Hirsutism and Ferriman-Gallwey Score
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Direct answer
Hirsutism is excessive growth of coarse terminal hair in a male pattern in women, and the Ferriman-Gallwey score grades it across nine body areas. Each area is scored from 0 to 4, giving a maximum total of 36, and polycystic ovary syndrome is the commonest cause. Evaluation starts with the score, the menstrual and drug history, and then targeted hormone tests.
What you must remember
- Scoring: the modified Ferriman-Gallwey score grades nine areas from the upper lip to the thighs, each from 0 to 4.
- Threshold: a total around 8 is widely used for significant hirsutism, though some Asian populations are assessed with lower cut-offs.
- PCOS: the commonest cause, usually with menstrual irregularity, anovulation and sometimes insulin resistance.
- Idiopathic hirsutism: normal androgen levels and regular cycles, reflecting increased sensitivity of hair follicles to normal androgen.
- Late-onset CAH: 21-hydroxylase deficiency, excluded by measuring 17-hydroxyprogesterone in the early follicular phase.
- Drugs: anabolic steroids, testosterone and danazol are androgenic and reversible causes.
- Red flags: rapid onset, deepening voice or clitoromegaly suggest an androgen-secreting ovarian or adrenal tumour.
- Treatment: combined oral contraceptive pills first, then antiandrogens such as spironolactone or cyproterone acetate where available.
A stepwise evaluation from score to treatment
The approach separates benign hirsutism from endocrine disease, because the urgency and treatment differ. Each step narrows the diagnosis before hormone tests are interpreted.
- Score the hair: record the Ferriman-Gallwey score, with photographs if helpful, to measure severity and track response.
- Check the cycle: menstrual irregularity, infertility or obesity point to PCOS, while acute onset points to a tumour.
- Review drugs: androgenic medicines and anabolic steroids are a common and reversible cause.
- Measure androgens: total and free testosterone and DHEAS are checked, with 17-hydroxyprogesterone in the early follicular phase to exclude late-onset CAH.
- Exclude other causes: prolactin and TSH are checked, and pelvic ultrasound supports the diagnosis of PCOS.
- Start treatment: combined oral contraceptives come first, then an antiandrogen, with topical eflornithine or laser for cosmetic hair removal.
Metformin improves insulin resistance in PCOS but has a limited direct effect on hair growth. It is therefore an adjunct for metabolic features rather than a primary hirsutism treatment.
Where the exam tries to catch you
Stems on hirsutism test whether you separate PCOS from rarer and dangerous causes, and whether you protect a woman who might become pregnant.
- Trap: assuming every hirsute woman has high androgen levels. Correct: idiopathic hirsutism occurs with normal androgen levels, because the follicles are more sensitive to androgen.
- Trap: measuring 17-hydroxyprogesterone at any time in the cycle. Correct: the test is valid only in the early follicular phase, otherwise results can be falsely raised.
- Trap: prescribing an antiandrogen without contraception in a woman who may conceive. Correct: antiandrogens are contraindicated in pregnancy, so reliable contraception must be ensured.
Frequently asked questions
What Ferriman-Gallwey score indicates significant hirsutism?
A total score around 8 is widely used as the threshold for significant hirsutism in the Ferriman-Gallwey system, though some Asian populations are assessed with lower cut-offs. The score grades nine body areas from 0 to 4, so the maximum total is 36.
Which hormone test excludes late-onset congenital adrenal hyperplasia?
17-hydroxyprogesterone measured in the early follicular phase of the cycle excludes late-onset congenital adrenal hyperplasia in women with hirsutism. A raised value then warrants an ACTH stimulation test to confirm the diagnosis.
Does metformin treat hirsutism in polycystic ovary syndrome?
Metformin improves insulin resistance and the metabolic profile in polycystic ovary syndrome, but its direct effect on hair growth is limited. Hirsutism is usually treated with combined oral contraceptives or an antiandrogen, with metformin reserved for insulin-resistant patients.
Why is a rapid onset of hirsutism concerning?
Rapid onset of hirsutism, especially with a deepening voice or clitoromegaly, suggests an androgen-secreting ovarian or adrenal tumour. Very high testosterone levels with rapid hair growth are an indication for imaging and specialist referral.