland release testosterone. If the blood level of testosterone is significantly elevated, it is important to find out whether it is coming from the ovary, or the adrenal, or both. Usually, testing is required to do this.

The best test for determining where the testosterone is coming from is the dexamethasone suppression test. Dexamethasone (similar to cortisone) is given for about a week to suppress the adrenal. Any testosterone remaining in the blood at the end of the test must be coming from the ovary. For example, if the testosterone is 75 before the test and 60 at the end of it, most of the testosterone is coming from the ovary. But if the post-test value is 15, most of the testosterone is adrenal in origin. In women on the birth control pill however, the ovary is suppressed and so the testosterone in their blood is usually mostly from the adrenal. There are other situations in which it is clear without special testing that the adrenal is the source.

PCOS which has four main features: skin and hair changes due to testosterone [links to acne and alopecia] , problems with the menstrual cycle, difficulty controlling weight and underlying metabolic changes such as insulin resistance. The extra weight tends to be on the upper body with the hips and legs usually being thin.

Readers of my book know that I do not like the term "Polycystic ovary syndrome." Somehow this term scares women and makes them fear that what they have is worse than it really is. The other reason is that most affected women have only some parts of the syndrome. If a woman does have all the four features, it is reasonable to make the diagnosis of PCOS. But many women have only some features, not all. This can be termed mild PCOS but medical texts usually do not make clear that a woman can have some but not all features of the condition.

Another situation in which the term PCOS is incorrect is when the extra testosterone comes not from the ovary but from the adrenal. This can be caused by a relatively rare condition called late-onset congenital adrenal hyperplasia. Special testing can detect this condition. Sometimes women are told they have this condition when they really don't -- all they have is a slightly increased amount of testosterone coming from the adrenal. So some women have slightly elevated testosterone but do not have PCOS.

Actually, the most common cause of hirsutism is not in the adrenal or ovary but in the hair follicle itself. Many women with increased facial and body hair have quite normal levels of testosterone and other hormones. But the hair follicle over-reacts to these normal levels Some people have follicles that are so sensitive to testosterone that even normal levels stimulate them. In fact, this is by far the most common reason for increased hair growth in women. Women with sensitive follicles do not have a hormonal disorder at all. Their ovaries and adrenals are working fine. Sometimes they are told, incorrectly, that they have PCOS when their hormones are perfectly normal.

Many of the women I see at the Hormone Center of New York for extra hair have been frustrated because doctors told them, "Your tests are normal; there's nothing wrong with you." These women do not think it is normal for them to have to remove facial hair every morning and they are right. There is an abnormality but it is in the hair follicle, not in the hormones themselves. This condition of extra sensitivity to hormones is highly treatable. Women do not need abnormal tests to get help.

While I've been discussing increased hair, the same applies to the other testosterone produced skin and changes -- acne and scalp hair loss. These too occur with normal hormones because the oil glands or hair follicles over-react to testosterone.

So we had best admit that our medical terminology for androgenic conditions -- those causing extra hair, acne or scalp hair loss -- is not as clear as it should be. But this need not make affected women feel discouraged. Whatever one calls these conditions, they can be treated.

Geoffrey Redmond, MD

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