Endocrine
Perspective
by
GEOFFREY P. REDMOND, M.D.
Past Endocrine Columns
Dear Dr. Redmond:
Can you give me some guidelines as to when I should suggest to a client with
increased hair growth that she have a medical evaluation? Also, how does one
find a doctor who is helpful? In my experience many do not take the problem
seriously.
Electrologists can be helpful to their clients
by suggesting medical evaluation when it is deemed appropriate. I’ll try to
offer some suggestions. Keep in mind, however, that medical diagnosis is
complex; that is why the education of a physician takes so long. I cannot cover
all the possible situations, so the first thing I will say is that it is never
amiss to suggest that a client see a doctor when there is a question of a
medical problem. I’ll discuss here the signs and symptoms which raise particular
concern, but this is not to suggest that those with milder cases do not need to
see a doctor.
There are two reasons a woman with hirsutism might seek medical help. First, to
find out if an underlying condition is present that might affect her well-being
in other ways. Second, is the hope of finding a treatment which will reduce the
unwanted hair.
The first reason has the highest priority, but of course it is distress at the
changes in appearance which usually motivates a woman to seek medical advice.
Women want a clear diagnosis to put their mind at ease, but are understandably
frustrated when treatment is not offered. Let’s consider both of these goals of
medical consultation.
The most common underlying condition associated with hirsutism is polycystic
ovary syndrome (PCOS). This condition has four main features: 1. skin and hair
changes related to testosterone (oily skin, acne, hirsutism, loss of scalp
hair); 2. irregular periods, and sometimes, difficulty becoming pregnant; 3.
problems with weight; and 4. metabolic abnormalities, principally high insulin
levels.
It is important to state clearly that while many women with unwanted hair have
PCOS, many more do not. Unfortunately, many sources of health information list
PCOS as the only cause of hirsutism. In my practice I often see women who have
been told that they have PCOS — but do not. Often these women have read about
PCOS online, and are frightened into thinking they may be infertile, or that
they may develop diabetes, even though they actually have no risk factors for
those problems.
What, then, does suggest PCOS? The first thing is the severity of the hirsutism.
The electrologist will notice that despite extensive treatment, new hair appears
nearly as fast as existing hair is removed. This is frustrating to both the
client and her electrologist. When there is strong hormonal stimulation, the
hair growth rate may be as rapid as it is in men. Some women with this
unfortunate situation must remove the hair with a razor, daily or sometimes even
twice a day. There are some women with PCOS however who do not have a lot of
hirsutism.
The next factor is weight. Being overweight tends to bring out a tendency to
PCOS and the PCOS makes weight harder to lose, a very unfair situation.
Overweight women with hirsutism are more likely to have an underlying hormone
problem. I should make it clear that I am referring to women who are 20-30
pounds or more overweight. I am not talking about the woman who feels she needs
to lose five pounds to look better in her bikini — that is a cosmetic problem,
not a medical one.
Irregular periods are the next important sign of PCOS. Here we need to be
precise. Some women consider their periods irregular because not every cycle is
exactly twenty-eight days. In fact, it is a rare woman who is absolutely
regular. As medically defined, a normal cycle should be between three and a half
and five and a half weeks long. This of course does not refer to the number of
days of bleeding, which should be a week or less, but to the time from the
beginning of one period to the beginning of the next.
Many women with PCOS have periods quite infrequently, sometimes as few as one or
two a year. This always requires medical evaluation because it is a risk factor
for cancer of the lining of the uterus (endometrium). An exception is missed
periods while on birth control pills, which generally is not a sign that
something is wrong, unless there is reason to suspect pregnancy has occurred.
We can, then, generalize about two sorts of woman with hirsutism. One has normal
weight, regular periods, and (usually) a relatively mild degree of unwanted
hair. The extra hair is due to the effect of the hormone, testosterone, but her
level will probably not be elevated; rather her follicles are particularly
sensitive to this hormone. Medical treatment with spironolactone or other means
of blocking testosterone may help reduce hair growth and can supplement the
benefits of electrolysis.
The second situation is a woman with a much greater degree of hirsutism, who
probably carries out daily hair removal at home in addition to having
electrolysis, which may be weekly. This woman is probably 175 pounds or heavier
and has been frustrated in her efforts to control her weight. She may have
periods only infrequently. She is likely to have PCOS or, much less commonly,
another underlying hormonal disorder. Women in this situation definitely need
medical evaluation and should be encouraged to obtain it. Other conditions
besides PCOS can produce a similar clinical picture: Only a medical workup can
pinpoint the exact cause. More details on the possible causes are available in
my medical text, Androgenic Disorders, and my book for lay people, The Good News
About Women’s Hormones. (Both of these books were published in 1995 and are now
out of print, but they may be available in libraries.)
There is another situation I should mention: the woman with sudden appearance of
substantial hirsutism. Facial and body hair generally becomes noticeable in the
mid teens through the early twenties. After that there may be an increase but it
is usually gradual. If a woman who has had no significant problem with unwanted
hair suddenly develops it in substantial amounts, an adrenal or ovarian tumor is
a possibility. Referral is essential in such cases.
I do feel I must add here a word of caution. It is not always possible to tell
without a workup who has a serious condition and who does not. Thus it is always
safe to suggest medical evaluation; and risky to tell a client that she doesn’t
need an evaluation. By this I do not mean that electrologists should tell all
their clients to see a physician, but simply that it is always better to be
safe, than sorry.
Finally, we must address the most difficult issue of all: How to find a doctor
who is sympathetic and knowledgeable about hair growth problems in women. The
specialties involved are endocrinology and gynecology. However, only a few
practitioners in these fields have a real interest in hirsutism or PCOS. Most
useful, is to ask clients whom they have found helpful. The Polycystic Ovary
Syndrome Association directory of professional members can be found on its
website (www.pcosupport.org)
and is a useful resource. Unfortunately, though hirsutism is both extremely
common and extremely distressing, only a few physicians take an interest in it.
Some do however, and it is worth the effort to find one.
Past Endocrine Columns
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