What are the treatment options for excess hair growth on the face, particularly in cases related to hormonal imbalances such as polycystic ovary syndrome (PCOS) or idiopathic hirsutism?

Laboratory Evaluation for Facial Hirsutism

For women presenting with excess facial hair growth (hirsutism score >6 on modified Ferriman-Gallwey scale), measure total or free testosterone, DHEAS, and consider additional endocrine testing based on clinical features. 1

Essential Laboratory Tests

First-Line Hormonal Assessment

• Total testosterone or bioavailable/free testosterone: Levels >200 ng/dL suggest an androgen-secreting tumor requiring urgent imaging 1
• DHEAS (dehydroepiandrosterone sulfate): Elevated levels point toward adrenal sources of androgen excess 1
• Androstenedione: Helps differentiate between ovarian and adrenal androgen production 1

Additional Screening Tests

• TSH (thyroid-stimulating hormone): Thyroid disorders can contribute to hirsutism 2, 1
• Prolactin: Hyperprolactinemia may present with hirsutism 1, 3
• Glucose/insulin levels: Assess for insulin resistance, particularly in PCOS 1

When to Expand Laboratory Workup

Signs Requiring Full Endocrine Evaluation

The American Academy of Dermatology recommends comprehensive testing when hirsutism occurs with: 2

• Oligomenorrhea or amenorrhea (irregular or absent periods)
• Infertility
• Clitoromegaly (genital virilization)
• Truncal obesity
• Rapid onset over weeks to months (tumor concern) 3

Routine Testing NOT Recommended

• Mild hirsutism without other hyperandrogenic signs does not require endocrine testing 2
• Microbiologic testing is not indicated for hirsutism evaluation 2

Imaging Studies

Pelvic Ultrasound Indications

• Suspected PCOS: Look for >10 peripheral cysts (2-8 mm diameter) with thickened ovarian stroma 1
• Pelvic examination: Assess for adnexal masses suggesting ovarian tumors 1

When to Order CT/MRI

• Testosterone >200 ng/dL: Obtain adrenal and pelvic imaging to locate androgen-secreting tumors 1
• Markedly elevated DHEAS: Focus on adrenal imaging

Special Diagnostic Considerations

Testing for Specific Conditions

• Non-classical congenital adrenal hyperplasia: 17-hydroxyprogesterone level, particularly in women of Mediterranean, Hispanic, or Ashkenazi Jewish descent 1, 4
• Cushing syndrome: 24-hour urinary free cortisol or overnight dexamethasone suppression test if clinical features present 1

Medication History

Document use of: 1

• Exogenous androgens (testosterone, DHEA supplements)
• Certain antiepileptic drugs (valproate, phenytoin) - women with epilepsy have 10-25% prevalence of PCOS 1
• Androgenic progestins (norethisterone, levonorgestrel) 1

Clinical Assessment Components

Physical Examination Findings

• Acanthosis nigricans: Dark, velvety skin suggesting insulin resistance 1, 4
• Androgenetic alopecia: Male-pattern baldness 2, 1
• Severe acne: Particularly treatment-resistant cases 2
• Body habitus: Central obesity pattern 1

Family History

• Strong genetic component: PCOS and androgen receptor sensitivity run in families 4
• Similar symptoms in female relatives support idiopathic or PCOS-related hirsutism 1

Common Diagnostic Pitfalls

• Asian women may have normal androgen levels despite significant hirsutism due to increased 5α-reductase activity 4
• Idiopathic hirsutism (5-15% of cases) presents with normal ovulation and normal androgen levels - diagnosis of exclusion 4, 5
• PCOS accounts for 70-80% of hirsutism cases but requires only 2 of 3 criteria: hyperandrogenism, ovulatory dysfunction, or polycystic ovaries 2, 1