Hirsutism in women is often difficult to judge because there are major ethnic and racial variations. Women from Scandinavia and Asia are much less likely to have hirsutism than women from the Mediterranean regions.

Androgen excess and drug-induced hirsutism must be ruled out. Tests for dehydroepiandrosterone sulfate, testosterone, follicle-stimulating hormone/luteinizing hormone ratio, and prolactin help rule out endocrinologic causes. Androstenedione, cortisol, sex hormone-binding proteins, and 17-hydroxyprogesterone levels may also be obtained, depending on clinical suspicion.

Among the diseases one needs to rule out in hirsutism are polycystic ovarian disease, adrenal hyperplasia, Cushing's syndrome, adrenal tumors, ovarian tumors, pituitary tumors, and hypothyroidism. Both hypothyroidism and obesity can reduce sex hormone-binding globulin, thus causing an increase in free testosterone and hirsutism. A first-line test to diagnose polycystic ovarian disease is a serum testosterone level.

Most women with hirsutism have no hormonal abnormalities, or only minor ones, and are placed in the familial or idiopathic group. As hormonal assays become more sophisticated, it is being appreciated that many patients in this group have subtle androgen "abnormalities." One should not let a familial history of hirsutism lull one into thinking a patient has "familial hirsutism." The congenital adrenal hyperplasias (21-hydroxylase defect and 11-hydroxylase defect) are inherited.

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