Synopsis
Separate androgen-dependent terminal hair from generalised excess growth, detect virilising disease promptly, investigate endocrine or medicine causes proportionately, and offer safe physical and medical hair reduction.
- Hirsutism means coarse terminal hair in androgen-dependent sites such as chin, upper lip, chest, lower abdomen and back; hypertrichosis is excess hair outside that sexual distribution.
- Ask what has changed from the person's baseline and what removal methods conceal. Hair density varies normally by family and ancestry, so a visual score is not a universal disease threshold.
- Slowly progressive hirsutism with irregular cycles, acne or metabolic features commonly reflects PCOS, but normal cycles and hormones can coexist with idiopathic follicular androgen sensitivity.
- Rapid virilisation, marked androgen elevation, an abdominal or pelvic mass and postmenopausal onset are tumour or ovarian-hyperthecosis warnings and need expedited specialist assessment.
- Hypertrichosis can be congenital or follow minoxidil, ciclosporin, phenytoin, glucocorticoids, malnutrition, porphyria or systemic disease; the distribution and timeline determine investigation.
- Measure total testosterone with a validated assay and sex hormone-binding globulin when androgen excess is plausible, then extend adrenal or ovarian tests through a specialist pathway rather than ordering an indiscriminate panel.
- Shaving does not increase follicle number or make androgen excess worse. Waxing, depilation, electrolysis and laser are legitimate treatments while the cause is investigated.
- Eflornithine slows facial hair growth but does not remove existing hair; apply twice daily at least eight hours apart and discontinue if no benefit after four months.
- Systemic anti-androgens are off-label for hirsutism in the UK and require reliable pregnancy prevention plus medicine-specific renal, potassium, hepatic and interaction safeguards.
Key red flags
Rapid progression over months, deepening voice, clitoromegaly, increased muscle bulk, temporal scalp recession, severe biochemical androgen excess or new postmenopausal hirsutism requires urgent endocrine and gynaecological or adrenal localisation.
Deep voice, clitoral enlargement, rapid temporal recession, increased muscle bulk or reduced breast tissue indicates androgen effect beyond ordinary hirsutism.
Investigation priorities
Confirm biochemical androgen excess and identify a result requiring faster specialist localisation.
Management branches
Terminal hair has increased gradually without virilisation or a severe systemic feature.
- Document tempo, cycles, pregnancy goals, acne, scalp loss, medicines, supplements, family pattern and removal methods, then examine hair distribution, blood pressure and metabolic or Cushing features.
- Measure validated testosterone and SHBG and select pregnancy, thyroid, prolactin or 17-hydroxyprogesterone tests from the phenotype; complete a PCOS assessment when supported.
- Offer the person's preferred physical removal immediately and discuss eflornithine or hormonal treatment only after reproductive, vascular and medicine-safety assessment.