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ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 477-481

Quality of life in patients having hirsutism


1 Department of Dermatology, Andrology and Venrology, Faculty of Medicine, Menoufia University, Egypt
2 Department of Dermatology, Andrology and Venerolgy, Sadat City University, Menoufia, Egypt

Date of Submission20-Oct-2019
Date of Decision04-Dec-2019
Date of Acceptance07-Dec-2019
Date of Web Publication30-Jun-2021

Correspondence Address:
Sara A El-Sayed
Department of Dermatology, Andrology and Venerolgy, Sadat City University, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_328_19

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  Abstract 


Background
Women with hirsutism have social phobia, insecurity about interpersonal relationships, shattered confidence, and profound psychological sequelae.
Patients and methods
This cross-sectional study was conducted on a sample of 200 female patients aged greater than or equal to 18 years, having hirsutism, with a Ferriman and Gallwey scores (F-G scores) greater than 6, (moderate: F-G score 8–15 and severe: F-G score 16–36), with normal or irregular menstruation, with or without polycystic ovarian disease, and normal/abnormal hormone profiles. Demographic characteristics like name, age, marital status, and address; severity of hirsutism; and F-G scores of hirsutism were recorded.
Results
The study showed that 78.0% of cases had a large effect on QoL (DLQI score was 11–20), 21.5% had a very large effect (DLQI score was 21–30), and only 0.5% had a moderate effect (DLQI score was 6–10). There was no significant difference in DLQI between different F-G scale of hirsutism (P = 0.741). There was a nonsignificant negative correlation between DLQI and F-G scale (P = 0.872) and between BMI and F-G scale (P = 0.747).
Conclusion
Hirsutism had potent effect on the QoL of Egyptian women with marked negative effect on personality, daily activities, and interpersonal relationships.

Keywords: female, Ferriman and Gallwey scores, hirsutism, life, psychological, quality, sequelae


How to cite this article:
Gaber MA, El-Sayed SA. Quality of life in patients having hirsutism. Menoufia Med J 2021;34:477-81

How to cite this URL:
Gaber MA, El-Sayed SA. Quality of life in patients having hirsutism. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:477-81. Available from: http://www.mmj.eg.net/text.asp?2021/34/2/477/319710




  Introduction Top


Hirsutism was derived from a Latin word 'hirsutus,' which meaning hairy, and is considered as the main dermatological complaint, which affects 5–15% of women during middle reproductive age. Hirsutism was characterized by excessive hair growth in female patients with male distribution, and its distribution is mainly on the face, upper arms, chest, abdomen, back, and thighs [1].

The distribution and degree of hair growth is often used to classify hirsutism. Ferriman-Gallwey (F-G) scale is the most widely recognized scoring method, devised in 1961. A score of 1–4 is given for nine androgen-dependent areas of the body. A total score less than 8 is considered normal, a score of 8–15 indicates mild hirsutism, and a score greater than 15 indicates moderate or severe hirsutism. A score of 0 indicates absence of terminal hair [2].

However, hirsutism is idiopathic in most cases and associated with profound stress in affected women owing to cosmetic and psychosexual implications. Hirsute women have social phobia, insecurity about interpersonal relationships, shattered confidence, and profound psychological sequelae [3].

Unwanted hair in females has psychological and social consequences, which affected the life quality of these women together with the amount of time, energy, and money spent on hair removal [4].

The aim of this study was to find the effect of hirsutism on quality of life (QoL).


  Patients and methods Top


This cross-sectional study was conducted on a sample of 200 female patients from April 2019 to October 2019, with age greater than or equal to 18 years, having hirsutism for last 1 year or more, with a F-G scores greater than 6, (moderate: F-G score 8–15, and severe: F-G score 16–36), with normal or irregular menstruation, with or without polycystic ovarian disease and normal/abnormal hormone profiles. After approval of the study by a local Ethical Committee, formal consent was taken from every woman to freely accept to participate in the interview and to fill in the questionnaire; all participants were given assurance of confidentiality.

Exclusion criteria included patients having other dermatoses involving face, for example, melasma, acne, and nevi, and those with hypertrichosis owing to local disease, systemic illness, or drugs.

Demographic characteristics like name, age, marital status, address, and BMI; severity of hirsutism; F-G scores of hirsutism; and dermatology life quality index (DLQI) were recorded.

The DLQI is a dermatological-specific instrument that measures how much the skin problem has affected patients' life over the past week. It consists of 10 items, each with four response categories, ranging from 0 (not at all) to 3 (very much). The DLQI can be calculated as a total score, but it also includes six subscales: symptoms and feelings (possible score range: 0–6), daily activities (possible score range: 0–6), leisure (possible score range: 0–6), work and school (possible score range: 0–3), personal relationship (possible score range: 0–6), and treatment (possible score range: 0–3). To facilitate the clinical interpretation of the DLQI scores, the grading according to Hongbo et al. [5] can be used.

The meaning of the DLQI total scores is as follows: 0–1 = no effect, 2–5 = small effect, 6–10 = moderate effect, 11–20 = large effect, and 21–30 = very large effect.

The F-G scale is a widely used scoring system in determining androgen-dependent hair growth in women. Nine body areas are scored from 0 to 4 (extensive terminal hair growth), and the scores in each area are summed for a total hair growth score. The maximal score is 36, and a total score from 6 to 8 or higher is generally considered to represent hirsutism [6].

The F-G score is categorized based on the following thresholds [7]: F-G score 8–10 (mild hirsutism), F-G score 11–14 (moderate hirsutism), and F-G score greater than or equal to 15 (severe hirsutism).

Statistical analysis

Based on a review of past literature study by Baig et al. [3], regarding QoL in patients of hirsutism, the prevalence of hirsutism patients was 15%. The sample size was calculated at power 80% and confidence interval 95%, and it was 200 participants. Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, interquartile range, and median. The significance of the obtained results was judged at the 5% level. A χ2-test was used for categorical variables, to compare between different groups. Monte Carlo correction for χ2 was used when more than 20% of the cells have expected count less than 5. Kruskal–Wallis test was used for abnormally distributed quantitative variables, to compare between more than two studied groups, and post-hoc (Dunn's multiple comparisons test) test for pairwise comparisons. Spearman coefficient was used to correlate between two distributed abnormally quantitative variables.


  Results Top


Of the total, 52.0% of our cases were aged less than or equal to 30 years, and 65.0% were working. Moreover, 56.0% had university education, 26.5% had average education, and 17.5% only read and write. In addition, 65% were married, 14.5% were still engaged, and 20.5% were single. Regarding income, 71.5% had moderate income, whereas 12.5% had high income, and 16% of them had low income. The mean value of weight in our cases was 78.26 ± 13.58 (ranged 51.0–107.0) kg, height was 162.0 ± 5.85 (ranged 150.0–180.0) cm, and BMI was 29.82 ± 5.32 (ranged 20.69–44.44).

Regarding the DLQI, 39.5% of our cases had a little pain in the past week, 40% had a lot of embarrassment, 40.5% had a lot of difficulties in usual activities, 38% choose clothes very much carefully, 41.5% had a lot of social activities, 34.5% of them had little participation in sports training, and 41.5% were studying or working a lot [Table 1].
Table 1: Distribution of the studied cases according to dermatology life quality index (n=200)

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The mean value of DLQI was 17.73 ± 3.25 (ranged 9.0–25.0). Overall, 78.0% of our cases had a large effect on life of quality, as DLQI score was 11–20; 21.5% had very large effect, as DLQI score was 21–30; and only 0.5% had moderate effect, as DLQI score was 6–10.

The mean value of F-G scale was 17.73 ± 4.865 (ranged 8.0–27.0). Overall, 46.5% of our cases had severe hirsutism, as F-G scale was greater than or equal to 15; 33.5% had mild hirsutism as F-G scale was 8–10; and only 20% had moderate hirsutism, as F-G scale was 11–14.

There was no significant difference in DLQI between different F-G scale of hirsutism, as P was 0.741. In mild cases, 80.6% had large effect on DLQI (11–20) and only 19.4% had very large effect on DLQI (21–30). In moderate cases, 82.5% had a large effect on DLQI (11–20) and only 17.5% had a very large effect on DLQI (21–30). In severe cases, 74.2% had large effect on DLQI (11–20) and only 24.7% had very large effect on DLQI (21–30) [Table 2].
Table 2: Relation between the level of hirsutism and dermatology life quality index categories (n=200)

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Regarding mean DLQI scores of patients with respect to severity of hirsutism using F-G score, there was no significant difference in DLQI mean value between different F-G scales of hirsutism, with P was 0.430, as patients with mild hirsutism had mean value of 29.45 ± 4.93 of DLQI, whereas those with moderate and severe hirsutism had scores of 31.17 ± 6.06 and 29.51 ± 5.22, respectively.

There was a nonsignificant negative correlation between DLQI and F-G scale (r=−0.012 and P = 0.872), and between body mass index and F-G scale (r=−0.023 and P = 0.747).


  Discussion Top


Many questionnaires were available to measure the effect of diseases on the QoL. One of them was DLQI, which was common, valid, and simple and was designed to measure the extent of disability caused by different skin diseases [3],[8].

There are many studies on hirsutism in Egypt, but few of them are concerned on the effect of hirsutism on QoL. So, the aim of this questionnaire-based study was to determine the effect of hirsutism on QoL.

In the current study, 52.0% of our cases were less than or equal to 30 years, and 65.0% were working. Overall, 56.0% had university education, 26.5% had average education, and 17.5% only read and write. Moreover, 65% were married, 14.5% were still engaged, and 20.5% were single. Regarding income, 71.5% had moderate income, whereas 12.5 had high income, and 16% of them had low income. In agreement with our finding, among a total of 100 hirsute women included in the study by Kiran et al. [9], the mean age was 24.41 years. A total of 65 hirsute women were unmarried in our study. Overall, 25% had completed graduation, 74% had studied till primary, and 1% was illiterate. Moreover, 18% belonged to upper class of socioeconomic standard, 50% from the upper middle class and only 16% from both the lower middle and upper lower class. In addition, 23% were housewives and 15% were working women.

In the current study, the mean value of the weight of our cases was 78.26 ± 13.58 (ranged 51.0–107.0) kg, mean height was 162.0 ± 5.85 (ranged 150.0–180.0) cm, and mean BMI was 29.82 ± 5.32 (ranged 20.69–44.44).

This was in line with the study by Baig et al. [3], which reported the mean BMI was 26.09 ± 5.59, and a trend toward obesity was noted.

DLQI scoring system describes the effect on the patient's life. In the current study, regarding the DLQI, 39.5% of our cases had a little pain in the last week, 40% had a lot of embarrassment, 40.5% had a lot of difficulties in usual activities, 38% choose clothes very much carefully, 41.5% had a lot of social activities, 34.5% of them participated little in sports training, and 41.5% were studying or working a lot.

In harmony with our results, in the by Kiran et al. [9], mean DLQI scores showed the highest affection on the daily activity (2.07) followed closely affection of feelings secondary to hirsutism (2.02).

In the current study, the mean value of DLQI was 17.73 ± 3.25 (ranged 9.0–25.0). Overall, 78.0% of our cases had a large effect on life quality, as DLQI score was 11–20, 21.5% had a very large effect, as DLQI score was 21–30, and only 0.5% had a moderate effect as DLQI score was 6–10, which is higher than the scores in the study by Loo et al. [10], where mean DLQI scores were 12.8 ± 8.5.

Our study population had a poorer QoL and hence high DLQI scores probably because of relatively longer duration of hirsutism, lack of awareness of medical causes of hirsutism by both patients and family, difficult and delayed access and referral to concerned medical specialists, lack of treatment facilities in the periphery, problems of affordability of expensive photoepilation procedures, long waiting lists for treatment with laser in the government hospitals and poor compliance of drugs and adjuvant topical therapy owing to a lack of proper counseling, and poor motivation in patients who are uneducated and belong to low socioeconomic status.

In the study by Kiran et al. [9], mean DLQI score of 100 hirsute women was 6.67 ± 4.57. Regarding DLQI of 100 hirsute women, 12% had no effect, 34% had small effect, moderate effect in 37%, had very large effect in 17%, and no patients were extremely affected. Daily activity had highest mean DLQI followed by symptoms and feelings. So, the patient's life was affected moderately on an average owing to the presence of hirsutism.

Mean DLQI of our study was similar to the mean scores of the study by Baig et al. [3] and Loo et al. [10], where it was 17.9 ± 5.71 and 12.8 ± 8.5, respectively. So, on the average, patient's life in our study was moderately affected.

In the current study, the mean value of F-G scale was 17.73 ± 4.865 (ranged 8.0–27.0). Overall, 46.5% of our cases had severe hirsutism as F-G scale greater than or equal to 15, 33.5% had mild hirsutism as F-G scale was 8–10, and only 20% had moderate hirsutism as F-G scale was 11–14. Moreover, in the study by Kiran et al. [9], 38% had severe hirsutism.

In agreement with the current study, Baig et al. [3] found no patient had mild hirsutism (F-G score <8). There were 20 patients who had moderate hirsutism (F-G score 8–15), and the remaining 180 patients had severe hirsutism (F-G score 16–36). None of the patients had mild disease because our population has a trend to present late in disease either owing to lack of awareness, affordability issues, or lack of proper medical personnel access in the periphery.

However, the mean F-G score was 13.57 ± 6.83 in the study by Rahnama et al. [11], which was lower than our results. Thirty nine (40.6%) persons had severe hirsutism in this study, as they conducted their study on different ethnic population.

However, different results were reported by Hodeeb et al. [12], how that among case about two-thirds (63.0%) of females had moderate hirsutism and about one-third (29.0%) had mild hirsutism, and this can be explained by different sample size and different age group in both studies.

Baig et al. [3] reported that as DLQI scores are very close in both groups, these results suggest that QoL of patients was almost equally affected with moderate and severe hirsutism, which means whatever the degree of hirsutism, it is markedly disturbing to patients. This difference is not conclusive as QoL assessment was depends on subjective evaluation, which may increase the bias.

In the current study, regarding mean DLQI scores of patients with respect to severity of hirsutism using F-G score, there was no significant difference in DLQI mean value between different F-G scales of hirsutism, as patients with mild hirsutism had mean value 29.45 ± 4.93 of DLQI, whereas those with moderate and severe hirsutism had scores of 31.17 ± 6.06 and 29.51 ± 5.22, respectively.

Regarding the mean DLQI scores of patients with respect to severity of hirsutism using F-G score, Baig et al. [3] found the patients with moderate hirsutism had a mean DLQI score of 18.20 ± 5.57, whereas the value for severe hirsutism was 17.88 ± 5.74, without significant difference between them, which is consistent with our results.

In this study, there was a nonsignificant negative correlation between DLQI and F-G scale. In line with our results, Drosdzol et al. [13], in their study on hirsutism, found a negative effect of hirsutism on QoL in these patients.

In contrast, a positive significant correlation was reported in the study by Hodeeb et al. [12], where women with severe levels of hirsutism (F-G ≥15) scored significantly higher both on item and dimension levels of DLQI compared with women with mild (F-G = 8–10) levels of hirsutism, indicating that there was a highly significant association between the clinical severity and QoL in hirsute patients.

Moreover, the findings of present study were not in concordance with Zhuang et al. [14], who revealed that there was a significant correlation between the clinical severity of hirsutism and DLQI index. The more severe the degree of disease, the greater the effect on the DLQI scores. To a certain extent, these results revealed that the clinical severity of hirsutism affects the QoL of patients.

Moreover, our findings are not in concordance with Reid et al. [15], who stated that the more severe the form of the disease, the more bothered the patient regarding QoL.

In contrast, Rahnama et al. [11] found there was a significant correlation between DLQI and F-G score in their study. Symptom and feelings and leisure had significant correlation with F-G score.

In all studies with different results than our observation, the significance may be increased owing to a larger number of cases included in their study.

In the current study, there was a nonsignificant negative correlation between BMI and F-G scale. This means not all hirsute patients were overweight. This is in accordance with Reingold and Rosenfield [16], who found the causes of hirsutism among their group of patients was insulin resistance with increased sensitivity to the normal level of sex hormones.

This finding is not consistent with the study by Sotoudeh et al. [17], in which hirsutism scores were higher among overweight and obese women BMI greater than or equal to 25 kg/m2 than normal weight women, as insulin at specific levels activated the insulin-like growth factor 1 receptors in the theca cells which increased androgen production, which is responsible for increases in the prevalence of hirsutism in overweight people, and this may be owing to coincidental metabolic syndrome in their cases, which was not evaluated in our study.


  Conclusion Top


We can conclude that hirsutism had potent effect on the QoL of Egyptian women. Hirsutism has a very large effect on patients' QoL with marked negative effect on personality, daily activities, and interpersonal relationships.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2]


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