# Hirsutism > Hirsutism for FMGE Gynaecology: Ferriman-Gallwey scoring, PCOS workup, testosterone DHEAS 17-OHP testing and anti-androgen therapy. - Canonical URL: https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/hirsutism-fmge - Exam / course: FMGE · Subject: Obstetrics and Gynaecology - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Hirsutism", PrepElephant, https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/hirsutism-fmge ## Direct answer Hirsutism is excess terminal hair in a male-pattern distribution (face, chest, abdomen, back, thighs) in women, scored by the modified Ferriman-Gallwey system — nine body areas graded 0-4, with 8 or more conventionally defining hirsutism — and caused in over 80 per cent of Indian clinic practice by polycystic ovary syndrome, followed by idiopathic hirsutism, non-classic congenital adrenal hyperplasia, Cushing syndrome, androgen-secreting tumours, drugs (minoxidil, phenytoin, anabolic steroids) and hyperprolactinaemia. The workup pairs total testosterone, dehydroepiandrosterone sulphate (an adrenal marker), 17-hydroxyprogesterone (screening for 21-hydroxylase deficiency), prolactin, thyroid function and a pelvic ultrasound; testosterone above 150-200 ng/dL or rapid virilisation (clitoromegaly, voice deepening) triggers tumour search. Treatment combines cosmetic measures, combined oral contraceptives as first-line pharmacotherapy, and anti-androgens such as spironolactone 100 mg daily with contraception cover. ## What you must remember - **Ferriman-Gallwey:** nine androgen-sensitive areas (upper lip, chin, chest, upper and lower abdomen, upper and lower back including sacrum, upper arm, thigh) each scored 0-4; a modified total of 8 or more defines hirsutism — the number the exam wants. - **Cause hierarchy:** polycystic ovary syndrome first (with oligo-anovulation, ultrasound morphology, androgen excess), idiopathic hirsutism second (normal androgens, likely increased 5-alpha-reductase skin sensitivity), then non-classic congenital adrenal hyperplasia, Cushing syndrome, hyperprolactinaemia, acromegaly, and tumours. - **Laboratory set:** total testosterone (tumour threshold around 150-200 ng/dL), dehydroepiandrosterone sulphate (adrenal tumour marker above roughly 700 microgram/dL), early-morning 17-hydroxyprogesterone (basal over about 2-4 ng/mL proceeds to ACTH stimulation), prolactin, thyroid-stimulating hormone, and androstenedione where available. - **Red flags for tumour:** rapid onset, progression over months, virilisation (clitoromegaly, deepening voice, male-pattern balding, muscle bulk), testosterone or dehydroepiandrosterone sulphate in tumour range, or postmenopausal onset. - **Pharmacotherapy ladder:** combined oral contraceptive (e.g., ethinylestradiol with drospirenone or cyproterone acetate) as first line — suppresses ovarian androgen and raises sex hormone-binding globulin; add spironolactone 100 mg daily (up to 200 mg) if inadequate after 6 months; alternatives finasteride 5 mg, cyproterone acetate 50-100 mg; flutamide rarely, for hepatotoxicity. - **Mechanism note:** all anti-androgens are teratogenic to a male fetus — mandatory contraception while on them, a standard exam caveat. - **Physical methods:** laser photoepilation and electrolysis give durable reduction and combine well with drugs, since pharmacotherapy takes 6-12 months to show (hair cycle length) and stops working when stopped. - **Metformin treats insulin resistance, not hair:** it improves cycle regularity in polycystic ovary syndrome but is a weak agent for hirsutism itself — a discriminating option in exams. ## Working through the clinic pathway A 24-year-old presents with increasing facial and abdominal hair over three years, irregular cycles every 45-60 days, body mass index 29. Modified Ferriman-Gallwey totals 11. Screening: testosterone 68 ng/dL, dehydroepiandrosterone sulphate 240 microgram/dL, 17-hydroxyprogesterone 1.4 ng/mL (early morning), prolactin and thyroid-stimulating hormone normal; ultrasound shows 12+ follicles per ovary with increased stroma. The picture is polycystic ovary syndrome hirsutism: combined oral contraceptive started (weight-neutral progestin preferred), spironolactone 100 mg daily added at review for insufficient response at six months, with explicit contraception counselling. Laser sessions run alongside; weight loss of 7 kg over the year lowers free androgen further — the only intervention that treats the substrate. The contrast case: a 38-year-old with six months of rapidly thickening hair, frontal balding, deepening voice and clitoromegaly — virilisation. Testosterone is 260 ng/dL, imaging (transvaginal ultrasound, then adrenal computed tomography) hunts the tumour, and surgery, not anti-androgens, is the treatment. The third variant, hirsutism with galactorrhoea, sends you to prolactin and thyroid-stimulating hormone — hypothyroidism raising prolactin is a reversible cause seen in Indian clinics. ## How the exam frames it Three question types recur: the score ("which cut-off on modified Ferriman-Gallwey defines hirsutism" — 8), the hormone map ("which marker suggests an adrenal tumour" — dehydroepiandrosterone sulphate; "which screens congenital adrenal hyperplasia" — 17-hydroxyprogesterone), and the therapy pick (first line combined pill; add-on spironolactone; teratogenicity caveat). Virilisation versus hirsutism is the discriminating concept — hirsutism alone never means tumour, but virilisation demands exclusion — and the idiopathic label (normal androgens, excess hair) is the "most common cause after polycystic ovary syndrome" answer. Time-to-response (6-12 months because of the hair growth cycle) is a favourite "why didn't the drug work in 3 months" stem. ## Frequently asked questions ### What score on the modified Ferriman-Gallwey chart defines hirsutism? A total of 8 or more across nine androgen-dependent body areas, each graded 0 to 4 by hair density and extent. ### Which investigations form the first-line workup of hirsutism? Total testosterone, dehydroepiandrosterone sulphate, early-morning 17-hydroxyprogesterone, prolactin and thyroid-stimulating hormone, with pelvic ultrasound where polycystic ovary syndrome is suspected. ### Which features argue for an androgen-secreting tumour? Rapid onset, progression over months, virilisation (clitoromegaly, deepened voice, temporal balding), testosterone above roughly 150-200 ng/dL or dehydroepiandrosterone sulphate above 700 microgram/dL. ### What is the first-line drug for hirsutism? A combined oral contraceptive, which suppresses ovarian androgen production and increases sex hormone-binding globulin; anti-androgens like spironolactone 100 mg daily are added if response is inadequate. ### Why must contraception accompany anti-androgen therapy? Spironolactone, finasteride, cyproterone and flutamide can feminise a male fetus, so effective contraception is mandatory during therapy.