Many patients that seek the help of the electrologists for what they perceive
to be a cosmetic problem actually demonstrate androgen excess,
which is an endocrine/metabolic abnormality. It is the responsibility of the electrologist to determine whether the client is a high risk for this disorder,
and then refer them appropriately.

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In a 1988 scientific study it was found that of 105 hirsute women referred for electrology, 58 (55%) had abnormally high circulating values for at least one androgen, particularly free testosterone, DHEAS and/or androstenedione. In this study there was no significant correlation between the level of androgens, the hirsutism score, or the frequency of menstrual disturbances.

In another study1 of 46 women referred for electrology, one (2.2%) demonstrated 21-hydroxylase deficient non-classic adrenal hyperplasia (NCAH), which is consistent with the general prevalence reported by other investigators in non-Jewish Caucasian individuals. It should be noted that these two reports arise in patient populations that were referred for electrology to university dermatology departments, which may have biased the patient population seen. Furthermore, these investigators did not pre-select patients for further evaluation, according to the degree of hirsutism or the presence of menstrual abnormalities. More recent studies, conducted at the University of Alabama at Birmingham¹, have attempted to address the issue of androgen excess among hirsute patients self-referring for electrology to community practices.

The improvement of hirsutism occurs slowly, often requiring six to eight months of therapy prior to observing a difference. Patients, physicians and electrologists often focus solely on the cosmetic aspects of androgen excess. Nonetheless, there is increasing evidence that patients with androgen excess demonstrate multiple and various metabolic abnormalities similar to that of many other multifactorial disorders such as type 2 (non-insulin dependent) diabetes mellitus (Type 2 DM) and coronary artery disease (CAD). Furthermore, the resultant irregular (infrequent) ovulation and hyperestrogenism is associated with an increased risk of endometrial and breast carcinoma. Patients need to be counseled in this regard and physicians need to direct their management in order to decrease these risks.

Hirsutism due to polycystic
ovary syndrome
Although there may be major negative psychological effects attached to excessive hair growth on women, it is important to note that hirsutism in and of itself does not have any significant associated medical risks. Nonetheless, 60-80% of hirsutism is due to polycystic ovary syndrome (PCOS), and PCOS does have some significant metabolic effects, as follows:

Obesity
Obesity has been associated with PCOS since the syndrome was described by Stein and Leventhal. Overall 20-50% of patients with PCOS will be defined as “obese,” the incidence varying depending on the criteria used to define overweightness. When obesity is defined as 20% above ideal body weight, the frequency of obesity among PCOS patients may not be much higher than its prevalence in the general population of the U.S. Furthermore, the ovarian changes observed in women with morbid obesity do not appear to be similar to the pathological findings in PCOS or those seen following long-term androgen treatment. This data suggests that while there is a relationship between obesity and irregular or infrequent ovulation, PCOS and obesity-related irregular or infrequent ovulation are not identical.

It is unclear whether obesity follows or precedes the development of hyperandrogenism. Obesity, particularly during or before pubertal development, appears to act as a promoter of PCOS, but is not essential for the development of the syndrome.

Obesity can lead to the development of PCOS through a multitude of mechanisms, e.g. through increased insulin resistance and a rise in insulin circulating levels, which in turn can lead to an increased ovarian secretion of androgens and decreased sex hormone binding globulin (SHBG), a protein in the blood that traps hormones.

The presence of obesity is associated with increased metabolism of androgens, reflected in both an elevated production and a clearance rate. This hypermetabolic state will magnify any small dysfunction of either increased androgen production or decreased clearance, leading to the development of symptoms. Moreover, increased peripheral production of estrogens may play a (not yet defined) role in the ovulatory dysfunction of PCOS. Overall, obese women are more susceptible to the development of excess male hormones and subsequent PCOS than their normal weight counterparts.

Alternatively, it is possible an androgen excess may predispose to obesity. For example, patients with PCOS will have more androgens available for conversion to estrogens. Thus, while obesity appears to increase the risk of PCOS, the development of excess male hormones may in turn encourage or aggravate overweightness.

 Insulin resistance
Approximately 50 percent of patients with PCOS demonstrate insulin resistance. Patients with insulin resistance and normal pancreatic beta-cell function will develop high levels of insulin. The excess insulin appears to then act on ovarian supporting tissue, resulting in increased androgen secretion. In addition, the high levels of insulin may be associated with an increase in other risk factors for the development of coronary artery disease. A recent study found that in a population of 254 women with PCOS — with an average age of 29 years — 7.5% had diabetes mellitus type 2, and 31% had glucose intolerance.

 Hypertension
In another long-term study of 33 women with PCOS, examined 22-31 years after diagnosis, 39% were being treated for hypertension, compared to 11% of controls. Furthermore, non-obese PCOS patients had higher systolic and diastolic blood pressures when compared to controls with equal body fat mass.

Coronary artery disease
In a study evaluating 102 women undergoing coronary artery cauterization, hirsutism was found more common in those women with confirmed CAD. Furthermore, an apple-like body shape (more mid-body fat) was associated with the presence of hirsutism and CAD. As would be expected for a disorder that takes a number of years to develop, these associations were strongest in older women. In spite of the increased incidence of risk factors for CAD in PCOS women, a study from the UK (which followed 786 women with PCOS for an average of 30 years), did not observe a higher than expected mortality from CAD among their patients.

Malignancy
Chronic irregular or infrequent ovulation is a well-known risk factor for the development for endometrial carcinoma. More specifically, PCOS patients not receiving treatment are at significant risk of developing endometrial carcinoma. A 1957 study involving 43 patients with the Stein-Leventhal syndrome noted that 16 patients (37%) had malignant endometrial lesions. A number of early investigations noted that almost 20% of women who developed endometrial cancer at 40 years of age had clinical evidence of PCOS. More recently, seven of ten patients aged 15 to 25 with endometrial cancer had clinical characteristics of PCOS. It appears that early diagnosis and follow-up of patients with this syndrome may reduce their risks of developing endometrial malignancy. In a 1992 report, not one of 18 patients who underwent ovarian wedge resection 22 to 31 years earlier developed endometrial cancer or other problems of that type.

Determining the prevalence
of PCOS among women
seeking electrology
To determine the prevalence of PCOS among women seeking electrology in the general community, clients presenting for electrology at nine centers were asked to complete a questionnaire. Selected women identified as having potential risk factors were referred to the University of Alabama at Birmingham. The selection criteria for further studies included:

a. the presence of upper lip, chin, chest, abdomen or buttock terminal hair

b. irregular cycles greater than 35 days in length; and/or

c. a family history of excessive hair growth.

The selected study subjects underwent a full physical examination, including Ferriman-Gallwey (F-G) scoring, and a blood analysis for total and free testosterone. Of the 779 consecutive patients seeking electrology and completing the questionnaire, 315 (40%) responded as having potential risk factors for hyperandrogenism and were referred for further evaluation. Of those referred, only 82 (26%) patients completed their medical evaluation. Of these, 6 patients were excluded secondary to being prepubertal or menopausal. Of the remaining 76 patients, 21%, 13% and 21% had F-G scores greater than 6, 8 and 10, respectively. Forty-nine (64%) of the patients reported a history of irregular menstrual cycles. Twelve patients were receiving hormonal therapy at the time of their evaluation; therefore, androgen levels were not obtained in these women.

Of the 25 patients with regular menstrual cycles who were not receiving hormonal therapy, 17 (68%) had at least one abnormal androgen value, while 33 (85%) of the 39 women with irregular cycles had at least one abnormal value, not a significant difference. There was no difference in the mean androgen values or the F-G scores between women with and without irregular menstruation. Overall, PCOS was evident in 39 (51%) of the 76 women studied.

In our study above, we suggested selection criteria for women complaining of excessive hair growth (see Table 1.) and who may require further evaluation. In general, the presence of terminal hairs on the upper lip, chin, neck, sideburn/cheek area, chest, abdomen, buttocks, back, and upper arms all suggest significant androgen excess. The presence of irregular or infrequent cycles, generally defined as cycles greater than 35 days from the beginning of one menses to the beginning of the next, or less than eight periods per year, also suggests a central cause for the hirsutism. Furthermore, a strong family history of excessive hair growth is consistent with many disorders resulting in androgen excess including the HAIRAN syndrome, NCAH, and PCOS.

Certain physical features also suggest androgen excess. For example, the presence of acanthosis nigricans (i.e. a diffuse thickening and darkening of the skin, often accompanied by skin tags; and most prominent in the crease areas of the body, such as the nape of the neck) may suggest the presence of severe insulin resistance, as in the HAIRAN (hyperandrogenic - insulin resistant – acanthosis nigricans) syndrome. Furthermore, abdominal obesity in a woman, in contrast to the regular female obesity affecting the buttocks and thighs, also suggests androgen excess. The presence of acne and/or scalp hair loss (androgenic alopecia) along with hirsutism also may suggest a central cause for the problem. These selection criteria are listed in Table 1.

It is most important to educate patients concerning their disease. Many assume that there is nothing wrong and that this is simply a cosmetic problem, or that they themselves have done something to deserve their hirsutism. Providing educational literature is very useful. For example, the American Society for Reproductive Medicine (ASRM) publishes the patient educational brochure entitled Hirsutism and the Polycystic Ovarian Syndrome, which reviews the basics of androgen excess. The ASRM also publishes clinical guidelines for the evaluation and treatment of the hirsute woman and the patient with androgen excess, which electrologists may find useful. These and other publications can be obtained by calling (205) 978-5000.