D rAseem Sharma, Chief Dermatologist, Skin Saga Centre of Dermatology, shares his approach to patients with excessive hair growth or thinning of hair due to PCOS, in conversation with Shriyal Sethumadhavan.

Why does PCOS lead to excessive hair growth?

Especially in women, hair on the face is driven by something known as androgens, which are basically male hormones. In PCOS, you have a large amount of the male androgen floating in female bodies or in the female blood. And high level of androgens tends to trigger the hair follicles to increase in size. This is different from the regular fine hair, which is know as peach fuzz. These are actually thick, black terminal hair that grow on areas such as the upper lip, in the sideburns, and they also occur on the chest and back, which are normally male hairy areas. Hence, the level of the circulating androgens in the body is high, which leads to an increase trigger to the hair follicles to grow.

Has there been an increase in the number of patients approaching dermatologists for treatments related to excessive hair growth due to PCOS?

Laser hair reduction is one of the prime focuses in most aesthetic practices, especially in metropolitan cities; a lot of queries come in for the same. In the case of body hair, unless somebody has severe PCOS, we go ahead with laser hair reduction without any tests. But nowadays, in my practice, I experience a lot of patients coming in with Hirsutism or increased hair growth on the face, and the androgen dependent areas in women. My approach is a blood test, an ultrasound and a clinical assessment to rule out PCOS before we start laser hair reduction for the face. If this is not done, and somebody does have PCOS, you remove all the hair and it might come back again in a matter of years. Hence, pre-empting it is more important. But yes, I am seeing a lot of it in my practice now.

How do you approach your patients for PCOS right from the time they step into your clinic with the first appointment?

When a patient comes down for increased facial hair, what we essentially first do, which is part of my clinical assessment as well is to look for other signs of hyperandrogenism. Women can have adult acne, which is acne on the lower 1/3rd of the lower half of the face. Acne which is worsening during the menstrual cycle – could be premenstrual or even post menstrual in some people. Then we look for any thinning of the hair, which is female pattern hair loss, because that also constitutes to be a part of the hyperandrogenism gambit. We also look for any recent increase in weight gain, especially stubborn weight. And lastly, we look for any changes in the menstrual cycle. If the patient has always had regular periods, but suddenly have an irregularity in their menses, that again points towards hyperandrogenism or even PCOS.

Once I have the clinical assessment in place, I run a series of blood tests that include the sexual hormones, the adrenal hormones and the pituitary hormones. These are a few tests we run if I feel that there is a correlation with PCOS. If required, I get a pelvic ultrasound done to see how the ovaries are. Once the assessment is done, even if I find that the results are normal, it is not confirmatory of somebody not having PCOS underlying or not having an underlying hyperandrogenism.

Based on my clinical assessment, I usually have the patient started on an anti-androgen that could be a combined oral contraceptive pill, a simple anti androgen, or it could be a receptor blocker. We then proceed to do the procedures and apart from laser hair reduction, if the hair is sparse – about 10 or 12 hair on the face – then we can also go in for radiofrequency electrolysis. These are the two approaches that I commonly use in my practice.

Additionally, there is another topical called eflornithine. It’s a cream that only helps in slowing down the rate of hair growth. For patients who do not want to get laser hair reduction done early on, or want a solution that will help slow down the process, I do prescribe the cream. But you do need to do procedures along with the cream, and that is how the cream is also formulated.

How about post treatment care?

When I am treating cases of hirsutism with PCOS, like with underlying PCOS, a ballpark of 60 to 70 per cent women with PCOS have hirsutism. While treating such patients, I give them a lifetime validity in terms of packages. This is because sometimes the hair goes off in six sessions, sometimes it takes about eight sessions, and women take about 10 sessions to clear up completely. But you always keep them on a follow-up for at least five years post that to keep a check on any other hair symptoms or if the hair growth is coming back. Having said that, the follow up for anybody coming to my clinic with hirsutism with diagnosed PCOS is at least five years.

Any message that you would like to share on a concluding note.

We try to label patients with PCOS. It is a syndrome, which has to check a few boxes. Even on clinical assessment, if you find that the symptomatology is quite strong and there is a lot of clinical hyperandrogenism, you should go ahead and start treating patients. More often than not, as dermatologists, we are the first-hand responders for PCOS because women come to us at an early stage in life with acne and hirsutism. If you miss PCOS at that time, maybe later on in life, they would find it difficult to conceive because one of the commonest causes of infertility nowadays is PCOS. As dermatologists, it is our responsibility to clinically evaluate, to evaluate biochemically, radiographically and then take a decision on whether or not to refer out to a gynaecologist or an endocrinologist if some of us are not comfortable with the hormonal medications and the assessment. We are probably first responders so we should take that job very, very seriously.