Polycystic Ovary Syndrome and Hirsutism: Understanding Chin Hair Growth

Hirsutism, characterized by excessive hair growth in women, is often a primary concern for those with Polycystic Ovary Syndrome (PCOS). This article explores the connection between PCOS and hirsutism, specifically focusing on chin hair, its causes, diagnosis, and various treatment options available.

Understanding Hirsutism

Hirsutism is defined as the excessive growth of facial or body hair on women, presenting as coarse, dark hair in areas where women typically don't have much hair. These areas include the face, chest, lower abdomen, inner thighs, and back. It's important to note that perceptions of what constitutes "excessive" vary widely.

Types of Hair

Adults have two types of hair: vellus and terminal. Vellus hair is soft, fine, generally colorless, and short, covering the face, chest, and back in most women. Terminal hair, on the other hand, is long, coarse, dark, and sometimes curly, growing on the scalp, pubic, and armpit areas in both men and women. Hirsutism occurs when excess androgens cause some vellus hairs to change to terminal hairs, and cause the terminal hairs to grow faster and thicker. Once a vellus hair has changed to a terminal hair, it usually does not change back.

Hair Growth Cycle

Hair growth occurs in cycles, with some follicles growing, others resting, and still others shedding. Hormonal changes can synchronize hair growth, making it appear to grow and shed more than usual.

Polycystic Ovary Syndrome (PCOS) and Hirsutism

PCOS is a common hormonal disorder affecting 5%-10% of women. It is a condition associated with hormonal imbalances that cause the ovaries to overproduce androgens. In women with PCOS, multiple small follicles develop in the ovaries, appearing as cysts. These cysts are actually immature ovarian follicles that failed to mature and ovulate.

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The Link Between PCOS and Hirsutism

Hirsutism is a common symptom of PCOS. In PCOS, the ovaries produce excessive amounts of androgens, leading to the development of terminal hair in androgen-sensitive areas such as the upper lip, beard area, breasts, lower abdomen, inner thighs, and lower back. Hirsutism in PCOS is associated with both androgen excess and the individual response of the pilosebaceous unit to androgens.

Symptoms of PCOS

Symptoms of PCOS include hirsutism; acne; irregular, absent, or heavy menstrual periods; lack of ovulation; and infertility. More than 50% of PCOS patients are overweight or obese.

Hormonal Imbalance in PCOS

In PCOS, the pituitary gland releases follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which control egg and hormone production. Insufficient FSH may impair ovarian follicle development and prevent ovulation, resulting in infertility. The multiple small cysts formed in the ovary from follicles that failed to mature and ovulate result in the PCOS appearance on ultrasound. Lack of ovulation in PCOS results in continuous high levels of estrogen and insufficient progesterone, which can lead to heavy and/or irregular bleeding.

Other Causes of Hirsutism

While PCOS is the most common cause, hirsutism can also be caused by other factors:

• Congenital Adrenal Hyperplasia (NCAH): An inherited disorder causing the adrenal glands to overproduce androgens. NCAH is associated with irregular menstrual cycles.
• Insulin Resistance: High levels of insulin stimulate the ovaries to overproduce androgens, leading to hirsutism, acne, and irregular ovulation.
• Cushing Syndrome: Overproduction of cortisol by the adrenal glands.
• Tumors: Androgen-producing tumors in the ovaries or adrenal glands.
• Medications: Certain drugs, such as anabolic steroids, danazol, phenytoin, minoxidil, and diazoxide, can cause hirsutism.
• Around the time of menopause: The decreased levels of estrogen may allow the androgens to have a greater impact, leading to an increase in the number of dark terminal hairs, especially on the face.
• Family history: Several conditions that cause hirsutism, including congenital adrenal hyperplasia and polycystic ovary syndrome, run in families.
• Ancestry: Women of Mediterranean, Middle Eastern and South Asian ancestry are more likely to have more body hair with no identifiable cause than are other women.
• Obesity: Being obese causes increased androgen production, which can worsen hirsutism.

Diagnosis of Hirsutism

To diagnose hirsutism, physicians distinguish between terminal hairs growing in a male pattern and hair growth due to genetic or ethnic predisposition. If hirsutism is diagnosed, blood tests, ultrasound, special x-rays, and hormone tests may be performed to evaluate the function of the ovaries and adrenal glands.

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Modified Ferriman-Gallwey (mFG) Score

The degree of hirsutism and effectiveness of therapy may be guided by the modified Ferriman-Gallwey score. This index is a clinical method of evaluating and quantifying body hair growth in women. A score of 1 to 4 is given for nine areas of the body. A total score of less than 8 is considered normal in white or black women, less than 9 for Mediterranean, Hispanic, and Middle Eastern women, and less than 2 for Asian women.

Biochemical Hyperandrogenism

While most women with PCOS and hirsutism have higher than reference values for serum androgen levels, some may not present with biochemical hyperandrogenism, representing a challenge to the diagnosis of PCOS.

Treatment Options for Hirsutism

Treatment for hirsutism should be based on the amount of distress it causes the patient. The most effective treatment includes a long-term approach that reduces androgen receptor activity, thus decreasing new terminal hair development, and the removal of existing terminal hairs.

Medical Interventions

• Combined Oral Contraceptives (COCs): These medications reduce androgen production by suppressing circulating luteinizing hormone and follicle-stimulating hormone and decrease free testosterone by stimulating sex hormone-binding globulin production.
• Spironolactone: The most commonly used androgen blocker, it competes with dihydrotestosterone (DHT) by binding to the androgen receptor and inhibits enzymes involved in androgen production.
• Finasteride: Inhibits the conversion of testosterone to DHT.
• Flutamide: A nonsteroidal androgen receptor antagonist, not recommended due to potential hepatotoxicity. When used without COCs, other effective methods of contraception are needed secondary to teratogenicity.
• Eflornithine: A topical facial cream that inhibits the enzyme ornithine decarboxylase to treat hair that is already present. Improvement in hirsutism has been shown in 60% of patients after 6 months of use. Eflornithine plus laser treatment is superior to laser alone.

Hair Removal Techniques

• Temporary Methods: Shaving, plucking, waxing, and depilatory creams. Patients should be advised to avoid plucking hairs to prevent scarring, pigmentation, and folliculitis.
• Photoepilation: Laser treatment and intense pulsed light, generally requiring multiple sessions to achieve adequate results. Women with dark hair and light skin are better candidates for laser therapy, especially during the anagen phase of hair growth.
• Electrolysis: Intended to result in permanent hair removal by the destruction of the follicle, but is painful and technically difficult, and best suited to treatment of small areas.

Additional Considerations

• Insulin-Sensitizing Agents: Metformin has not been shown to have clinically significant effects on hirsutism.
• Hormone Treatment: Generally prevents new terminal hairs from developing and may slow the growth rate of existing hairs. About 6 months of hormone therapy is required before the rate of hair growth decreases significantly. Ongoing medical treatment is required to manage it. Hirsutism will frequently return if medical treatment is stopped.

The Emotional Impact of Hirsutism

Hirsutism can be emotionally distressing, leading to feelings of self-consciousness and even depression. Seeking support from healthcare providers and exploring treatment options can significantly improve quality of life.

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