Excess Body Hair

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

  • Congenital Adrenal Hyperplasia (1 in 5000)
  • Anabolic Steroid Abuse
  • Ovarian Tumours: Arrhenoblastoma, Hilus Cell Tumour, Luteoma
  • Adrenal Tumours: Carcinoma and Adenoma
  • Congenital (1 in 5000 Live Births) and Juvenile Hypothyroidism

Rare Diagnoses

Ready Reckoner

Key distinguishing features of the most common diagnoses

ConstitutionalPCOSAnorexiaMenopauseDrugs
Excess Vellous HairNoNoYesNoPossible
Facial HirsutismPossiblePossibleNoYesPossible
Oligo/AmenorrhoeaNoYesYesYesNo
Otherwise WellYesYesNoPossiblePossible
Weight LossNoNoYesNoNo

Possible Investigations

Likely:None.

Possible:Serum testosterone, SHBG, pelvic ultrasound, FBC, U&E, TFT.

Small Print:FSH/LH, other tests of endocrine function and specialised imaging techniques (for adrenal/pituitary disorders), urinary porphyrins.

  • Serum testosterone and SHBG: Probably the most useful investigation. Mild elevation (up to three times the normal value) and normal or low SHBG suggests PCOS; testosterone levels above this indicate a possible tumour.
  • FBC, U&E: Possible iron deficiency anaemia and electrolyte disturbance in anorexia; U&E may be deranged in adrenal disorders.
  • FSH/LH and TFT: The former may help to confirm menopause and may point towards PCOS (elevated LH, normal FSH); the latter reveals hypothyroidism.
  • Other tests of endocrine function and imaging techniques: To investigate possible adrenal and pituitary disorders (usually undertaken in secondary care).
  • Pelvic ultrasound: Multiple ovarian cysts characteristic of PCOS; may also reveal ovarian tumour.
  • Urinary porphyrins: For porphyria.

Top Tips

  • Mild, long-standing hirsutism does not require investigation.
  • Enquire about self-medication, especially in athletes – anabolic steroids may occasionally be the cause.
  • Take the problem seriously and be prepared for questions about cosmetic treatments such as bleaching, depilatory creams and electrolysis.

Red Flags

  • Sudden and severe hirsutism is the most important marker for serious underlying pathology.
  • Other clues suggesting a possible hormone-secreting tumour include amenorrhoea, onset of baldness at the same time as hirsutism and a patient who seems generally unwell.
  • Consider psychological factors: Hirsutism can cause – or be the presenting complaint in – significant depression.
  • Recent onset of significant headache and visual field defect raise the possibility of a pituitary adenoma.

Published: 2nd August 2022 Updated: 10th April 2024

Report errors, or incorrect content by clicking here.

What is Nursing in Practice Reference?

Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

Learn More

Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.