Abstract
We were pleased to read the article of Chin et al. entitled “Prevalence of Hirsutism Among Reproductive-Aged African American Women,” published recently in the Journal of Women's Health. 1
The article addresses a relevant topic, the prevalence of hirsutism in African American women. It also brings interesting connections with other clinical manifestations of hyperandrogenism, such as alopecia and acne. Although very relevant and attending one of the highlights of the Androgen Excess Polycystic Ovary Syndrome SocietyTaskforce (AE-PCOS), we would like to highlight some points of this study, as is shown below: The prevalence of hirsutism was obtained from a cohort of women with uterine fibroids (the study of environment, lifestyle, and fibroids). We look at these data with attention since there is evidence from the literature linking an inversion chance of uterine fibroids in PCOS.
2
Although no consensus about this relationship exists, the study of Huang et al. suggests that insulin resistance, present in almost half of PCOS women, may be protective against the development of fibroids in PCOS.
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Since hyperandrogenism is a hallmark of PCOS (∼75%–85% of PCOS women are hirsute), and this cohort may have fewer PCOS patients, we can speculate whether the real prevalence of hirsutism would be underestimated. Indeed, the number of women who presented with PCOS using the Rotterdam Consensus criteria in the study was 5.2% of the studied population (82 in 1556 individuals), inferior to 8% of the study of Azziz et al.
4
The definition of hirsutism was based on the self-reported modified Ferriman–Gallwey (mFG) and not the mFG established by trained investigators. From our point of view, these tools are not equivalents, and the self-reported mFG questionnaire should be previously validated and compared with clinician mFG. Furthermore, self-reported mFG tends to overestimate real mFG. For example, in the study of Pasch et al., the mean difference (standard deviation) between patient self-assessment mFG score and investigator mFG score was so high as 4.66 points.
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So, as a consequence, the prevalence of hirsutism based just on the self-score criteria among African American women in this study may be falsely increased. The use of self-score questionnaire is useful, but they may create some particular caveats. According to the study, 463 women (29.75% of the total number of enrolled participants) reporting an mFG of “zero” complained about excessive hair growth. Future investigations would help to comprehend how the self-perception of hirsutism is affected in this group of women. We understand the several difficulties of accessing hirsutism during premenopausal years. However, it appears that a suspension of oral contraceptive treatments as long as one month, as it was proposed in the study, may not be enough to modify the whole pattern of hair growth.
Finally, we congratulate the authors for this excellent and important study that probably will base other similar studies in the future.