In spite of the recent changes in public perception of masculinity and femininity, there is one thing, which has not changed no matter what: it is hardly acceptable for women to have hair on body, and especially on their face. While that this is not biologically accurate – most women do have at least some extra hair somewhere – that did not change the common perception that it should not be visible.
In fact, our society seems to have grown more “trichophobic” - phobic about body hair. Even pubic hair is now often shaved or waxed. This dislike of hair is not confined to women - more and more men are opting to have chest or back hair removed.
Menopause and Unwanted Hair Growth
Unfortunately, unwanted facial hair is very common in menopausal women. As much as 30 percent of women who have passed menopause report that they have unwanted hair on the face. An increase in facial/body hair is called hypertrichosis. When hypertrichosis is seen in areas where visible hair is usually seen in men, it is called hirsutism.
Like in all menopause symptoms, the story of unwanted facial hair during menopausal stage is mostly related to female hormone estrogen, or to be more precise, the relationship between levels of estrogen and testosterone in the body. Estrogen affects every body organ system, including skin. Estrogen receptors appear to be most abundant around the face, genital area lower limbs. That means these areas are most vulnerable to reduced amounts of circulating estrogen. Thus, skin conditions involving these areas, such as unwanted hair, are more common in peri- and post-menopausal women than in their younger counterparts.
When estrogen predominates, a woman’s face typically has vellus hair –fine, short and almost invisible like ‘peach fuzz’. Men, in contrast, have terminal hair, the longer, coarser, darker beard-type hair. The key hormone that controls the type of the hair on your face is dihydrotestosterone (DHT). Higher DHT levels cause your facial hair to convert from vellus to terminal hair production.
During reproductive years, the higher relative levels of estrogen to testosterone usually keep production of DHT low. However, as menopause approaches and estrogen levels drop, there’s an increase of DHT in the hair follicle. It’s at this point many women begin to see frustrating ‘beard-like’ hairs in places they’ve never seen them before—chin, jaw line, cheeks, and even the forehead.
Other Reasons for Hirsutism
While Hirsutism is always due to the excess of testosterone, stimulating the hair follicles, the hormone misbalance might not be related to the natural menopause effect, but other underlying conditions. Some women, for example, have hair follicles which are extremely sensitive to testosterone, and those with more sensitive follicles have more hair. A sudden or large increase in hair requires prompt medical evaluation to check the hormone levels and verify they are not unusually high. If they are, a hormonal disorder is present and more work-up may be needed. If levels are normal, there is usually no hormonal disorder, just a problem with sensitive follicles.
Some medications may induce unwanted hair growth acceleration. For example, using minoxidil (brand name Rogaine) for hair loss may be causing the undesirable side effect – face hair growth. A dozen or so uncommon drugs can cause hypertrichosis, leading to the hair growth on the body as well as the face. A lot of people are taking an OTC supplement called DHEA (dehydroepiandrosterone), a male-type hormone, to give them energy. This can cause facial hair, as can prescription strength androgens (male hormones) like testosterone.
Ethnicity and Facial or Body Hair
Asians, both men and women, have relatively little body hair. However, many women in Japan find even slight extra hair growth disturbing. Sometimes it is assumed that women from Mediterranean countries (Italy, Greece, etc.) will not be bothered by extra hair since it is more common in those parts of the world. However in the media there, as everywhere, photographs of women do not show how much facial and body hair they really have. The result is that women with average or slightly more than average amounts of hair think they are abnormal. Sadly, this tends to create a feeling of isolation.
Blacks have fewer hairs than whites but the hair tends to be equally noticeable because it is curly and dark, so the incidence of visible hirsutism is similar in whites and blacks.
African-Americans have another problem when they develop excessive hair. The curliness makes the hairs more likely to become ingrown after they are removed. This can result in a pimple-like breakout termed PFB (pseudofolliculitis barbae). As these lesions heal, they often leave dark patches do not fade completely. Proper treatment of the hirsutism to reduce ingrown hairs is important to maintain smooth skin coloring.
There are basically three approaches: self-removal at home, use of electrolysis or laser.
- Home removal. All sorts of methods are in use, but the most common one, tweezing, is the worst -- because it pulls the hair out by the root, which injures the skin. Done for a long time it can give a bumpy look to the skin over the jaw. Snipping with a scissors is better than plucking though it does not last as long. Bleaches and depilatories are OK too; but with depilatories, be sure not to leave them on longer than the instructions say otherwise there can be considerable irritation. A razor is an effective way to remove hair but many women understandably do not like to use one. Despite widespread belief to the contrary, removing hair by a razor or other means does not make it grow in faster or darker.
- Electrolysis is a well-established method which is permanent. Continuing treatment is often needed for women with substantial hair growth because new follicles become active. To get a good result, electrolysis needs to be done by skilled professional using proper equipment.
- Laser has been heavily promoted. It is said to offer “permanent hair reduction” though how much the hair is actually reduced in the long term is difficult to tell. Current laser technology is not suitable for those with very light or very dark skin. Some get pigmentary changes from it. Long term studies are lacking so that it is hard to tell how happy people will be with the results later on.
Although hirsutism shows on the skin, it is started by hormones in the blood. It is therefore as much an internal as external condition. Treatment directed at the hormonal cause can be quite effective. Most of the prescription medications are FDA approved for other indications but not for hirsutism. They can be prescribed for hirsutism however.
Proper treatment depends on hormone levels. It generally involves two components:
- Lowering the level of free testosterone. Oral contraceptives (OCs) are often used to lower testosterone levels and the indeed can reduce the testosterone amount in half. However the practical effect is minimal. The hair growth rates slow down slightly but not back to the normal. It is recommended to combine oral contraceptives with the next form of medical treatment.
- Blocking the effect of testosterone on the hair follicle. Several medications have this effect. Here are some of the most often used:
- Spironolactone. The medication most commonly used to block testosterone is spironolactone (Aldactone) but it must be used in the proper dose. Originally introduced for treatment of high blood pressure, spironolactone is probably now more often used for hirsutism. Doses for hirsutism are higher than those for high blood pressure. Because it is a diuretic (water pill) spironolactone can cause slight dehydration. Signs of this include mild fatigue and dizziness but this can be almost always be prevented by adequate water intake.
- Finasteride (Proscar and Propecia). Finasteride is sold in different doses under the brand names Proscar and Propecia for prostate enlargement and male pattern baldness respectively. This medication blocks the enzyme 5 alpha-reductase which converts testosterone to its more active form, DHT (dihydrotestosterone). A form of this same enzyme is active in the hair follicle and plays a role in both increased hair and loss of hair from the scalp. Finasteride may not be quite as effective as spironolactone.
- Vaniqa (eflornithine). Vaniqa is a new medication, FDA approved for treatment of facial hair. It is applied twice a day and works by slowing the metabolism of the hair follicle. It does not eliminate the hair but simply slows its growth. By slowing down how quickly it regrows, Vaniqa can decrease how often hair needs to be removed and make a woman more confident that her secret will not be apparent a few hours after removal. It can be combined with other medications.
While the lifestyle changes may not resolve magically the hormone related medical issues, they do help to minimize the negative effects and they do not have any medical complications. It is highly recommended to lower androgen domination by eating a balanced diet rich in quality proteins, complex carbohydrates, and colorful fruits and vegetables. When the body is getting too many refined carbohydrates, such as simple sugars, white bread or pasta, it produces more insulin. And one of the ways the body can respond to high insulin is by increasing androgen production.
Other ways to prevent unwanted hair growth include balancing your hormones, taking a high-quality multivitamin to fill in any nutritional gaps, reducing stress, and keeping your body fat under 30%. Both stress and excess fat can lead to increased androgen production.
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