Hirsutism is characterized by excessive androgen-dependent hair growth in women, assessed using the Ferriman-Gallwey scoring system. This scoring evaluates hair distribution in nine areas, with scores indicating severity, and it helps in monitoring treatment response. Testosterone and its conversion to dihydrotestosterone plays a critical role in stimulating hair growth, while a minimum of 6-9 months is required to assess medication efficacy.

1. Hirsutism Scoring
Elvina sibi
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2. • Hirsutism is defined as excessive growth of androgen dependent
sexual hair (terminal hair) in facial and central part of the body that
worries the patient.
• The clinical assessment of hirsutism is very subjective To reduce this
subjectivity , clinical evaluation should be by a visualised scoring
system like Ferriman-Gallwey scoring system.

4. Normal hair growth pattern
• Three phases- anagen( growing phase ,85-90%)
- catagen( rapid involution)
- telogen( quiescent phase )
• The therapeutic modalities which either stimulate or decrease the
hair growth primarily act on anagen phase.
• A minimum of 6-9 months time is required to asses the efficacy of any
medication.

5. Sex hormones and hair growth
• 2 Types of hair * Non sexual hair, independent of hormone influence
(eyebrow, eyelashes , forearm and lower leg)
* Sexual hair, these are under the influence of
hormones that convert one type of hair to another
effects of various hormones include
i. Androgen initiate growth, increases pigmentation and diameter of keratin column
(except on scalp).
ii. Oestrogen retards the growth and produces finer less pigmented hair.
iii. Progestin has indirect effect by altering the available androgen to the hair follicle.

6. Mechanism of excessive hair growth
• The pilosebaceous unit consists of sebaceous gland and hair follicles.
Both are sensitive to androgens but sebaceous glands are more
sensitive.
• The stimulus for excessive hair growth is testosterone. Testosterone
binds to androgen receptors in the hair follicle .This is followed by
activation of the enzyme 5-α reductase.
• This will convert testosterone to most potent androgen –
dihydrotestosterone(DHT) and androstenediol which stimulate
proliferation of terminal hair ( anagen phase)

7. • Once the black terminal hair is produced , the changes persist even in
the absence of a continuing androgen excess.
• Increased hair follicle stimulation and increased 5-αreductase activity
enable prohormones DHEA and androstenedione to be metabolized
directly to DHT.
• This later phenomenon explains continued growth even if the
initiating testosterone source has been removed.

8. Physical examination
• Before scoring and assessment of hirsutism it is important to ask the
woman when she last removed the hair
• Documentation of the severity is mandatory( The modified ferriman-
gallwey scoring system is generally used)
• This scoring system quantitates the hair growth in 9 androgen
sensitive areas each area gives scores from 0 to 4 , adding upto a
total score of 36.
• 0 – no terminal hair visible, 4-terminal hair consistent with a well
developed male
• A score 8 or more is considered as hirsutism.

9. • Hirsutism is graded as mild ( score 8-15),moderate ( score 16-25) and
severe ( score >25)
• Scoring also helps in assessment of response to therapy.
• A cut off of 4-6 has been suggested based on ethinicity
• Usually in india , a cuttoff of 6 is taken

10. Ferriman-Gallwey (1961) Scoring system
• Abnormal hair distribution is assed in eleven body areas and is
scored from 1 to 4.
site Grade Definition
Upper lip 1
2
3
4
• Few hairs at outer margin
• Small moustache at outer margin
• Moustache extending halfway from outer
margin
• Moustache extending to midline
Chin 1
2
3,4
• Few scattered hair
• Scattered hairs with small concentrations
• Complete cover , light and heavy

11. Chest 1
2
3
4
• Circumareolar hair
• With midline hair in addition
• Fusion with these areas , with 75% cover
• Complete cover
Upper back 1
2
3,4
• Few scattered hair
• Rather more ,still scattered
• Complete cover , light and heavy
Lower back 1
2
3
4
• Sacral tuft of hair
• With some lateral extension
• 75% cover
• Complete cover
Upper
abdomen
1
2
3,4
• Few midline hairs
• Rather more still midline
• Half- and full cover

12. Lower
abdomen
1
2
3
4
• Few midline hairs
• Midline streak of hair
• Midline band of hair
• Inverted v shaped growth
Arm 1
2
3,4
• Sparse growth affecting not more than 25% of limb
surface
• More than this cover still incomplete
• Complete cover light and heavy
Forearm 1-4 Complete cover of dorsal surface, two grades of light and
two grades of heavy growth.
Thigh 1-4 As for arm
Leg 1-4 As for arm

14. Reference
• Dc dutta’s textbook of gynecology 8th edition
• Paediatric and adolescent gynecology , neera Agarwal, amita suneja
• Essentials of gynecology , lekshmi Seshadri ,third edition

15. Thank you