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Managing hirsutism in PCOS

Hirsutism can be defined as excessive growth of dark and coarse hair in women that appears in a male pattern, usually on the face, chest, lower abdomen, inner thighs, and back – typically the areas where women usually don’t have hair. It is generally associated with symptoms due to excess androgens in the body. PCOS being its prime cause, it is prevalent in 70-80% of women suffering from the same.
Researches have shown that female hirsutism can make women immensely self-conscious, threatening their sense of femininity and self-esteem. Michelle G. Lipton et al. carried out a research on the psychological and behavioral burden of facial hair in women with suspected PCOS. The results included, that more than half of the women reported continually checking in mirrors or checking in by touch. Few felt uncomfortable in social situations. High levels of emotional distress and psychological morbidity were detected; some reported depression above the clinical cutoff point, while others reported clinical levels of anxiety.

Why do women with PCOS get hirsutism?

  • Usually, women with PCOS suffer from Insulin resistance due to improper utilization of insulin by the body due to various factors like obesity, and hormonal imbalances. This results in hyperinsulinemia. Excess Insulin along with excess Luteinizing hormone (LH) enhances the production of androgens.
  • Excess facial and body hair is a result of excess androgens (like testosterone) that are usually seen in PCOS.
  • Peripheral 5α-reductase is the enzyme that converts testosterone to dihydrotestosterone (DHT). Both of these alter the hair cycle, resulting in the transformation of vellus (soft) hair into terminal (coarse) hair which is thicker and darker, especially in the face, neck, chest, and pubic regions – called “ androgen-sensitive sites”. (Yildiz BO et al.) and thus, hair starts to grow asynchronously.
  • Not only this, but androgens also augment sebum (oily secretions of sebaceous glands) production, which results in oily skin and acne – some other manifestations seen in PCOS.

    • HAIR-AN syndrome

    The HAIR-AN syndrome stands for HA- Hyperandrogenism, IR- Insulin Resistance, and AN- Acanthosis Nigricans, is a sub-type of PCOS, that has a similar presentation to that of PCOS but with prominent HA and AN. It varies from PCOS as oligomenorrhea and polycystic ovaries are NOT the diagnostic features of this syndrome.
    Thus, this could also be, the potential cause of Hirsutism.

    Does Hirsutism stop after reversing the PCOS?

    Yes, the reversal of PCOS can stop the excessive growth of facial and body hair. Reversing the PCOS will result in a proper balance of the hormones, especially Insulin, enhancing the sensitivity which will result in a reduction of androgen production, therefore, preventing the growth.

    Management:

    • Management of hirsutism involves addressing the androgen excess that has been caused due to Insulin Resistance. Thus, interventions to decrease hirsutism in PCOS include the suppression of androgen excess by enhancing Insulin sensitivity.

    • Proper diet (low carb, high protein, and, moderate fat),  Losing weight, Regular exercise (moderate intensity), and lifestyle modifications are some ways to be practiced that would help decrease the resistance and improve the insensitivity.

    • Insulin causes theca cells (of ovaries) to generate and release androgens directly or indirectly. It stimulates androgen synthesis in the ovary and inhibits or reduces the development of sex hormone-binding globulin (SHBG) in the liver. (Haigang Ding et al.) Inhibition of SHBG results in free testosterone (more than normal) in the blood and thus cause cutaneous manifestations like hirsutism, acne, and alopecia (male pattern baldness).

    • Inés Domínguez-López et al. in the Journal of Nutrients correlated the positive effect of consumption of Phytoestrogens on improving the sex hormone-binding globulin (SHBG) expression by liver cells, enhancing estrogen and progesterone synthesis in ovaries. The sources include flax seeds, sesame seeds, peaches, soybean, tofu, wheat bran, etc.

    • Medical management- Oral Contraceptive Pills (OCPs) are commonly used for the suppression of excess androgens. Insulin sensitizers like Metformin have also been shown to reduce hyperandrogenism and hyperinsulinemia in women with PCOS.

    How to get rid of the excess hair?

    There are many ways in which the grown hair could be taken care of. Combination therapy is the most suitable treatment modality. It includes hormone therapy along with –
    1. Mechanical (shaving, bleaching, or chemical depilation of hair) or Cosmetic means.

    2. Laser treatment- which includes permanent destruction of hair follicles.

    3. Electrolysis – where a thin wire is inserted under the surface of the skin and an electric current (minimal) is passed down the wire leading to the destruction of the roots.
    To conclude, Hirsutism is a symptom and not a disease. Proper lifestyle and necessary efforts can therefore, help along manage hirsutism well.
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    In conclusion, discussing PCOS with your doctor can help you better understand your condition and take proactive steps to manage your symptoms. By asking the right questions, you can work with your doctor to develop a treatment plan that works best for you. Remember to be honest and open with your doctor about your symptoms, concerns, and goals. With the right information and support, you can successfully manage your PCOS and live a healthy, fulfilling life.

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