Hirsutism is one of the signs of hyperandrogenism that frequently causes issues in young girls. The excessive growth of androgen-dependent sexual hair (terminal hair), which is concerning to the patient, is known as hirsutism or PCOS hair growth.
Causes of Hyperandrogenism or Hirsutism
1. Ovarian Causes
- Polycystic ovarian syndrome (PCOS)
- Sertoli-Leydig cell tumour
- Hilus cell tumour
- Lipoid cell tumour
- Hyperthecosis – Luteoma of pregnancy
2. Adrenal Causes
- Adrenal hyperplasia (congenital or late onset)
- Cushing’s syndrome ( overactive adrenal glands)
- Adrenal tumour
3. Weight gain due to genetic and environmental factors
- Insulin resistance and androgen excess
- HAIR–AN syndrome
4. Exogenous (drug therapy)
Androgens, anabolics, oral contraceptives, synthetic progestogens, danazol, phenytoin, diazoxide, cortisone, etc.
6. Pituitary tumor — secreting
7. Excess ACTH (Cushing’s disease)
8. Excess growth hormone (acromegaly)
9. Idiopathic: Increased sensitivity to androgens.
1. Polycystic Ovary Syndrome PCOS
Polycystic ovary syndrome is a heterogeneous condition that is primarily distinguished by increased androgen production by the ovaries. The condition known as polycystic ovary syndrome is polygenic and multifactorial.
The presence of any two of the following three criteria forms the basis for a diagnosis:
- Oligo and/or anovulation.
- Clinical and/or biochemical hyperandrogenism
- Polycystic ovaries.
It is necessary to rule out additional causes, such as CAH, thyroid dysfunction, hyperprolactinemia, and Cushing syndrome. The incidence ranges from 0.5 to 4 per cent, and it is more prevalent among infertile women. It affects young women (20–30%) who are fertile. 20% of normal women may have polycystic ovaries.
1.1) Clinical Features of Polycystic Ovary Syndrome
The patient expresses complaints of infertility, oligomenorrhea, amenorrhea, or DUB, as well as growing unintentional weight gain or obesity (abdominal – 50%). Acne and the presence of hirsutism or PCOS hair growth, are key characteristics (70%). While many people with polycystic ovary syndrome, develop thicker facial or body hair, some can experience female pattern hair loss, which is when hair thinning and hair loss occurs. Virilism and acanthosis nigricans are other PCOS symptoms.
2. Androgen Sources in Females
Regardless of whether you have PCOS symptoms or not, both sexes generate certain hormones called androgens, including testosterone, though men normally create more of these sex hormones. Androgens play a role in the start of puberty and initiate hair development in the pubic and underarm regions.
Dehydroepiandrosterone sulphate (DHEA-S), dehydroepiandrosterone (DHEA), androstenedione, testosterone (T), and dihydrotestosterone (DHT) are the main androgens in females. Dihydrotestosterone and testosterone are responsible for all androgenic effects. The first most potent androgen in use is dihydrotestosterone, while testosterone is the second.
About half of testosterone is produced peripherally, primarily from androstenedione and other prohormones. Skin, muscle, fat, liver, and lungs are the main sites of peripheral conversion. About equal portions (25%) of the circulating levels of testosterone are contributed by the ovaries (theca, stroma, and granulosa) and the adrenal glands (z. Reticularis and z. Fasciculata).
Only the adrenal glands produce dehydroepiandrosterone sulphate (DHEA-S), whereas the adrenals also secrete around 50% of DHEA. Equal amounts of androstenedione are produced by the ovaries and the adrenals.
Virilisation is a result of increased androgen production brought on by polycystic ovary syndrome. The emergence of more male traits, such as increased hair growth in areas where it doesn’t typically grow, such as the face, neck, chest, and torso, is referred to by this phrase.
Additionally, especially close to the front of your scalp, these extra androgens can start to thin out the hair on your head. This is also referred to as female pattern hair loss or androgenic alopecia. Contrary to excessive PCOS hair growth, however, hair loss is not as prevalent a side effect of PCOS because it requires rather high testosterone levels to experience this sort of hair loss resulting in female pattern baldness.
3. Pathophysiology of Excessive PCOS Hair Growth/ Androgenic Alopecia
It combines a number of the following:
- An increase in the serum levels of androgen, particularly testosterone.
- A decrease in sex hormone binding globulin (SHBG) levels leads to an increase in free testosterone (testosterone itself reduces SHBG level).
- An increase in the target organ’s (the skin’s) receptivity to the common androgens circulating in the blood. This might have anything to do with ethnicity. Compared to Caucasian women, Oriental women have fewer hair follicles per square inch of skin.
- A rise in the activity of the enzyme 5α-reductase, which turns testosterone into DHT in hair and skin follicles.
As a result, PCOS hair growth and hair follicle stimulation are sacrificed for androgen metabolism to occur in the hair follicle as a secondary location.
4. Treatment of Hirsutism
- Correction of an underlying cause
- Weight reduction in obesity
- Drugs that suppress androgen production
- Cosmetic therapy
4.1) Correction of an Underlying Cause
Surgery is required to remove any adrenal or ovarian tumours. Corticosteroids must be used to treat CAH. Drug withdrawal is an option if drug-induced. This helps to eliminate PCOS hair growth.
4.2) Weight Reduction
The severity of PCOS Hair Growth or hirsutism is exacerbated by obesity, hence weight loss should be promoted. Losing weight raises SHBG levels, which will increase the amount of testosterone bound and potentially treat PCOS hair growth.
Antiandrogens should ideally be prescribed in combination with a combined oral contraceptive because, theoretically, they have the potential to cause hormonal disorders in a male foetus. Menstrual irregularity, most often metrorrhagia, is another issue that most antiandrogens have. Menstruation will become more regular when combined with oral contraceptives.
i) Cyproterone Acetate
The most popular antiandrogen used for the treatment of PCOS hair growth is this one. It is a synthetic progestin that primarily inhibits testosterone and DHT at the androgen receptor level through competitive inhibition. For 21 days, a combination pill containing 35 ugs of ethinyloestradiol and 2 mg of cyproterone acetate can be administered in mild and moderate cases.
Additionally, it will reduce gonadotropins and raise SHBG. It may also be employed for maintenance. The impact on acne and seborrhea is noticeable soon after beginning treatment, however, it takes 6–12 cycles to see a discernible impact on treating PCOS hair growth, and hirsutism.
It is also very beneficial for PCOS hair growth when taken daily in doses of 50-100mg. Spironolactone is an aldosterone antagonist and also blocks the androgen receptor. Inconsistencies during menstruation are the main side effects.
iii) Other Antiandrogens
Flutamide, finasteride, and ketoconazole are further medications that are clinically used for PCOS hair growth. The nonsteroidal antiandrogen flutamide works by preventing androgens’ ability to attach to the nuclei in its target tissues. Ketoconazole, an antifungal medication, prevents the important enzymatic processes involved in the production of androgen. The 5α-Reductase enzyme is selectively inhibited by finasteride.
4.3) Drugs that Suppress Androgen Production
i) Ovarian Suppression with Oral Contraceptives
For polycystic ovary syndrome patients who do not want to become pregnant, birth control pills remain the mainstay of treatment. The pill’s oestrogen component raises SHBG, which reduces free testosterone. Ovarian androgens are reduced as a result of the progestin’s suppression of LH. By inhibiting 5α-Reductase, oestrogen also lessens the conversion of testosterone to DHT.
The most effective oral contraceptives would be ones that make use of progestin with less androgenic potential. Because of the low androgenic action, combined action birth control pills comprising newer progestins such as desogestrel, gestodene, norgestimate, and drospirenone are preferable for the treatment of PCOS hair growth.
ii) Ovarian Suppression with GnRH Agonists
Leuprolide acetate, a long-acting GnRH agonist, may have a moderate effect on PCOS hair growth when administered every three weeks. They can assist in distinguishing between causes from the adrenal and ovarian systems by specifically lowering the levels of androgen in the ovaries. The main issue is the adverse consequences of hypoestrogenism, such as bone loss and vasomotor symptoms.
iii) Adrenal Suppression with Glucocorticoids
Only when there is an adrenal component, such as in late-onset CAH, are glucocorticoids beneficial. The dosage is 0.25 to 0.5 mg before bed. Dexamethasone may be helpful in some PCOS individuals who see a small elevation in DHEA-S.
4.4) Cosmetic Treatments
The only procedures by which PCOS hair growth or unwanted facial hair can be removed are permanent and consist of laser treatments and electrolysis. They work best after medical treatment has stopped future development, ideally after three to six months. Other cosmetic techniques are frequently undervalued. Contrary to common opinion, shaving is an excellent way of reducing PCOS hair growth without changing its texture or quality. Another method to remove unwanted hair is by waxing. Another option is bleaching, albeit it is not always successful. The best course of action is to prevent plucking, which stimulates PCOS hair growth.
Additionally, depilatory creams should be avoided because they may result in pigmentation and skin irritation. In cases of facial PCOS hair growth, eflornithine hydrochloride cream has been proven to be helpful.
5. PCOS and Hair Loss
While excessive body or facial hair is a challenging symptom that people with PCOS cope with, there is also a sign on the other side of the coin: unexpected hair loss as well as limp, lifeless and thinning hair that breaks easily and is dry and damaged. On a physical and emotional level, PCOS-related hair loss can be one of the more distressing PCOS symptoms than PCOS hair growth, and treatment can be challenging.
Additional causes that may contribute to hair loss include:
- extreme temperature exposure
- Chronic illnesses and infections
- Using particular drugs
- Anaemia (iron deficiency)
- vitamin and trace element deficiency
Medical terms for this PCOS-related hair thinning or loss are androgenic alopecia and female pattern baldness.
In situations of male pattern baldness or male pattern hair loss, the hair follicle is destroyed, making it impossible for hair to regrow naturally. Since the hair follicles in female pattern baldness are still alive, there is a chance that certain treatments will restore hair growth.
It is first important to balance the hormone levels to solve the issue. With a series of intricate examinations, gynaecologists and endocrinologists can accomplish this and make suggestions for hormonal therapy. A treatment might be recommended by a trichologist to revive hair follicles.
6. Symptoms of PCOS Related Hair Loss
Polycystic ovary syndrome PCOS hair loss can result in significant daily hair loss. It’s possible that there is more hair than usual on the furniture or clothes, and hair frequently gathers overnight on the pillowcase. In the shower, hair may also come out in clumps resulting in hair loss.
With PCOS, hair loss can happen at the root, where the complete hair shaft and follicle emerge, or it can happen as breakage because the hair is drier and more vulnerable to harm from heat and brushing. The effect of hair breakdown is greater frizz, which can make the scalp more noticeable, especially around the crown and hairline.
Moreover, the scalp could feel drier and itchier. Additionally, some polycystic ovary syndrome PCOS patients mention buildup and dandruff. It may be more difficult to style hair without using a lot of product to give it more body and fullness and it may appear finer than usual.
Hair often thins significantly in the middle and primarily falls out in the frontal-parietal region as a symptom of polycystic ovary syndrome PCOS.
7. Treatment of PCOS Hair Loss
There are treatments available for PCOS-related hair loss or to treat androgenic alopecia. Start with conventional over-the-counter therapies like speciality shampoos, hair treatments, and vitamins for healthy skin, hair, and nails. If tested methods aren’t producing the desired results, a hairstylist or medical professional may have further suggestions.
The issue of PCOS-related hair loss must be handled holistically, both physically with the aid of correct hair care and internally by caring for the body with nutrition and exercise as well as talking to a doctor about the potential benefit of drugs.
The results of hair treatment could take anywhere from six months to a year to appear. Both medication administration and hair care methods should follow a precise timetable.
It’s also crucial to remember that, if hormonal imbalances are a contributing factor in hair loss, restoring hair health may be feasible by balancing hormone levels.
A well-balanced diet that includes vitamins or supplements that a medical professional suggests may also assist in improving the health of your hair and helps in stimulating hair growth.
The minerals magnesium, zinc, and iron, as well as the vitamins A (found in carrots), B (found in shellfish, cheese, bananas, and tomatoes), E (found in oats), and F (found in fatty fish), are all excellent sources of health-promoting nutrients.
One of the major contributors to hair loss is iron deficiency, and PCOS patients often have decreased ferritin levels. Raising iron levels can be accomplished by eating foods high in iron or by taking supplements.
Zinc, selenium, silicon, biotin (vitamin B7), choline, and selenium all have a significant impact on hair development (vitamin B4). The amount of these vitamins and minerals in the body can be measured using straightforward assays. Simple dietary modifications can easily correct minor deficiencies. Zinc is abundant in nuts and pumpkin seeds, selenium in beans and broccoli, silicon in rice, biotin in peanuts and liver, and choline in eggs and shellfish. If the insufficiency is severe, seeking therapy from a healthcare professional is worthwhile.
To promote hair growth, selecting the appropriate hair products is also crucial. Wax and mineral oils, which can create a film on the scalp and interfere with normal sebum production, should not be present in hair care products. The hair may benefit from products with hydrolyzed proteins (such as keratin and collagen) and B vitamins.
Weakened hair can be damaged by high temperatures from blow drying or from using a curling or flat iron, as well as harsh chemicals like hair colours, perms, straighteners, or relaxers resulting in hair loss
7.1) Medical Treatments
PCOS-related hair loss is treatable medically, as is the illness itself. To help manage hair loss and scalp issues including dryness and dandruff, a doctor may prescribe OCPs, antiandrogens, or a prescription-strength medicated shampoo.
Rogaine is the only over-the-counter medication now licenced for treating female pattern hair loss (minoxidil). Although Rogaine won’t reverse PCOS-related hair loss, it might help control it. Remember that hair loss might return if you stop taking Rogaine.
Iron supplements are another over-the-counter choice. According to certain research, iron deficiency contributes to female-pattern hair loss, and iron supplements may be able to stop it. However, there is presently no convincing proof that taking iron supplements helps stop hair loss once it has started.
Other drugs directly affect sex hormones. If Rogaine is ineffective or blood tests show that you have abnormally high testosterone levels, they may be recommended. Having said that, there is little evidence to back up their use. Results may differ.
The following are a few examples of prescription drugs used to treat female pattern hair loss:
- Spironolactone: This water pill-like oral diuretic contains anti-androgenic qualities. For PCOS patients, spironolactone is frequently used with birth control tablets. Rogaine can also be used with it.
- Finasteride: This oral medication, which is marketed under the brand names Proscar, Propecia, and others, is frequently used to treat an enlarged prostate. In PCOS patients, it can be used off-label to reduce testosterone. Given the possibility of birth abnormalities, it must be used in conjunction with birth control.
- Flutamide: Formerly marketed as Eulexin, this medication is frequently used to treat prostate cancer while also having anti-androgenic properties. However, there is a considerable risk of liver toxicity and liver damage linked with it.
The weight loss that results from taking Metformin can help regulate insulin levels in persons with PCOS, and it can also have a good impact on hair loss and hormonal balance.
7.2) Surgery and Specialist-Driven Procedures
If the hair loss is severe, some patients could choose to have surgery for hair transplantation. This includes follicular unit extraction (FUE), which involves removing and transplanting individual hair follicles. Another treatment involves harvesting hair follicles from the scalp and transplanting them, called follicular unit transplantation (FUT).
Injections of platelet-rich plasma (PRP) are an additional alternative. Blood is spun during this procedure to separate the major liquid component, plasma, from the blood cells. Injecting PRP into the scalp may be able to reverse alopecia in those who experience patchy hair loss.
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