Synopsis
Distinguish common slowly progressive hirsutism from severe androgen excess, investigate ovarian and adrenal sources accurately, and relieve unwanted hair without exposing a pregnancy to anti-androgen harm.
- Hirsutism is terminal hair growth in androgen-dependent areas; hypertrichosis is diffuse non-androgen-pattern hair growth and has a different medicine and systemic differential.
- PCOS is the commonest cause of hirsutism, but rapid tempo, virilisation, postmenopausal onset or severe laboratory abnormality must not be squeezed into that diagnosis.
- Ask how quickly hair changed, what removal methods conceal, whether cycles altered, and whether voice, scalp hair, muscles, libido or genital anatomy changed.
- Measure testosterone with a reliable method and sex hormone-binding globulin, then use the 2025 Society for Endocrinology androgen-excess pathway for additional ovarian, adrenal and dynamic tests.
- Hormonal contraception changes ovarian production and sex hormone-binding globulin; record it and involve specialists before stopping essential contraception solely to obtain an ideal sample.
- Non-classic congenital adrenal hyperplasia, Cushing syndrome, severe insulin resistance, ovarian hyperthecosis, medicines and androgen exposure are important alternatives to PCOS.
- Hair removal is legitimate treatment at every stage; shaving does not increase follicle number or make biological androgen excess worse.
- Medical improvement takes at least several hair cycles, so define a six-month or longer review and pair androgen suppression with the person's chosen physical method.
- Systemic anti-androgens can affect development of a male fetus and require reliable pregnancy prevention, clear off-label consent and medicine-specific monitoring.
Key red flags
Change over months with deep voice, clitoromegaly, accelerated scalp loss or muscle change is a tumour or severe androgen-excess red flag rather than routine PCOS.
New or rapidly worsening hirsutism after menopause raises concern for ovarian hyperthecosis or an androgen-secreting ovarian or adrenal lesion and needs specialist review.
Androgen excess with an adrenal mass, bruising, proximal weakness, broad purple striae, hypertension or hypokalaemia may indicate adrenal tumour or Cushing syndrome.
Extensive acanthosis nigricans, dysglycaemia, lipodystrophy or striking hyperandrogenism suggests a severe insulin-resistance syndrome beyond common PCOS.
Investigation priorities
Confirm androgen excess and identify a result severe enough to accelerate specialist assessment.
Management branches
Slowly progressive unwanted terminal hair with no rapid systemic or genital change.
- Document onset, tempo, cycle and pregnancy history, medicines and supplements, removal practices, family pattern and psychosocial impact; examine androgen distribution, scalp, skin, blood pressure and Cushing features.
- Measure validated testosterone and SHBG and screen selected mimics with pregnancy testing, thyroid, prolactin and early-morning 17-hydroxyprogesterone according to the clinical pattern.
- If findings fit PCOS, complete its menstrual, metabolic and fertility assessment; if hormones are normal with regular cycles, consider idiopathic follicular sensitivity after review.
- Offer physical hair removal immediately and agree whether hormonal or topical treatment is desired, with a realistic response interval and safety review.