Hirsutism, Normal Androgens and Diagnosis of PCOS

Abstract

Hirsutism is defined as the presence of terminal hair with male pattern distribution in women. While in the general population, hirsutism affects around 4-11% of women, it is the main manifestation of hyperandrogenism in women with polycystic ovary syndrome (PCOS), with a prevalence estimated at 65-75%. Hirsutism in PCOS is associated with both androgen excess and individual response of the pilosebaceous unit to androgens. The modified Ferriman-Gallwey (mFG) scoring system has been widely used in clinical practice to visually score excessive terminal hair, thus standardizing hirsutism evaluation and facilitating data comparison. Although a universal mFG score cutoff would be useful for comparisons, ethnic variations, as well as skin type and other factors, should be considered when evaluating hirsutism in distinct populations. In turn, androgen levels, measured by conventional techniques, have been shown to correlate poorly with the severity of hirsutism. Indeed, while most women with PCOS and hirsutism also have higher than reference values for serum androgen levels, some of them may not present with biochemical hyperandrogenism, representing a challenge to the diagnosis of PCOS. In this article, we critically review this not uncommon condition in women with PCOS presenting with hirsutism but normal androgen levels.

Keywords: Ferriman–Gallwey score; biochemical hyperandrogenism; hirsutism; polycystic ovary syndrome.

Figure 1

Role of androgens in the hair follicle and its peripheral response. A: androgens; AR: androgen receptor; ↑ peripheral response to androgens is expressed graphically by the modified Ferriman–Gallwey scale.

Figure 2

Hirsutism scores in women with polycystic ovary syndrome (PCOS) according to geographic distribution. PCOS was diagnosed by the Rotterdam, US National Institutes of Health (NIH), or Androgen Excess Society (AES) criteria. Black lines indicate unselected studies. Superscript numbers indicate sample size. mFG: modified Ferriman–Gallwey score.