What initial assessments should I perform to evaluate a woman presenting with hirsutism?

Initial assessments for a woman presenting with hirsutism should include:

• Clinical history and physical examination: Assess the severity of hair growth using the woman's own perception and, if possible, the modified Ferriman-Gallwey score to quantify hair growth severity. Note any rapid onset or progression of hair growth and signs of virilisation such as voice deepening, increased muscle bulk, or clitoromegaly, which may indicate an androgen-secreting tumour. Also, check for pelvic or abdominal masses.
• Biochemical tests: Measure serum total testosterone levels. A testosterone level above 4 nanomol/L warrants consideration for referral, with urgent referral if levels exceed 6–7 nanomol/L or if an androgen-secreting tumour is suspected. Measure 17-hydroxyprogesterone levels to exclude non-classical congenital adrenal hyperplasia if elevated above 6 nanomol/L.
• Assess impact on quality of life: Evaluate how hirsutism affects the woman's psychological and social well-being to guide management decisions.
• Exclude other endocrine disorders: Consider further investigations if clinical suspicion arises for conditions such as Cushing syndrome or adrenal hyperplasia.

Urgent referral to endocrinology is indicated if there are features suggestive of an androgen-secreting tumour or markedly elevated testosterone levels. Otherwise, initial assessment and management can be performed in primary care with appropriate advice and treatment options discussed.

These assessments align with expert opinion and guidelines from the Royal College of Obstetricians and Gynaecologists, Primary Care Dermatology Society, Endocrine Society, and Canadian guidelines on hirsutism evaluation and management ¹.