Women’s health articles

I have hair where? — coping with unwanted hair growth

by Dixie Mills, MD

Occasionally women will come to the clinic with extra hair growing in places where they’ve never had hair before, or in greater amounts than usual. Our feelings about the hair on our bodies and faces can be a highly sensitive topic, and our perspectives vary widely based on personal preference. Many women want to get rid of it as quickly and permanently as possible; others are happy to just let it go, viewing it as a natural (and yes, beautiful, thank you!) expression of themselves. Body hair also carries with it all kinds of cultural and social associations — there’s no question that how much is too much is a “time period” phenomena.

In today’s celebrity fashion craze, for example, no hair anywhere is the rule, with waxing salons on every corner. (However the Brazilian may be on its way out, and a more natural look in!) Those of us who lived through the “hippie days” of the 60’s and 70’s, clearly remember going au naturale with what would appear to today’s viewers as “shocking” amounts of underarm, leg and pubic hair. But at one point or another, most women have hair appearing in places they’d probably rather not for different reasons.

Fortunately, unwanted hair growth is usually just a benign annoyance. But there are cases where it could be signaling higher-than-normal levels of insulin and — sometimes as a result of insulin resistance — higher than normal levels of androgen hormones like testosterone. So let’s talk about the difference between common and uncommon hair growth, the reasons why you may have more hair than you used to, and what you can choose to do (or not do!) about it.

Is this hair normal?

Women in menopause will often speak to me about wrestling with alopecia, or hair loss, but many don’t realize that hormonal imbalances can also cause unwanted hair growth. For many of my patients, managing “extra” body hair is more than just an annoyance; it can create real frustration, anger and resentment — some even have called it a “battle” they’ve fought all their lives. Aside from wanting to find the quickest solutions, women often want to know if excess hair could be a sign of a health problem — maybe they’ve heard that hair growth is related to a change in their body’s insulin sensitivity, or that it might even be a signal for PCOS (polycystic ovarian syndrome). But the question I hear most often is, “What is normal for a woman when it comes to hair growth?”

To distinguish between normal and not-so-normal hair growth, it helps to think about the types of hair the human body grows, and the stage of life when it grows, or doesn’t. We actually have hair all over our bodies from the very beginning — in the womb, the fine layer of hair that covers a fetus and keeps it insulated is called lanugo. After birth, we develop very soft and light vellus hair (better known as “peach fuzz!”) which stays on our bodies for our entire lives. Vellus hair can be a little thicker or darker depending on the person, but it’s usually less than 2 mm long, and can appear all over the body.

But uncommon hair growth in women is usually associated with terminal hair. Terminal (or androgenic) hair begins to appear during puberty with hormone changes, and continues to develop long after. It’s darker and coarser than vellus hair, and is found on the scalp, beard or chin region, armpits, and the pubic area in women. (Because men have higher amounts of androgens in their bodies, they have more terminal hair on their bodies.)

Based on your genetic makeup, increased or reduced production of certain hormones can cause unwanted hair to grow in many different ways, depending on a person’s age, ethnicity and sex — but for some women, this unwanted hair can be a signal of a condition called hirsutism.

Hirsutism can be a symptom of hormonal imbalance

Hirsutism (also called hypertrichosis) is the growth of terminal hair (or thickened vellus hair) in places more typically seen in men in women. It can be genetic, or it can also be one of the body’s natural reactions to hormonal and biochemical imbalances, like insulin resistance and a high level of androgen dominance.

How severely or quickly hirsutism develops (and where) varies depending on many variables, but here are the three main factors:

• Production of abnormally high levels of androgens like testosterone.
• How much of those androgens are being bound up by SHBG (sex-hormone–binding globulin), versus how much is freely available in the bloodstream.
• To what degree the androgen receptors around your hair follicles themselves become sensitized to androgen hormones.

In your body, androgens are being produced by your ovaries, your adrenals, and also peripherally in your fat tissues. From there, they are transported throughout the bloodstream to your hair follicles, where testosterone is converted into its more potent, follicle-active form. More “sensitive” hair follicles can spend more time in the anagen (or active) phase of hair growth.

If you have higher-than-usual levels of free testosterone, or your hair follicle receptors have become hypersensitive to androgens, excess or unusual hair growth can appear anywhere on your body (even on the palms and soles of the feet!). Increased facial hair, for example, commonly develops in menopausal women, where it is sometimes said to be caused by “unopposed androgen.” But for most women, hirsutism is typically identified in the moustache, beard, chest (usually between the breasts or around the nipples), and genital regions.

What causes hirsutism?

Let’s start off by saying that hirsutism is a lot more common than most people think. At least one in 20 women in America deals with this kind of hair growth, and the reasons for it can vary depending on the person. Hirsutism is not a disease per se; it’s a natural expression of a woman’s hormonal makeup, which may or may not be in its optimal state. So many things influence our hormones and the growth of our hair, some of which we can influence through diet and lifestyle. But hirsutism is usually linked to one or more of the following factors:

Genetics. In most cases, the specific cause for hirsutism is genetic, as the underlying blueprint for how much hair we have is linked to our familial heritage. It can also be caused by relatively rare, yet “normal” genetic variants called atavisms, or throwbacks to an earlier time in human evolutionary history — in this case, to a time when our ancestors were much hairier creatures than we are!

Drugs, hormones and other growth factors. In some women, hirsutism may be related to past or present use of drugs or growth factors, or exposure to toxins that increase androgen production or disrupt the way in which hormones are metabolized in the body. These are factors that we do have some control over, and include (but are not limited to) the following:

• phenytoin sodium, carbamazepine or Tegretol (anti-seizure medications)
• minoxidil (Rogaine, Regaine)
• glucocorticoids or steroids like cortisone
• danocrine or Danazol
• cyclosporine
• diazoxide or Proglycem
• metyrapone or Metopirone (given to treat Cushing’s disease)
• bFGF (basic fibroblast growth factor)
• PDGF (platelet-derived growth factor)
• IGF-I (insulin-like growth factor I)
• insulin
• birth control pills (which can also decrease hair growth)

All of these can trigger an excess in the level of androgens in the body. But what’s unique about androgens is that just having an excess of androgens won’t necessarily mean that a woman will experience hirsutism. Women with high testosterone are not necessarily more aggressive or do better in sports either!

As I explained above, some women with hirsutism have hair follicles that are extra-sensitive to normal amounts of androgens (combined with higher-than-normal circulating androgen levels), whereas others have decreased metabolism, or enhanced receptor bindings. So both too much and too little are possible causes of hirsutism. And then there is also the idiopathic variety, where the medical profession just can’t find a cause. So how it happens can be a real mystery until you meet with your healthcare practitioner.

Am I “hirsute,” or just a little hairy? — Talking about hair with your healthcare practitioner”

If you experience a marked change in your hair growth over several weeks or months, then having your hormonal profile checked is probably a good idea. In other words, the speed and amount of your body hair growth matters. It can be just the expression of your genetic heritage, or a representation of where you are in relation to your hormonal or life cycle. If it’s the latter, it’s best not to think about this hair growth as the end-all-be-all, but merely one piece of your current whole hormonal expression. Ask yourself the following questions:

• Is the amount of hair growth unusual, given my past or family hair history?
• Do I have other irregular symptoms, such as irregular periods, weight gain/loss, or a deepening of the voice
• Is the hair growth sudden or gradual?
• Is the hair growth appearing in an “uncommon” place?
• Have I recently experienced an emotional change in my life?

Knowing those answers will help your healthcare practitioner more quickly identify whether this unwanted hair is genetic, a symptom of hormonal imbalance, or a signal for something more serious, like PCOS. It can also help to specifically target where you’re seeing more hair than unusual, in identifying whether you’re hirsute, or just a little hairy.

The body areas where you can look for androgen sensitivity first are the places where terminal hair usually grows on women (in descending order of sensitivity):

• pubic area
• axillae (underarms)
• perianal area
• sideburns
• upper lip
• periareolar (around the nipple) areas
• the chin and “beard” region
• arms and legs
• between the breasts area
• shoulders
• buttocks
• back
• abdomen

Hair growing in the above areas more heavily (or earlier) than is normally seen such as in puberty can be a sign of androgen excess. If caught early enough, it can often be treated relatively easily by making sure our hormones return to their regular healthy levels. But if you’re curious whether this unwanted hair growth is something you should bring up with your healthcare practitioner, you can begin by evaluating your hair growth yourself with a scoring tool known as the Ferriman–Gallwey score.

The Ferriman–Gallwey test was developed in the 1960’s, and is still helpful today for measuring the degree of hairiness or hirsutism a woman is experiencing. You can take a look at the images and gauge where your hair growth ranks from 0 (no terminal growth) to 4 (maximal growth). You can print the chart, bring it in to your healthcare practitioner, and talk about what’s normal for your own personal hair growth versus what’s been happening lately. Although the results can vary for everyone, women with scores higher than 3 represent hair growth that’s typically outside the norm.

The last step is making sure that this hair you’re seeing genuinely is something unusual for you. Dramatic changes in our external lives can also sometimes trigger changes in how we perceive ourselves — as well as how we think others perceive us.

Self-perception: emotions and our hair

Confidence about our bodies oftentimes mirrors our inner emotional lives. So if you find yourself blaming the hair on your body for negative emotions, it might be time to step back and ask yourself whether you have recently experienced an emotional shift in your life (though some women would call them earthquakes!).

Such transitions can involve a partner entering or leaving your life, or some other unsettling event that triggers the quake — and menopause often qualifies! In such events, the hair on our bodies may or may not have changed all that dramatically, but the way we see ourselves has. So before you leap to the conclusion that the hair is something that needs to be “fixed,” ask yourself whether this growth is sudden, or whether it’s happened gradually over time. Is there really a difference in your hair growth, or are you looking at yourself differently these days? Everything should be taken in context.

I always remember one patient of mine in her 30’s. We got to talking about hair growth, and she explained that she had been sick for a couple days and finally went to the ER and was diagnosed with appendicitis — but because she didn’t feel well, she hadn’t shaved her legs. The ER doctor was concerned about her excess leg hair. So while recuperating, she got a work-up for it, and nothing was ever found. But the whole issue made her upset because she felt her hair was just her, and not anything abnormal — but no one had listened.

So when I see a woman who has had heavy hair growth much of her life, I tell her this usually isn’t indicative of a serious physical problem. If the heavy hair growth is sudden, however, it might be time to speak with your healthcare practitioner about your hormone status. Meantime, let’s get to the question that all of my patients want answered: “So what can I do about it?”

Solutions for unwanted hair growth

Most women who deal with their extra hair on a regular basis have some sort of system in place: they shave (and No, shaving does not cause hair to grow faster or coarser — that is a myth!), pluck, tweeze, use creams or wax for immediate hair removal. But for women who have sudden, rapid hair growth, or other signs of hormonal imbalance, here are some suggestions to help get you started:

• Learn your hormonal profile. Although it’s tempting to just grab the tweezers and get to work, remember that removing the unwanted hair from our bodies is not as important as identifying our condition as common or uncommon, and (if uncommon) finding the treatment that’s right for you. This includes speaking with a healthcare practitioner and finding out about your own personal hormonal profile to see if you have insulin resistance; or see a specialist to check for an imbalance of androgens or androgen metabolites.


• Reverse your insulin resistance. You can facilitate your body’s natural healing pathways with dietary and lifestyle changes that reduce insulin resistance. Regular gentle exercise, along with meals and snacks with a low glycemic load, can bring both insulin and androgen production, regulation, and metabolism back to a more balanced state.
  
  If your insulin resistance is more advanced, or you find the nutritional aspects of insulin control difficult, there are medical foods available today that are specifically designed to support insulin and glucose stabilization. At our clinic we use Metagenics products with excellent result in helping women with more troublesome insulin resistance. (You will need to work with a practitioner of functional medicine when using medical foods.) Studies have shown that the specific phytonutrients these products contain work by modulating insulin signaling and actions in the body. By targeting pathways upstream of where drugs like metformin (Glucophage) do their work, the nutrients help heal your metabolism without the unwanted side effects associated with drugs.
  
  Best of all, healing your metabolism may not only help diminish unwanted hair growth, but will also bring you better balance on every other level. For more guidance, see our page on insulin control and the four food groups.


• Drink spearmint tea regularly. New studies in the journal Phytotherapy Research show a promising natural alternative. Drinking spearmint tea twice a day reduces the effects of the levels of androgens in the body which can cause hirsutism. Hot spearmint tea with a dollop of honey is very soothing and satisfying after meals, in place of dessert. Spearmint tea is delicious chilled, too — add a bit of stevia or unfiltered apple juice if you need a little sweetener.


• Laser or electrolysis treatments. Laser therapy is being chosen by more and more women as an alternative to the skin irritation, scarring, messiness, re-growth, and inconvenience associated with older methods of hair removal. As laser technology has become more advanced, it has also become more available and more affordable. It can leave your skin feeling smoother, and the results can last for much longer than with electrolysis or the somewhat painful, at-home removal techniques (a friend of mine once had a downright frightening experience with an “Epilady” in the 80’s!). Laser hair removal has also been shown to help women who have genuine anxiety, depression, or just plain frustration about their hair.


• Try a prescriptive medication. There are no FDA–approved medications for hirsutism at this time. There are some drugs, like spironolactone or aldactone, which bind to the hormone receptors that react with androgens — and that can decrease unwanted hair growth. Metformin, a treatment for PCOS, does seem to reduce testosterone, and thus decrease hair growth. But this is also our least favorite solution for general treatment. Many of the anti-androgen medications take a long time to work (over a year) if they work at all, and once you stop, the hair growth comes back. They also have some undesirable side effects, like nausea and diarrhea, or more seriously, high blood sugar and chest pain.

Loving the hair we have — the Women to Women approach

How much hair we choose to keep (and where we decide to keep it) are deeply personal decisions. But for the most part, the kind of hair that will develop on our bodies is determined by our lineage: many studies have shown that our natural hair growth varies widely in amount and thickness, largely due to our genetic makeup, and even the region of the world where our ancestors came from. Learning to accept your natural hair growth can be very liberating, or if you feel more confident without it, that can be equally liberating. What we want you to know is that you have a choice!

But if you have experienced a rapid amount of sudden hair growth (and especially alongside other health concerns), it’s a good idea to speak with your healthcare practitioner, as it could be your body’s response to underlying hormonal and chemical imbalance. As I tell my patients, view this as an opportunity to improve your total health — to feel healthy and beautiful, inside and out.

Related to this article:

References & further reading on unwanted hair growth

Original Publication Date: 05/26/2008
Last Modified: 02/16/2010
Principal Author: Dixie Mills, MD