Hirsute women most likely have androgen excess-related disorders, primarily polycystic ovary syndrome

Among women in their child-bearing years, even minimal amounts of unwanted hair in male-type patterns – especially in the presence of other subtle changes – may be a sign of a hormonal imbalance linked to a variety of serious side effects and medical conditions, according to the December 2004 issue of the American Journal of Obstetrics and Gynecology.

In a study of 188 women conducted by researchers at Cedars-Sinai Medical Center and the University of Alabama, Birmingham (UAB), 102 subjects with minimal excess hair growth had excessive levels of androgens, "male" hormones that normally exist in women in lesser amounts.

"We know that excess hair growth in the male pattern in women, which we call hirsutism, generally is a good indicator that there is an underlying hormone imbalance. Now this relatively large study shows that nearly 55 percent of women who have minimal unwanted hair growth have an androgen excess-related disorder, primarily the polycystic ovary syndrome," said Ricardo Azziz, MD, MPH, MBA, Chair of Cedars-Sinai's Department of Obstetrics and Gynecology, Director of the Center for Androgen-Related Disorders, and Executive Director of the Androgen Excess Society, an international research organization.

Among all 188 women in the study complaining of minimal unwanted hair growth, 102 were found to have an underlying androgen excess disorder. Ninety-four of the 102 suffered from polycystic ovary syndrome (PCOS), a disorder characterized by numerous small cysts on the periphery of the ovaries. Women with PCOS often struggle with menstrual irregularities, skin problems, and excess weight and they are at increased risk of developing Type II diabetes, hypertension and heart disease.

Four of the study participants were diagnosed with non-classic adrenal hyperplasia (NCAH), an adrenal gland dysfunction that often leads to premature development of pubic hair, irregular menstrual periods, hirsutism and severe acne, although patients with milder forms may notice few if any symptoms. Another four patients were found to have a multi-system disorder that stems from a long-term excess of insulin in the bloodstream that up-regulates ovarian secretion of androgens. Called HAIRAN (hyperandrogenic insulin resistant acanthosis nigricans) syndrome, the disorder increases risk of hirsutism and masculinization. It may be recognized by characteristic thickened patches of dark skin (acanthosis nigricans) and other symptoms.

The patient evaluations were completed between Jan. 1, 1995 and June 30, 2002 at UAB, where Dr. Azziz served as Professor in the Department of Obstetrics and Gynecology and in the Department of Medicine before joining Cedars-Sinai. Participants completed a medical history form and underwent a complete physical exam during which they were assessed for several conditions, including the presence of coarse hairs on the upper lip, chin and neck, chest, upper abdomen, lower abdomen, thighs, upper arms, upper back, and lower back.

"In our study population of women with minimal unwanted hair growth, there were few predictors of an androgen excess disorder," said Dr. Azziz, now serving as Professor and Vice-Chair of the Department of Obstetrics and Gynecology and Professor in the Department of Medicine at The David Geffen School of Medicine at UCLA. "Compared to their non-affected counterparts, those with an androgen excess disorder did not differ in race, body mass, degree of hair growth or family history. However, patients with an identifiable androgen excess disorder were slightly younger and more likely to complain of infertility."

Acne was seen in about one-fourth of the study population, affecting those with and without an androgen excess disorder equally. But at least half of the women with acne and minimal unwanted hair growth had elevated androgen levels and infrequent, irregular ovulation cycles. Previous studies have shown that even without excessive hair growth, 55 to 86 percent of women with acne have elevated androgen levels. The authors recommend, therefore, that women with acne, especially those who complain of unwanted hair growth, receive in-depth hormonal evaluation.

The single best predictor of an androgen excess disorder among patients with minimal excess hair growth was the presence of oligomenorrhea, infrequent menstrual periods, although some women who claimed to have regular periods were found to have irregular ovulatory cycles, and a significant number of these women had an androgen excess disorder.

A clinical diagnosis of hirsutism is made by a physician's evaluation and based on standardized scales. Women with true hirsutism often find professional help for their underlying conditions because the severity of their symptoms forces them to seek cosmetic services.

"Electrologists tend to be the front line for patients with hirsutism. When electrologists recognize that the symptom is part of a larger disorder, they are able to give appropriate referrals, which enables patients to find the diagnostic and treatment help they need. Women with only minimal unwanted hair growth, however, often have an underlying hormonal imbalance that goes undetected altogether," said Dr. Azziz, holder of The Helping Hand of Los Angeles Chair in Obstetrics and Gynecology at Cedars-Sinai.

"Unfortunately," he added, "whether the outward symptoms are minimal or significant, many women view hyperandrogenism as a cosmetic rather than an endocrinologic abnormality. We find that there is a great need for more education of physicians, related practitioners, and the public regarding prevalence, signs, morbidity and the treatments available for these disorders."

Cedars-Sinai's Center for Androgen-Related Disorders is one of the first programs in the country specializing in both up- and down-regulation of androgen levels in women. It offers in-depth testing, comprehensive treatments and support, and research into molecular mechanisms and future therapies.