PCOS Hirsutism: What Causes It and How To Treat It
PCOS hirsutism may be one of the most difficult symptoms to live with. Growing hair in places that a female normally wouldn’t can be devastating and it may even damage your confidence and self-esteem. Suffering from this symptom may have you questioning how is this possible and what can I do to stop it?
So in today's post, you will find out everything you need to know about hirsutism. You are going to learn what causes it and how to treat it naturally so you can stop the excess hair growth.
Let’s get started.
Is PCOS Hirsutism Reversible?
Hirsutism is a symptom some women with PCOS suffer from. This symptom can leave you feeling self-conscious and helpless, but hirsutism from PCOS can be reversed. PCOS is at its core caused by an imbalance of sex hormones. Women with PCOS are producing too many male hormones. This can occur for various reasons including, high insulin levels, chronic stress and inflammation. It is the excess male hormones that can lead to hirsutism. So by making diet and lifestyle changes, you can begin to rebalance your hormones and improve symptoms like hirsutism.
What is Hirsutism?
Hirsutism is a term that describes the transformation of vellus hair to terminal. Women with hirsutism experience excess growth of ‘male’ pattern hair. So, female body parts that tend to have vellus hairs like the face, chest and back become dark and coarse.
- Vellus hair is short (less than 2milimeters in length), soft and fine. This hair is barely noticeable.
- Terminal hair is long, coarse, dark. This type of hair grows on the scalp, armpit and pubic areas in men and women.
What Causes Hirsutism in Women With PCOS?
In women with PCOS, the ovary or adrenal glands (organs found on top of the kidneys involved in the stress response) produce too many male hormones. It is the high male hormones that can cause a woman’s vellus hairs to transform into terminal hairs.
Now, you might be wondering.
What causes high male hormones in women with PCOS?
First’s things first. All women have small amounts of testosterone, but women with PCOS are producing too much testosterone. But there isn't one thing causing high male hormones in every woman with PCOS. In fact, there are three potential causes, they include high insulin levels, high cortisol levels and inflammation in the body.
High Insulin Causes High Male Hormones
Insulin is a hormone created by the pancreas that signals to our cells to take sugar out of the bloodstream and use it as fuel. The primary cause of high insulin levels in women with PCOS is insulin resistance. This the most common root cause of PCOS, with about 70% of women suffering from insulin resistant PCOS.
Insulin resistance is a condition where the cells don't respond to the signal insulin is giving. As a result, there is a build-up of sugar in the bloodstream. Due to the rise in blood sugar levels, the pancreas starts producing even more insulin to lower them
Insulin can contribute to the production of testosterone in two ways. It can stimulate the ovaries and lower Sex Hormone Binding Globulin (SHBG).
Stimulates the Ovaries
High levels of insulin in the body has the unwanted side effect of telling the ovaries to produce more testosterone. Which then causes the PCOS symptoms women experience.
SHBG is a protein made by the liver. Its role in the body is to bind together with three sex hormones; estrogen, testosterone and dihydrotestosterone (DHT). SHBG then carries these hormones throughout the body to reduce the level of free hormones. Testosterone bound to SHBG isn’t used by the body.
But insulin can lower the production of SHBG. Therefore more testosterone than normal is used by the body. Leading to PCOS symptoms like excess hair growth.
High Cortisol Increases Male Hormones
When we are stressed we go into fight or flight mode. The body responds with the adrenals releasing stress hormones like cortisol into the bloodstream.
In addition to these stress hormones, the adrenals produce male hormones, including DHEA, DHEA-S, and androstenedione. These male hormones try to protect the body from the damaging effects of too much cortisol. However, the longer cortisol stays high, the more androgens are released. This then causes a hormonal imbalance in women and PCOS symptoms like hirsutism.
Around 20-30% of women with PCOS suffer from adrenal androgen excess. Meaning a percentage of women with PCOS produce high levels of male hormones from their adrenals.
What Can Cause Stress
We often associate stress as running late for work or studying for an exam. But stress is more than that. Below are a list of possible stressors that you may be experiencing on a daily basis.
- Lack of Sleep
- Low-calorie dieting
- Environmental toxins
- Overconsumption of caffeine
- Autoimmune disease
Inflammation Can Cause High Male Hormones
Researchers have found that some PCOS women suffer from chronic inflammation.
Inflammation is a response the immune system takes in an attempt to defend itself from outside invaders, such as viruses and bacteria.
While insulin resistance is a root cause of PCOS, studies have found obesity-induced inflammation can lead to insulin resistance. The inflammation and insulin resistance can then lead to the development of PCOS and its symptoms like hirsutism.
So, you now know why PCOS can cause hirsutism and why testosterone levels may be high in women with PCOS. But before we get into how to treat it, let’s look at some other possible causes.
Other causes of Hirsutism
If you are experiencing hirsutism, it does not always mean it is a result of PCOS. This symptom can occur for various reasons. Below I have mentioned some other possible causes of hirsutism in women.
Non-classical Adrenal Hyperplasia
Hirsutism is also a common symptom of Non-classical adrenal hyperplasia (NCAH). This is a genetic condition where the adrenals overproduce male hormones.
To diagnose NCAH, your doctor may measure the hormone 17 alpha-hydroxyprogesterone. This hormone is produced by the adrenal glands and with the help of several enzymes, it is transformed into cortisol. But if there are excess amounts of 17 alpha-hydroxyprogesterone, the adrenal glands produce less cortisol and instead more male hormones.
‘Idiopathic’ means that there is no clear explanation for what is causing something.
Less than 20% of hirsutism cases are idiopathic. This is where women have a normal menstrual cycle but no identifiable cause for their high male hormone levels.
How To Diagnose Hirsutism
If you have long dark hairs on parts of the body a female normally wouldn't, visit your doctor.
Below are some of the tests your doctor may do to determine if its hirsutism and your cause.
The Ferriman-Gallwey is a scoring system. It allows doctors and patients to score the amount of terminal hairs on 19 different areas of the body
- Upper lip
- Upper abdomen
- Lower abdomen
- Upper back
- Lower back
- Inguinal area (groin area)
- Perianal area
For each area of the body a score of 0 (absence of terminal hairs) to 4 (extensive terminal hair growth) is assigned.
Tests for PCOS
Doctors use the Rotterdam Criteria to diagnose PCOS. Women must show two out of the three signs. While you may have hair it may not be because of PCOS, so test for this. If you know you have PCOS skip to the treatment section,
As discussed, women with PCOS produce high levels of male hormones.
To know for sure if your hirsutism is a result of PCOS, you need to get a blood test. Using the blood test, your doctor can check your hormone levels. They will be looking for high male hormones like testosterone and DHEA-S. But also low SHBG levels
An irregular menstrual cycle
The average menstrual cycle is between 21 to 35 days (on average 28 days). A cycle is irregular if it lasts longer than 35 days or less than 21 days. A missed period would also be an irregular cycle. Your doctor may ask questions about the health of your menstrual cycle.
Despite the name, these are not actually cysts the way you may think of them, but many small follicles. These follicles contain eggs. When you don't ovulate the follicle does not break to release the egg and instead accumulates liquid. Becoming a 'cyst' in the ovary. For an ovary to be polycystic, it must contain at least 12 of these 'cysts'.
An ultrasound of the ovaries can identify whether there are ‘cysts’ on your ovaries. The ultrasound will either be an abdominal or transvaginal scan.
Once your doctor has identified the cause, a treatment approach can be recommended.
How To Treat PCOS Hirsutism
To treat PCOS hirsutism you must lower the high male hormones.
There are various treatment options for hirsutism. So I am going to split this section up into two parts, medication (pills, drugs, topicals) and natural treatment (diet and lifestyle changes).
So, let’s begin.
Medication can often be the first route of treatment for hirsutism. Common drugs include the birth control pill, anti-androgens and 5 alpha-reductase enzyme inhibitors.
The Birth Control Pill
The Birth Control Pill is a daily pill containing man-made hormones. These hormones act like a female’s real hormones.
There are two types of birth control pills. The combined contraceptive pill is a combination of progestin and estrogen, and the progestin-only pill. Progestin is made to act like the body's natural progesterone. As a result, it is able to do some of progesterone's tasks in the body. But it does not fully resemble progesterone. So in some situations, it may act differently to the real hormone.
The estrogen found in the combined pill increases the production of SHBG in the liver. More SHBG in the body means it can bind to active testosterone. As a result, decreasing testosterone levels which may improve PCOS hirsutism.
Progestin may also help lower testosterone levels. This is because progestin acts like natural progesterone found in the body. Progesterone is known to have anti-androgenic properties which means it can block testosterone.
Eflornithine (Topical Cream)
Eflornithine works by blocking an enzyme found in hair follicles called ornithine decarboxylase. The cream is applied to the areas of the skin that are affected to block the enzyme and stop the growth of hair. Eflornithine takes two to three months of regular use to notice an improvement. It must also be used indefinitely to maintain the beneficial effects. Side effects can include burning of the skin and acne.
Anti-androgens block the androgen receptor where testosterone binds and causes male features. Doctors may recommend these anti-androgens to PCOS women.
Spironolactone has been shown to block the effects of male hormones.
PCOS women who took spironolactone at a dose of 200 mg/day noticed a clear reduction in the diameter and rate of facial hair growth within two months.
Despite this evidence, Dr. Lara Briden, a naturopathic doctor, says spironolactone may not be a safe drug for PCOS. She says it can disrupt ovulation and causes an imbalance in estrogen. But can also hinder the functioning of the adrenal glands.
A study found PCOS women who took flutamide at a dose of 250mg experienced an improvement in their hirsutism after only 3 months. However, doctors don’t often recommend flutamide. This is because it has been linked to causing liver toxicity.
Cyproterone acetate is a strong progestin. As discussed, progestin acts like natural progesterone found in the body. A study found because of this it can lower testosterone levels.
Despite the potential benefits of cyproterone acetate, studies say it may cause liver damage. Therefore, it may not be the safest option.
5 alpha-reductase enzyme inhibitors
Finasteride prevents testosterone from being converted to more active male hormones. A study found PCOS women taking 5mg a day finasteride noticed a reduction in their hirsutism. But, studies have found they can cause breast cancer and infertility.
As you can see these drugs are effective in reducing hirsutism, but there are side effects to taking them. If you would like more information about them, visit your doctor. Now, having said that there are natural ways to treat PCOS hirsutism and lower male hormones.
PCOS Hirsutism Natural Treatment
The right treatment approach for you will be dependent on the root cause of your PCOS. So, treatment will vary based on whether your PCOS is caused by high insulin levels, chronic stress or inflammation. To find out what the root cause of your PCOS may be, check out my 'Types of PCOS: Ultimate Guide'.
Lower Insulin Levels to Decrease Male Hormones
If you suffer from high insulin levels, you must work on lowering them. Here are some of the ways you can do it
Combine carbohydrates with protein and fat
Avoid eating a high carb meal. Instead prepare balanced meals that contain all three macronutrients, protein, carbs and fat.
By combining carbs with protein and fat, spikes in insulin are reduced.
A study found eating fibre can lower blood sugar levels. This is because it slows down digestion and the release of sugar. High fiber foods include vegetables, fruits, oats, beans and legumes.
As well as the above diet tips, lifestyle changes can also help lower insulin levels. They include exercise and intermittent fasting.
Exercise for Insulin Resistance
While all forms of exercise can help treat insulin resistance. But researchers have found these two forms of exercises to be best.
Resistance training is any type of exercise that causes the muscles to contract. Resulting in increased strength, muscle mass and endurance.
Results from a study show each 10% increase in muscle was associated with an 11% relative reduction in insulin resistance. So, the more muscle you have, the better insulin works in the body.
HIIT Helps Insulin Resistance
HIIT is a vigorous form of exercise. It involves short bursts of energy followed by less intense recovery periods.
HIIT is a great way to increase insulin sensitivity. This is because during the intense intervals, your muscles use lots of glucose. During the recovery period, insulin is activated. As a result, allowing more glucose to enter the muscles to be used as energy.
Intermittent Fasting Reduces Insulin Levels
Intermittent fasting is a way to schedule you’re eating. It involves not eating for an extended period and then eating all your food in a short and specific time window. Research has found it to be one of the quickest ways to lower insulin levels.
Check out my post ‘Intermittent Fasting for PCOS: Is it Healthy?’ for more information.
Lower Stress Levels to Decrease Male Hormones
Managing your stress is key for hormonal balance. It is especially important if your hirsutism is caused by adrenal androgen excess. So, make it a priority to find ways to lower your stress levels.
Avoid intensity and endurance workouts
Intense and endurance workouts increase cortisol levels. So, instead, opt for low-intensity exercises like walking, swimming and yoga. Low-intensity exercises do not significantly increase cortisol.
Caffeine activates the stress response and causes the adrenal glands to release cortisol. So, to lower cortisol levels you may have to avoid or cut back on your caffeine intake.
For more information on caffeine for PCOS and which coffee I drink to manage the release of cortisol. Check out my ‘Caffeine and PCOS: Should You Avoid It?’ post.
Many people, unfortunately, do not prioritize sleep. But research shows a lack of sleep can increase cortisol levels.
So, start focusing on sleep. Create a bedtime routine that will allow you to get good quality sleep. Aim to go to bed between 9-11 pm and strive for 7-8 hours of sleep. To help you do this, avoid all blue light. This means no looking at your mobile phone or any other screen at least 1 hour before bed. Going for a long walk can also help your body relax.
Adaptogens are plant-based supplements that regulate the release of cortisol. As a result, preventing the HPA axis from being constantly activated. This then protects the body from adrenal fatigue and the depletion of nutrients. Popular adaptogenic herbs include Ashwagandha and Rhodiola.
Lower Inflammation Levels to Decrease Male Hormones
Inflammation is a huge driver of PCOS. So, below are some diet and lifestyle tips that can help lower the level of inflammation in the body.
Avoid Inflammatory Foods
Inflammatory foods are those that cause inflammation in the body. They include sugar, seed oils, gluten and A1 casein (found in dairy). You must also eat plenty of anti-inflammatory foods like salmon and turmeric.
A study found that the risk of high inflammation was 63% lower in the group which followed a high fiber diet.
Aim to eat 25g of fibre a day. Fibre-rich foods include fruits, vegetables, seeds, oats, beans.
Exercise is important for our health, so I not saying you avoid exercise entirely. But I suggest you avoid over exercising. This is because when we exercise, we experience acute inflammation. This type of inflammation is short term. But this acute inflammation can become chronic if the body isn’t given time to rest. So, scheduling rest days is so vital for your health and hormones.
Is Your Hirsutism Caused By PCOS?
PCOS hirsutism is the result of excess male hormones like testosterone. This may be due to high insulin levels, chronic stress or inflammation.
But hirsutism can also be a result of non-classical adrenal hyperplasia (NCAH) and idiopathic hirsutism.
Get to the Root Cause of your PCOS
Doctors often prescribe medications like the birth control pill and spironolactone. While they can be effective in treating PCOS hirsutism they have side effects.
Depending on what is causing the high male hormones, making dietary and lifestyle changes may help stop hirsutism.
If your root cause is insulin resistance, balancing blood sugar levels is key. You can achieve this by combining carbs with protein and fat. Eating more fibre and avoiding all forms of sugar, including artificial sweeteners. As well as by doing more resistance and HIIT exercise.
PCOS caused by high cortisol levels will require a focus on lowering stress levels. This includes avoiding intense and endurance workouts, avoiding caffeine and getting enough sleep. Include long walks in nature, yoga or meditation into your daily routine.
PCOS women suffering from inflammation must work on lowering inflammation in the body. You can do this by avoiding inflammatory foods, eating more fibre and not over-exercising.
Reversing PCOS hirsutism takes time, so you must be patient. But if you are consistent you will see results.
Hey there! I am Despina Pavlou, founder of PCOS Oracle and online coach. I want to share with you the diet and lifestyle changes I made to naturally reverse my PCOS and achieve hormonal balance. I believe using my holistic approach you too can take back control from PCOS.