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Hair Removal
Unwanted hair growth in women — causes, investigation and prescription treatment options including eflornithine (Vaniqa).
Key fact: Unwanted facial and body hair (hirsutism) affects up to 10% of women of reproductive age and is most commonly caused by polycystic ovary syndrome (PCOS). It is not caused by poor hygiene or shaving habits. Eflornithine cream (Vaniqa) is the only prescription medicine licensed in the UK to slow facial hair regrowth in women, and works best when combined with a regular hair removal method.
What Is Hirsutism?
Hirsutism is defined as the excessive growth of coarse, pigmented terminal hair in women in a male-pattern distribution. The areas typically affected include the upper lip, chin, sideburn area, chest, upper and lower abdomen, lower back, inner thighs and buttocks. This pattern of growth is driven by androgens — male sex hormones that all women produce in small amounts, but which in hirsutism are either elevated or act more potently on the hair follicles.
Hirsutism is distinct from the fine, unpigmented hair that covers much of the body (vellus hair), which is normal in both men and women. It is not caused by shaving, waxing or any other hair removal method — a common misconception. Shaving does not make hair grow back thicker or faster; it simply creates a blunt end that feels more coarse as the hair regrows.
The condition carries a significant psychological burden. Many women report reduced self-esteem, embarrassment, avoidance of social situations, and negative impacts on relationships and sexual wellbeing.
Hirsutism vs Hypertrichosis: An Important Distinction
| Feature | Hirsutism | Hypertrichosis |
|---|---|---|
| Who it affects | Women (androgen-driven) | Men and women |
| Distribution | Male-pattern: face, chest, abdomen, back, thighs | Generalised or localised; not pattern-specific |
| Hair type | Coarse, pigmented terminal hair | Vellus or terminal; varies |
| Cause | Excess androgens or increased follicle sensitivity | Congenital conditions, certain medications (ciclosporin, minoxidil, phenytoin), eating disorders |
| Hormonal basis | Yes — investigate androgens | No — androgen levels typically normal |
| Management | Treat underlying cause + hair removal + eflornithine | Address causative medication; hair removal |
Causes and Underlying Conditions
Polycystic ovary syndrome (PCOS)
The single most common cause, accounting for 70–80% of hirsutism cases. PCOS involves elevated LH, relative FSH deficiency, excess androgen production and insulin resistance. Hirsutism is often the presenting symptom alongside irregular periods and difficulty conceiving.
Idiopathic hirsutism
Excess hair growth with normal androgen levels and regular cycles. Attributed to increased sensitivity of hair follicles to circulating androgens, mediated through 5-alpha reductase activity in skin. Accounts for around 10–15% of cases.
Congenital adrenal hyperplasia (CAH)
Non-classical (late-onset) CAH due to 21-hydroxylase deficiency causes excess adrenal androgen production and is an important cause of hirsutism that is frequently overlooked. Diagnosed by elevated 17-hydroxyprogesterone on blood testing.
Cushing’s syndrome
Excess cortisol production (from adrenal adenoma, pituitary adenoma or exogenous corticosteroids) causes hirsutism alongside weight gain, proximal muscle weakness, abdominal striae, and a characteristic fat distribution. Relatively rare but important to exclude.
Androgen-secreting tumours
Rare but important to exclude in cases of rapidly progressive hirsutism or marked virilisation. Ovarian or adrenal tumours can produce very high testosterone levels (>5 nmol/L). Requires urgent investigation and specialist referral.
Medications
Anabolic steroids, systemic corticosteroids, ciclosporin, danazol, valproate and minoxidil can all cause or worsen hair growth. A full medication review is essential. Stopping the causative drug usually leads to gradual improvement.
Diagnosis and Investigation
Hirsutism is assessed clinically using the modified Ferriman-Gallwey (mFG) score, which grades terminal hair growth at nine body sites on a scale of 0–4. A total score above 8 in a UK/European population is generally regarded as hirsutism requiring investigation.
A prescriber will assess the following:
- mFG score — distribution and severity of terminal hair growth
- Menstrual history — regularity, cycle length, dysmenorrhoea
- Onset and rate of progression — gradual onset suggests PCOS or idiopathic; rapid onset raises concern for tumour
- Signs of virilisation: voice deepening, clitoromegaly, male-pattern scalp hair loss, increased muscle bulk
- Signs of Cushing’s: central obesity, striae, easy bruising, proximal weakness
- Medication history
- Family history of PCOS or hirsutism
Blood tests typically requested
| Test | What it assesses |
|---|---|
| Total testosterone | Elevated in PCOS, CAH, and androgen-secreting tumours. >5 nmol/L raises strong concern for tumour. |
| DHEAS (dehydroepiandrosterone sulphate) | Adrenal androgen marker; elevated in adrenal causes of hirsutism |
| 17-hydroxyprogesterone | Screens for non-classical congenital adrenal hyperplasia; taken in follicular phase |
| LH and FSH | LH:FSH ratio >2.5 supports PCOS diagnosis |
| Prolactin | Hyperprolactinaemia can cause menstrual irregularity alongside hirsutism |
| TSH | Thyroid dysfunction can affect hair growth and menstrual regularity |
| Fasting glucose / HbA1c | Insulin resistance screen, particularly relevant in PCOS |
Urgent referral required if testosterone is markedly elevated (>5 nmol/L), if virilisation is present, or if hirsutism has developed rapidly over weeks to months. These features may indicate an androgen-secreting tumour requiring specialist assessment and imaging rather than online prescription treatment.
Hair Removal Methods Compared
Cosmetic hair removal does not treat the underlying hormonal cause of hirsutism but provides immediate and significant improvement in appearance. Methods differ in their duration of effect, cost, suitability for different skin types and practicality.
| Method | How It Works | Duration | Best For | Limitations |
|---|---|---|---|---|
| Shaving | Cuts hair at skin surface | 1–3 days | Legs, underarms; fast and painless | Rapid regrowth; does not reduce hair growth rate |
| Waxing / threading | Removes hair from follicle | 2–6 weeks | Face, eyebrows, body | Painful; risk of folliculitis; temporary |
| Depilatory creams | Chemical dissolution of hair shaft | 1–2 weeks | Body; face (if formulated for facial use) | Skin sensitivity; not suitable for all skin types |
| Laser hair removal | Targets melanin in follicle with laser energy | Long-term reduction; multiple sessions | Dark hair on light skin; face and body | Less effective on light or grey hair; professional treatment required; cost |
| IPL (intense pulsed light) | Broad-spectrum light targets follicle melanin | Long-term reduction; multiple sessions | Body; face; larger treatment areas | Less precise than laser; less effective on dark skin tones |
| Electrolysis | Electrical current destroys individual follicles | Permanent (with sufficient sessions) | Any hair colour or skin type; the only FDA-recognised permanent method | Time-consuming; professional treatment required; cost |
Eflornithine (Vaniqa) — Prescription Treatment for Facial Hair
Eflornithine 11.5% cream (Vaniqa) is the only prescription medicine licensed in the UK specifically to reduce the rate of unwanted facial hair growth in women. It works by inhibiting ornithine decarboxylase, an enzyme essential for hair follicle cell division. By blocking this enzyme, eflornithine slows the rate at which hair follicle cells proliferate, reducing the speed at which hair grows back.
Key facts about eflornithine
- Does not remove existing hair — it must be used alongside a hair removal method of your choice
- Applied twice daily, at least 8 hours apart, to clean dry skin on affected facial areas
- Do not wash the treated area for at least 4 hours after application
- If also removing hair, apply eflornithine at least 5 minutes after the removal procedure
- Improvement typically begins after 8 weeks; maximum benefit at around 24 weeks
- Hair regrowth returns to pre-treatment rate within approximately 8 weeks of stopping
- Suitable for use on the face and adjacent areas under the chin only
- Not recommended during pregnancy; effectiveness in women over 65 has not been studied
Getting the most from eflornithine: Consistency is essential. Women who use eflornithine alongside a regular removal method (such as threading or laser) experience a compounding benefit — slower regrowth means less frequent removal is needed, reducing skin irritation and improving quality of life significantly compared to hair removal alone.
Hormonal Treatments for Hirsutism
Where hirsutism is caused by excess androgens — particularly in PCOS — addressing the underlying hormonal imbalance can reduce hair growth over time. These approaches require prescriber assessment and take 6–12 months to produce noticeable improvement in hair growth.
| Treatment | Mechanism | Evidence |
|---|---|---|
| Combined oral contraceptive pill | Reduces free androgen levels by increasing sex hormone-binding globulin (SHBG); suppresses LH-driven ovarian androgen production | First-line medical treatment for PCOS-related hirsutism; requires 6–12 months for maximum effect on hair growth |
| Spironolactone (off-label) | Anti-androgen; blocks androgen receptors and reduces adrenal androgen production | Effective for moderate-severe hirsutism; used off-label in the UK; contraceptive cover required (teratogenic); specialist prescribing |
| Metformin | Improves insulin sensitivity; reduces LH-driven androgen excess in insulin-resistant PCOS | Modest effect on hirsutism; primarily used for PCOS metabolic management; requires prescriber assessment |
When to Seek Help
Seek a clinical assessment if:
- You have noticeable facial or body hair growth causing distress or affecting your quality of life
- Hair growth has increased noticeably in a short period of time
- You have irregular or absent periods alongside excess hair growth — suggestive of PCOS
- You are struggling with acne and excess hair growth together — both may indicate elevated androgens
- Standard hair removal methods are becoming less effective or causing skin problems
- You are having difficulty conceiving alongside other PCOS symptoms
Seek urgent assessment if hirsutism is rapidly progressive, if you have signs of virilisation (voice deepening, clitoromegaly, male-pattern hair loss), or if blood tests show markedly elevated testosterone. These may indicate an androgen-secreting tumour requiring specialist referral.
Hair Removal Guides
In-depth guides on unwanted hair growth and the prescription treatments available through Access Doctor:
Frequently Asked Questions
What is hirsutism?
Hirsutism is the growth of coarse, pigmented terminal hair in women in a male-pattern distribution — typically affecting the face, chin, chest, abdomen and thighs. It affects up to 10% of women of reproductive age and is most commonly caused by PCOS. It is androgen-driven and should be investigated to identify any underlying hormonal cause.
What causes unwanted facial hair in women?
The most common cause is PCOS (70–80% of cases). Other causes include idiopathic hirsutism (normal androgens with increased follicle sensitivity), congenital adrenal hyperplasia, Cushing’s syndrome, androgen-secreting tumours, and certain medications including anabolic steroids, corticosteroids and minoxidil.
What is eflornithine (Vaniqa) and does it work?
Eflornithine (Vaniqa) is a prescription cream licensed to slow the rate of unwanted facial hair growth in women. It inhibits ornithine decarboxylase, reducing hair follicle cell proliferation. It does not remove existing hair but significantly slows regrowth when used consistently twice daily. Most women see improvement after 8 weeks, with maximum effect at 24 weeks.
What is the difference between hirsutism and hypertrichosis?
Hirsutism is androgen-driven hair growth in women in a male-pattern distribution. Hypertrichosis is generalised excess hair growth not related to androgens, occurring in both sexes. Hypertrichosis may be congenital or caused by certain medications. The distinction matters because hirsutism requires hormonal investigation; hypertrichosis does not.
When does unwanted hair growth need medical investigation?
Investigation is warranted when hirsutism is moderate to severe (mFG score >8), develops rapidly, is accompanied by irregular periods or acne, or is associated with signs of virilisation such as voice deepening or clitoromegaly. Blood tests including testosterone, DHEAS, 17-hydroxyprogesterone and LH/FSH are the standard first-line investigation.
Can I get eflornithine (Vaniqa) online in the UK?
Yes. Access Doctor provides eflornithine (Vaniqa) on prescription following a confidential online consultation with our GPhC-registered pharmacist independent prescribers. No GP appointment required. Discreet next-day delivery.
Prescription Hair Removal Treatment — Online Consultation
Access Doctor provides eflornithine (Vaniqa) cream on prescription for unwanted facial hair. Complete a short online consultation reviewed by our GPhC-registered pharmacist independent prescribers — delivered to your door across the UK in discreet plain packaging.
Find Out About Vaniqa →References
- National Institute for Health and Care Excellence (NICE). Hirsutism: Clinical Knowledge Summary. Updated 2023. cks.nice.org.uk/topics/hirsutism
- NHS. Hirsutism (excessive hair growth in women). NHS.uk, 2023. nhs.uk/conditions/hirsutism
- Martin KA et al. Evaluation and treatment of hirsutism in premenopausal women: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism. 2018;103(4):1233–1257.
- Electronic Medicines Compendium. Vaniqa 11.5% cream: Summary of Product Characteristics. 2024. medicines.org.uk/emc/product/2937
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.
