Figure 2. Evaluation and Treatment of Hirsutism in
Premenopausal Women
Initial evaluation of complaint of hirsutism
Normal
variant
Abnormal hirsutism score or local
sexual hair growth with clinical
evidence of hyperandrogenic endocrine
disorder*
Local hair growth,
isolated
Drug or
medicine use
Trial of dermatologic
therapy
Total testosterone
blood level by
specialty assay
Course
stable or
improving
Hair growth
progresses
Discontinue
if possible
Testosterone
normal
Testosterone
elevated
Hirsutism moderate-severe
and/or other clinical evidence
of hyperandrogenic endocrine
disorder*
Free testoserone blood
level (calculated from total
testosterone and sex hormone-
binding globulin [SHBG] or
equilibrium dialysis)
Free testosterone
normal
Free testosterone
elevated
Re-evaluate if
hirsutism progresses
Trial of dermatologic
or oral contraceptive
(OC) therapy
Course
stable or
improving
Hair growth
progresses
Idiopathic
hirsutism
Hirsutism mild
and isolated
Androgen
excess
laboratory
work-up*
Hyperandrogenemia
* Major hyperandrogenic endocrine disorders
to consider:
• Polycystic ovary syndrome
• Nonclassic congenital adrenal hyperplasia
• Cushing's syndrome
• Virilizing tumor
• Hyperprolactinemia
