Ferriman-Gallwey Score
The Ferriman-Gallwey (FG) score is a visual assessment tool that evaluates terminal hair growth across nine androgen-sensitive body areas, with a total score ≥8 indicating hirsutism in most populations, though this threshold varies by ethnicity. 1
How the Score is Calculated
The modified Ferriman-Gallwey (mFG) scoring system evaluates terminal (coarse) hair growth in nine specific body areas:
- Upper lip
- Chin
- Chest
- Upper abdomen
- Lower abdomen
- Upper arms
- Thighs
- Upper back
- Lower back
Each area is scored from 0 to 4:
- 0 = No terminal hair
- 1 = Minimal terminal hair
- 2 = More than minimal but less than complete coverage
- 3 = Complete coverage, light density
- 4 = Complete coverage, heavy density
The scores from all nine areas are summed to produce a total score ranging from 0 to 36. 1
Diagnostic Threshold for Hirsutism
A total mFG score ≥8 defines hirsutism in European and North American populations 1. The Endocrine Society guidelines classify severity as:
- Mild hirsutism: Score 8-15
- Moderate to severe hirsutism: Score >15 1
Critical Ethnic Considerations
The cutoff score of ≥8 is NOT universally applicable and must be adjusted for ethnicity:
- Asian populations: Even mild hirsutism may indicate androgen excess; lower thresholds should be considered 1
- South Asian populations: A cutoff of ≥5 has been proposed 2
- Latin American populations: A cutoff of ≥6 may be more appropriate 3
- Chinese populations: A cutoff of ≥2 has been suggested 4
Practical Clinical Application
Key Body Areas for Screening
The chin, lower abdomen, and thighs are the most clinically relevant areas for detecting hirsutism 5, 6. Research demonstrates:
- Terminal hair was present on the chin in 97.4%, thighs in 96.5%, and lower abdomen in 92.1% of hirsute women 5
- Evaluating just the chin, upper abdomen, and lower abdomen accurately predicts total body hirsutism and distinguishes hirsute from non-hirsute women 6
This simplified approach is particularly useful when full-body examination is impractical.
Important Clinical Caveats
The mFG score has significant limitations in clinical practice 1:
- Most women use cosmetic hair removal before medical consultation, making accurate scoring impossible
- The score does not correlate well with androgen levels due to variable follicular response to androgens 1
- Treatment decisions should prioritize patient distress rather than absolute score values 1
When to Investigate Further
Testing for androgen excess is NOT recommended for isolated mild hirsutism (score 8-15) with regular menses, as the likelihood of finding a treatable disorder is low 1.
DO test for elevated androgens when:
- mFG score >15 (moderate to severe hirsutism)
- Sudden onset or rapid progression
- Associated virilization (clitoromegaly, increased muscularity)
- Menstrual irregularity, infertility, or other PCOS features
- Abdominal or pelvic mass 1
Alternative Assessment Methods
Image-based mFG scoring using mobile phone photographs shows acceptable concordance with in-person evaluation (agreement 0.89), offering a valid alternative for telemedicine or pandemic conditions 7. Images should be acquired under standardized lighting conditions of all nine body areas.