Why does hirsutism sometimes begin later in life?

    Dear Dr. Redmond: Some of my electrolysis clients are in their 60s and 70s and they often ask why their hair growth increases at this late age. Most of my other clients had their problem begin at a much earlier age. Why does hirsutism sometimes begin later in life?

    I TOO, SEE WOMEN patients who had no particular problem with facial or body hair before menopause, who start to have increased hair growth later in life. Some wonder if they are imagining it, but the fact is, hirsutism does sometimes begin at 50 or later. While an increase in hair may not be as disturbing to a mature woman as it is to a teenager or young adult, it is still bothersome. The cause of this problem is not very well understood but it is possible to shed some light on it.

    Levels of testosterone and other androgens are usually very low after menopause. Some have the idea that testosterone goes up after menopause but this is rare. The appearance of hair in the 50s and after, is not usually associated with high androgen levels. Androgens are made in the ovary, which becomes inactive at menopause, and in the adrenal which remains active but seems to make less androgen after menopause. A few women have a condition in which there is an increase in the cells in the middle of the ovary which normally make testosterone. This is known as ovarian hyperthecosis. Testosterone levels can be very high in this condition.

    There are other conditions, including androgen-producing tumors, that can occur after menopause as well as before. Fortunately these conditions are quite rare. If, at an earlier age, a woman notices a sudden onset and rapid progression of hirsutism, she should have an evaluation by an endocrinologist.

    For the far greater number of post-menopausal women whose increase in hair is mild, testosterone levels are very low — much lower than they were before menopause. Hirsutism starting at this age seems to be different. While the hairs may be longer and thicker than before, they are usually soft and light rather than dark and bristle-like. Their quality is colloquially known as “peach fuzz.” There may be a few darker hairs on the chin, but dense hirsutism generally does not begin after menopause — and should prompt a work-up when it does for the reasons referred to above.

    Why, then, do some women experience more hair growth at this point in their life? The fall in estrogen levels does not play a clear role in hirsutism prior to menopause. Some have the impression that estrogen should help hirsutism, because it counteracts testosterone. However this is not exactly correct. While estrogens and androgens do have opposite effects on the levels of certain proteins in the blood, they do not oppose each other in their effects on physical characteristics such as body hair or breast development. Indeed, men can have breast development if their estrogen levels go up despite normal male testosterone levels. A little lump of breast tissue is quite common in normal men, but a larger amount is a condition called gynecomastia.

    Testosterone does counteract estrogen in its effect on sex hormone binding globulin (SHBG). This is a protein made in the liver which binds testosterone in the blood and keeps it from going out into the tissues. When SHBG is low, free testosterone (the form that can go into tissue) goes up. It had been theorized that the lack of estrogen after menopause caused free testosterone to go up. But when it became possible to measure free testosterone, it was apparent that free testosterone levels usually go down after menopause.

    Lack of estrogen, then, does not have a clear role in post-menopausal hirsutism. And in other situations in which women have low estrogen levels, increase in facial or body hair does not usually occur. Some women seem to notice an increase in hair growth with estrogen replacement (the increase is usually mild and of the “peach fuzz” type mentioned above) but the reason for this is unknown.

    Estrogen lengthens the hair growth cycle on the scalp, which is why many women notice their scalp hair is thicker during pregnancy. It is possible that estrogen replacement can lengthen the hair cycle on the face, so that each hair grows somewhat longer before it falls out. I must stress, however, that only a very few women notice more facial hair with estrogen replacement and the change, when it occurs, is usually very mild. It does not need to be a worry for women starting on hormone replacement.

    For most women with an increase in facial or body hair after menopause, there is no clear hormonal change which can be implicated as the cause. It has to be admitted, though, that we have only an incomplete knowledge of what regulates hair growth. We know androgens increase it on certain areas, but there must be other factors. Growth of scalp hair, eyebrows and eyelashes is stimulated by other factors. Hair on the forearms, lower legs and trunk seems to be regulated in part by androgens and in part by other factors not yet recognized.

    Perhaps when facial hair increases in the 50s or later, there is a different hormone involved.

    When hirsutism appears or increases at this age, it is useful to measure the main androgens, free testosterone and DHEA-S, to be sure there is no ovarian and adrenal problem, but this is not usually necessary when the increase in hair is very mild. If androgens are in the premenopausal mid-range or higher, treatment with anti-androgens is reasonable after work-up has been completed. Spironolactone (Aldactone®) can be used, but there is more concern about dizziness due to mild dehydration in this age group. Finasteride (Proscar®, also available as Propecia®) probably has fewer side effects; the major safety issue here — possible harm to a fetus — obviously is not a concern for women who are definitely menopausal. Neither is officially labeled for treatment of hirsutism, but there is some literature and clinical experience to support their use.

    Considering how mild most post-menopausal hirsutism is, electrolysis is probably the best option for most affected women. Very fine hairs can be bleached, or removed with a depilatory. It is unusual for this sort of hair to grow back in quickly.

    It is important to reassure women who have an unexpected increase in hair in their 50s or later, that it does not represent loss of femininity. It is often a relief for them to realize that it is normal for women to have some facial and body hair. A woman who never had to be concerned about hair growth earlier in her life may not realize this. With advances in hormone replacement for menopause and other improvements in women’s health, women in their 50s or beyond need not feel that their active participation in life is over, as some did in earlier generations.

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