PCOS on Skin and Hair: Hirsutism, Acne and Hair Loss

Why I am writing this

Almost every woman who comes to me because of PCOS talks about her menstrual cycle first. She talks about skin and hair later, more quietly, and often only when I ask. Yet that is exactly the part that takes up the most room in daily life. It deserves the same seriousness as a lab value.

You are standing in the bathroom in the morning. The light in there is more honest than you would like.

First the tweezers. Then the parting, which you push apart with two fingers because you want to know whether it has become wider. Then the spot along the jaw that has been sitting under the skin for a week and will not go away.

And then the thought you had actually forbidden yourself: I am not vain. I just do not want to start every morning like this.

Many women know this pattern. And most of them have heard at some point that all of this is only half as bad. Cosmetic. Not dangerous.

Both are true and both fall short. The visible signs themselves are as a rule not threatening, and they are still a burden that can be measured. What sits behind them does deserve a look, because skin and hair also say something about metabolism here. So I am not starting with reassurance, I am starting with what happens inside the follicle. Almost everything follows from that: why more grows below and less above, why a score can miss what you carry, and why six weeks of patience are physiologically too little.

First things first: when this should not wait

The signs described here usually develop slowly, over years. If any of them moves fast, it belongs in a prompt medical workup, because rarely an androgen producing tumour can sit behind it.

Virilisation within months: a clearly deepening voice, rapid gain in muscle mass, enlargement of the clitoris
Suddenly starting, strongly increasing hair growth on the face or trunk within a few months
Bleeding after menopause, very heavy or suddenly changed periods
Acute one sided lower abdominal pain, lower abdominal pain with fever
Headaches or visual disturbances together with milky discharge from the breast
Unintended weight loss without explanation

This is not a reason to panic, it is a question of pace. Slowly grown almost always means hormonal. Quickly grown means: please get examined soon, before anything else is tried.

What awaits you here

Why the same androgens act in opposite ways above and below
What receptor density, 5 alpha reductase and aromatase have to do with it
The Ferriman Gallwey score, where it comes from and where it ends
Why the cutoff of 8 is outdated and 4 to 6 applies today
Female pattern hair loss: pattern, regrowth, an honest timeline
Acne in adults and what about it is really PCOS specific
Acanthosis nigricans as a skin sign of metabolism
Contraceptives, antiandrogens, topical agents, laser and IPL with numbers
The functional route through insulin and SHBG, kept honestly small

RCT / Meta randomised or pooled Human cohort, cross sectional, tissue Guideline consensus with systematic search Cell study cell culture, not in humans Review summarising, without own measurements

Why skin and hair of all things weigh so heavily

An irregular menstrual cycle can be hidden. A lab value sits on a sheet of paper. Skin and hair sit in your face.

That is the whole difference. And it can be measured.

Cross sectional, questionnaire, n=88 104 minutes per week

A team around Lipton surveyed 88 women with suspected PCOS using standardised questionnaires, at a participation rate of 90 percent.

On average the women spent 104 minutes per week on hair removal. 67 percent checked constantly in the mirror, 76 percent by touching. 40 percent felt uncomfortable in social situations. 30 percent scored above the clinical cutoff for depression, 75 percent above the one for anxiety, and 29 percent above both.

For you this means: 104 minutes per week are roughly 90 hours a year. That is no longer a cosmetics topic, that is a part of your life that is missing somewhere else.

Lipton MG, Sherr L, Elford J et al. J Psychosom Res. 2006;61(2):161-168. PMID: 16880018 · DOI: 10.1016/j.jpsychores.2006.01.016 [Cross-sectional, Cohort, n=88]

I am not quoting these numbers to tell you how bad it is. You know how it is. I quote them because they show something important: what you carry is a finding, not a sensitivity. The guideline sees it the same way, more on that shortly.

The four signs this is about

Four things keep showing up on skin and hair in PCOS. How common they are depends strongly on where you count.

Cross sectional, clinical, n=100 What a dermatology clinic sees

A team around Keen examined 100 women with a confirmed PCOS diagnosis over one year at a dermatology centre in Kashmir.

Hirsutism was found in 78 percent, acne in 48 percent, female pattern hair loss in 31 percent, acanthosis nigricans in 30 percent, plus seborrhoea in 29 percent.

For you this means: these numbers show what occurs together, not how common it is in the population. These were women who came to a dermatology clinic because of their skin. The proportions are therefore skewed upwards, and they still describe the pattern well.

Keen MA, Shah IH, Sheikh G. Indian Dermatol Online J. 2017;8(2):104-110. PMID: 28405549 · DOI: 10.4103/2229-5178.202275 [Cross-sectional, Cohort, n=100]

78 %hirsutism in the clinic sample

48 %acne

31 %female pattern hair loss

30 %acanthosis nigricans

These four signs are not four diseases. They could be four answers of the same tissue to the same signal, in four different places. That may explain why they like to appear together.

What runs alongside emotionally has been studied too.

Meta-analysis, k=4 Anxiety is no side note in PCOS

A team around Dokras screened 613 papers, nine met the criteria, four entered the meta-analysis.

Generalised anxiety symptoms were found in 42 of 206 women with PCOS, that is 20.4 percent, compared with 8 of 204 in the control group, that is 3.9 percent. The odds ratio was 6.88 with a confidence interval of 2.5 to 18.9.

For you this means: if this topic occupies you more than you would like, you are not alone with that and you are not exaggerating. What remains important: this is an association. The study does not say what is cause and what is consequence.

Dokras A, Clifton S, Futterweit W, Wild R. Fertil Steril. 2012;97(1):225-230.e2. PMID: 22127370 · DOI: 10.1016/j.fertnstert.2011.10.022 [Meta-analysis, Systematic Review]

For context: what PCOS is overall, which criteria apply and which causes are discussed is described at length in the overview of polycystic ovary syndrome. And the mechanism of hormonal acne from the inside, independently of PCOS, is described in the article on hormonal acne. Here it is about the visible layer and about what can be done with it.

Reframe

The sentence I hear most often is: I know this is only cosmetic. The word only is the problem. Something that costs 90 hours a year and co-determines the mood every morning is not a side stage. It is the place where a hormonal disorder actually touches your life.

And now you know why I ask about it during the consultation instead of waiting until you bring it up yourself.

The paradox: less above, more below

It is the question almost every woman asks at some point. Usually with half a laugh, because it sounds absurd.

How can the same hormone make hair grow on the chin and make hair disappear on the crown?

The answer is surprisingly simple and it changes the view of the whole topic: what seems to decide is not the blood alone, but what the follicle makes of it.

Mechanism

Why the hair follicle gives its own answer

Testosterone circulates in the blood. It reaches every hair follicle at the same concentration, whether on the chin or at the parting.
Inside the follicle sits the androgen receptor. How many of them are present differs from body site to body site.
5 alpha reductase turns testosterone into the stronger dihydrotestosterone. The amount of that enzyme also differs by location.
Aromatase goes the other way: it converts testosterone into estradiol and takes androgen signal away from the follicle.
The answer emerges from this local mixture. On the chin, androgen can lengthen the growth phase and turn vellus hair into a firm terminal hair. On the crown it can shorten that phase and let the follicle grow smaller cycle by cycle.

A metaphor: the follicle is not a loudspeaker that simply plays whatever is sent. It has its own volume dial. Two follicles, the same signal, two entirely different volumes.

Review The paradox has a name

Randall summarised in a 2007 review what is known about the hormonal control of the hair follicle. The paper contains no measurements of its own, it places human and animal data in context.

The central sentence describes androgens as regulators of sexual hair growth with paradoxically different effects depending on body site, with beard growth and balding as the example pair. Hormones change the interplay of connective tissue and epithelium inside the follicle, meaning growth duration, size of the dermal papilla and activity of the cells involved.

For you this means: what you observe in yourself is not a contradiction and not a sign that two things are going wrong at once. It is a biological pattern that has been described for decades.

Randall VA. Semin Cell Dev Biol. 2007;18(2):274-285. PMID: 17379547 · DOI: 10.1016/j.semcdb.2007.02.004 [Mechanism Review, Narrative Review]

The good part is: the difference was not only described, it was measured. Directly in the tissue.

Tissue study, n=24 Why women get a different picture

Sawaya and Price took biopsies from frontal and occipital scalp in 12 women and 12 men with androgenetic alopecia in 1997, all between 18 and 33 years old. Androgen receptor, 5 alpha reductase type I and II and aromatase were measured.

In both sexes, frontal follicles held more receptors and more 5 alpha reductase than occipital ones, while aromatase was higher in occipital follicles. In frontal follicles of the women, androgen receptor content was about 40 percent lower than in men, aromatase six times higher, 5 alpha reductase three times lower (type I) and three and a half times lower (type II).

For you this means: fewer receptors, less converting enzyme, more breaking down enzyme. That may explain why the female picture looks different. It thins more diffusely instead of forming bald zones, and in this form the hairline usually stays. For other forms of hair loss that explicitly does not apply, more on that below.

Sawaya ME, Price VH. J Invest Dermatol. 1997;109(3):296-300. PMID: 9284093 · DOI: 10.1111/1523-1747.ep12335779 [Cohort, Tissue samples, n=24]

Staying honest

What these numbers do not say

It was 24 people, what was measured was tissue and not hair growth over time, and everyone involved already had androgenetic alopecia. So the paper explains a pattern, it does not support a treatment. I quote it anyway, because it delivers the only clean answer to the question of why.

In men the same mechanics run in a different direction, because more receptors and more 5 alpha reductase sit in the frontal area there. If you want to read up on the enzyme route in detail, you will find it in the article on DHT, hair loss and testosterone, described there explicitly from a male perspective. Here the female one applies.

Reframe

Many women look in the blood for the explanation of what they see in the mirror. And find nothing remarkable there. That is no proof that nothing is going on. It only shows that the decision is made elsewhere: in the tissue, not in the serum.

And now you know why a normal testosterone value is no reason to close the topic.

Hirsutism: the score, its limits and what you carry

If you see a doctor because of hair growth, a score is usually formed. Nine body areas, each rated from 0 to 4, a maximum of 36 points.

This scale has a name and an age.

Original paper, 1961 Where the yardstick comes from

Ferriman and Gallwey described the visual scale in 1961 in the Journal of Clinical Endocrinology and Metabolism. The paper comes from the United Kingdom. No abstract is stored in PubMed, so I stay with what is documented.

The scale was later modified by Hatch and reduced to nine areas. It is still used worldwide today, usually as the modified Ferriman Gallwey score, mFG for short.

For you this means: the yardstick your hair growth is measured against is over sixty years old and comes from a single region. That is not a devaluation. It only explains why later studies in other countries arrived at other cutoffs.

Ferriman D, Gallwey JD. J Clin Endocrinol Metab. 1961;21:1440-1447. PMID: 13892577 · DOI: 10.1210/jcem-21-11-1440 [Original paper, Basis for reviews]

And now comes the number this whole section exists for.

Cross sectional, population, n=633 The number that tells you it is not in your head

A team around DeUgarte scored the mFG in 633 unselected women at a pre employment examination, 283 white and 350 black women.

The values were not normally distributed, and a cluster analysis found no natural cutoff. A value of 3 or above was present in 22.1 percent. Of these women, 69.3 percent considered themselves hairy, compared with 15.8 percent below that value. At a value of 8 or above it was 70.0 percent. No significant differences were found between black and white women.

For you this means: someone at 5 is burdened practically as often as someone at 9. The difference between 69.3 and 70.0 percent is not a difference. So if someone tells you your score is too low to be a problem, a population study says otherwise.

DeUgarte CM, Woods KS, Bartolucci AA, Azziz R. J Clin Endocrinol Metab. 2006;91(4):1345-1350. PMID: 16449347 · DOI: 10.1210/jc.2004-2301 [Cross-sectional, Cohort, n=633]

Three countries, three cutoffs

The cutoff of 8 comes from a time when nobody had scored large unselected samples. Since then exactly that has happened, in three very different places.

Calculated cutoffs for the modified Ferriman Gallwey score from population samples. The numbers are taken from the abstracts of the original papers.
Sample	Size	Cutoff	Note
USA, university centre	633 women	3 and above	top quartile, no difference between black and white women
South China, 16 communities	2,988 women, 20 to 45 years	5	age dependent: 6 for 20 to 25 years, 5 for 26 to 30, 4 above 30
Colombia, Santander	323 women, 18 to 50 years	up to 6 normal	96 percent scored 6 or below
International PCOS guideline 2023	consensus from 71 countries	4 to 6	depending on ethnicity, recommendation 1.3.5

Cross sectional, population, n=2,988 The cutoff also depends on age

A team around Zhao examined 2,988 women between 20 and 45 years from 16 communities in South China, with examination, ultrasound and mFG scoring.

A value of 5 or above was found in 10 percent, a value of 2 or above in 25 percent. Cluster analysis produced 5 as the cutoff, age dependent 6 for 20 to 25 years, 5 for 26 to 30 and 4 for above 30. Among the hirsute women, acne, menstrual cycle disturbances, polycystic ovaries and acanthosis nigricans were significantly more common.

For you this means: hair growth decreases statistically with age, so the same score at 22 and at 38 does not mean the same thing. And the skin signs occur together, that is no coincidence.

Zhao X, Ni R, Li L et al. Fertil Steril. 2011;96(3):792-796. PMID: 21762890 · DOI: 10.1016/j.fertnstert.2011.06.040 [Cross-sectional, Cohort, n=2,988]

Cross sectional, population, n=323 Third population, third value

A team around Rios examined 323 women between 18 and 50 years from Santander in Colombia, all without risk factors for hirsutism, using the mFG scale.

The values ranged from 0 to 9. 53.5 percent of the women had a total score of 0 or 1, and 96 percent scored 6 or below. From this the authors recommend a regional cutoff of 6.

For you this means: three independent populations, three different numbers. That is exactly why the current guideline names a range instead of a fixed limit.

Rios X, Vergara JI, Wandurraga EA, Rey JJ. Biomedica. 2013;33(3):370-374. PMID: 24652172 [Cross-sectional, Cohort, n=323]

What the 2023 guideline made of it

Guideline, GRADE The cutoff of 8 is no longer the benchmark

The international evidence based PCOS guideline was updated in 2023. 39 organisations from 71 countries took part, 52 systematic reviews, GRADE methodology, approved by the Australian NHMRC. Result: 254 recommendations and practice points.

Recommendation 1.3.5 names an mFG range of 4 to 6 for detecting hirsutism, depending on ethnicity. Recommendation 1.3.6 states that the severity of hirsutism may vary by ethnicity, while the prevalence appears similar. Recommendation 1.3.4 states that the reported burden from unwanted hair growth and female pattern hair loss should be considered important, regardless of the apparent clinical severity. On self assessment it says that it carries a high degree of validity and deserves close attention.

For you this means: if you read the number 8 on the internet, you are reading an outdated position. And the sentence that your burden counts is not an alternative medicine add on. It is in the guideline.

Teede HJ, Tay CT, Laven J et al. Hum Reprod. 2023;38(9):1655-1679. PMID: 37580037 · DOI: 10.1093/humrep/dead156 [Guideline, Consensus Guideline]

A widespread claim, stated more precisely

No, the score does not simply measure past white women

You often read online that the scale was developed exclusively in white women and therefore maps ethnic differences poorly. This sharpened version cannot be supported with the original papers.

Something else can be supported, and it is just as relevant: the scale comes from the United Kingdom in 1961, and later population studies produced cutoffs of 3, 5 and 6 instead of 8. The US study explicitly found no difference between black and white women, and the guideline states that prevalence appears similar across ethnicities and that mainly the severity varies.

So the core of the criticism is not ethnic blindness, it is a single cutoff that was set too high. Someone who scores 5 falls through the old threshold and is burdened all the same.

The score describes how much hair can be seen. It does not describe how much room this topic takes up in your head. Both count for a treatment decision, and the guideline now says so itself.

Shukri Jarmoukli

Reframe

The score is a communication tool, not a verdict. It is meant to put two examiners in a position to talk about the same thing and to make change visible. What it was never meant for: telling you whether your suffering is justified. The score measures hair. It does not measure you.

And now you know why it can make sense at your next appointment not only to ask about the number, but to say how much time and attention this topic actually costs.

Hair loss in women: pattern, regrowth, timeline

It almost never starts with a shock. It starts with the parting.

It gets wider. First only in bad light, then in good light too. The ponytail feels thinner. There are more hairs on the pillow than there used to be, and you start counting them although you know it leads nowhere.

The difference from the male picture is no coincidence.

Guideline, Systematic Review How the professional society names it

An interdisciplinary task force of the Androgen Excess and PCOS Society reviewed the literature up to December 2017, with two reviewers each and a third as arbitrator.

The term female pattern hair loss is recommended instead of androgenetic alopecia. Two patterns are described: a centrifugal spread in the mid scalp and a frontal accentuation in the so called Christmas tree pattern. It is stated explicitly: isolated female pattern hair loss without elevated androgens does not count as a sign of androgen excess. In every affected woman a possible androgen excess should be worked up, and vitamin D, iron, zinc, thyroid hormones and prolactin are named as optional but recommended.

For you this means: two things at once. Female hair loss has its own pattern, no receding temples. And even an endocrine professional society recommends looking at iron, zinc, vitamin D, thyroid and prolactin as well.

Carmina E, Azziz R, Bergfeld W et al. J Clin Endocrinol Metab. 2019;104(7):2875-2891. PMID: 30785992 · DOI: 10.1210/jc.2018-02548 [Guideline, Systematic Review, Meta-analysis]

I find this last point remarkable, because at this spot it simply dissolves the border between the guideline based and the functional view. Both look at the same thing.

How much ferritin hair actually needs and why this value so often disappears into a subordinate clause is described in the article on iron deficiency and hair loss. And if skin and hair appear together with fatigue and feeling cold, it is worth looking at the thyroid and the female hormones, because both axes can produce the same symptoms.

Why the hairline usually stays

The reason is already above: frontal follicles in women hold around 40 percent fewer androgen receptors than in men, plus six times more aromatase and clearly less 5 alpha reductase. Fewer receivers, less amplifier, more breakdown. Out of that comes no sharply bounded retreat of the hairline, but a broad thinning. That is why you often see nothing in photos and still see it in the mirror.

Does it grow back?

This is the one question where every answer on the internet turns out too optimistic. So I take the two most honest papers that exist on it.

Cochrane meta-analysis, k=47 What is established in female pattern hair loss

A team around van Zuuren pooled 47 randomised studies with 5,290 participants. Only five of them had a low risk of bias.

For topically applied minoxidil versus placebo, 157 of 593 women reported a moderate to marked increase in hair growth compared with 77 of 555 under placebo, risk ratio 1.93 at moderate quality of evidence. Hair count was 13.18 hairs per square centimetre higher, that figure however at low quality of evidence. The same analysis also reports adverse events: 40 of 407 women on minoxidil 2 percent twice daily versus 28 of 320 under placebo, risk ratio 1.24 with a confidence interval of 0.82 to 1.87, so without a confirmed difference, at low quality of evidence. Finasteride 1 mg showed 30 of 67 versus 33 of 70 improvements, risk ratio 0.95, so no advantage. For spironolactone, cyproterone acetate and dutasteride the authors call for further randomised studies.

For you this means: topically applied minoxidil has the best evidence base, and it is moderate, not overwhelming. For exactly those agents that are frequently used in daily practice, robust randomised data are missing. That is uncomfortably honest and still the current state.

What belongs to honesty: even topical use is not nothing. Typical are irritation and itching of the scalp, increased hair growth in places where you do not want it, and in the first weeks often increased shedding before anything gets better at all. In pregnancy and while breastfeeding minoxidil is not used. And once more clearly: this is about the topical application. Minoxidil in tablet form is a different matter. For this indication it is used outside its licence, it has its own cardiovascular risk profile and it belongs exclusively in medical hands.

The amounts named here are study figures and not an instruction. Finasteride, dutasteride, spironolactone and cyproterone acetate are prescription only, and they are not interchangeable. Finasteride and dutasteride are not licensed for women of childbearing age and must not be used there. For cyproterone acetate a Europe wide restriction has applied since 2020, because meningiomas, that is tumours of the meninges, were observed under higher cumulative amounts. With that agent, liver values and thrombosis risk come on top. None of this means that these medicines are not used. It means that the choice is made and supervised medically, together with secure contraception.

van Zuuren EJ, Fedorowicz Z, Schoones J. Cochrane Database Syst Rev. 2016;2016(5):CD007628. PMID: 27225981 · DOI: 10.1002/14651858.CD007628.pub4 [Systematic Review, Meta-analysis, k=47]

Before and after, no control group, n=80 44 percent, and what that number does not say

First the framing that belongs with this section: oral antiandrogens are prescription only and several of them cause birth defects. They are prescribed and supervised medically, and only together with secure contraception. A team around Sinclair treated 80 women with biopsy confirmed follicular miniaturisation for at least twelve months with oral antiandrogens. Assessment used standardised photography with a stereotactic head holder, blinded by three experienced clinicians.

35 of 80 women, that is 44 percent, showed regrowth. The same number showed no recognisable change, 10 of 80, that is 12 percent, kept losing hair. Taken together, 88 percent could expect stability or improvement. The women were between 12 and 79 years old. Age, ferritin, hormone values and histological parameters did not predict the response. The one factor that did was the baseline grade at the midscalp, with p equal to 0.013. The authors themselves call for a placebo controlled study.

For you this means: there was no control group. Part of those 44 percent might have looked the same without treatment. Still it is the most concrete number that exists on this question, and it says: regrowth is possible, stability is more likely, and both need at least twelve months.

Sinclair R, Wewerinke M, Jolley D. Br J Dermatol. 2005;152(3):466-473. PMID: 15787815 · DOI: 10.1111/j.1365-2133.2005.06218.x [Cohort, Uncontrolled intervention study, n=80]

The timeline, without sugar coating

A hair that is programmed differently today looks different only months later. The growth phase of a scalp hair lasts years, and every hair sits at a different point of its cycle. That is why six months is the lower limit for a first judgement and twelve months the more honest moment. Whoever decides after six weeks is deciding about noise.

One limitation belongs with this patience: it applies only to the diffuse form this article is about. There are forms of hair loss where waiting costs follicles. Please seek medical advice promptly if your hairline is visibly receding, if your eyebrows are thinning, if the scalp burns, itches or is reddened, if the small hair pores disappear in one area, or if round bald patches appear. Behind that can sit a scarring alopecia or alopecia areata, and both need a different route. The same applies if the loss starts suddenly and heavily, because then a telogen effluvium after infection, surgery, weight loss or a medication is often behind it.

Reframe

Many women judge a treatment by whether new hair appears. Understandable, and for the beginning the wrong yardstick. The first realistic success is called standstill. Together with regrowth that was 88 percent in the antiandrogen study. Having nothing more to lose is already a result in this topic. Whether a prescription antiandrogen is an option for you at all is decided and supervised medically, and only together with secure contraception, because several of these agents cause birth defects.

And now you know why at the first follow up I ask for the picture from six months ago and not for the feeling from yesterday.

Acne in PCOS: why it behaves differently than at sixteen

As a teenager you may have had almost nothing. And now, at thirty, something sits along the jaw that does not open, does not go away and leaves a mark after two weeks.

That feels wrong. Acne was supposed to be a school years topic.

Physiologically it is a different picture, and that is well studied.

Cross sectional, clinical, n=280 Adult acne is distributed differently

A team around Khunger examined 280 patients over 25 years of age with acne at an Indian tertiary care hospital. Transferability to a German setting is therefore limited.

82.1 percent were women, the mean age was 30.5 years. 55 percent had inflammatory papular acne, only 6 percent a comedonal form. The most common site was the cheek at 81 percent, then the chin at 67 percent and the jaw area at 58.3 percent. Elevated laboratory values for hyperandrogenaemia were found in only 3.08 percent, although hormones were not tested in everyone, but in the women with alopecia, obesity, hirsutism or menstrual disturbance. 76.4 percent had scarring, 52.8 percent reported psychological burden.

For you this means: what you see on yourself is the standard case for adult acne. Deeper, more inflammatory, lower half of the face, hardly any blackheads. And the number 76.4 percent for scarring is why early treatment is no cosmetic luxury.

Khunger N, Kumar C. Indian J Dermatol Venereol Leprol. 2012;78(3):335-341. PMID: 22565434 · DOI: 10.4103/0378-6323.95450 [Cross-sectional, Cohort, n=280]

Important here: this study is not PCOS specific. It describes adult acne in general. And exactly from that a misunderstanding arises that sits everywhere online.

Correcting a widespread statement

A location on the chin does not prove PCOS

You often read that PCOS acne typically sits on the chin, along the jawline and on the neck, and that you can recognise it by this. The first part is imprecise, the second is not supported.

A team around Feng compared 186 women with PCOS and 113 age matched women without PCOS in northern China. Severity, location and type of acne did not differ between the two groups. What did differ was something else: between women with PCOS and acne and those without acne there were differences in the free androgen index (p equal to 0.036), in SHBG (p equal to 0.023) and in BMI (p equal to 0.001).

So the honest version reads: the distribution in the lower third of the face separates adult acne from adolescent acne. It does not separate PCOS from other adult acne. Deriving a diagnosis from a location on the chin goes beyond the data.

Feng JG, Guo Y, Ma LA et al. J Cosmet Dermatol. 2017;17(3):511-517. PMID: 28940857 · DOI: 10.1111/jocd.12387 [Case-control, Cohort, n=299]

More interesting than the location is the second finding of the same paper. Between women with PCOS and acne and those with PCOS without acne, the free androgen index, SHBG and BMI differed significantly. In which direction, the abstract does not state for those two groups, so it is not stated here either. For hirsutism the same paper does name the direction: higher total testosterone, higher DHEA-S, higher free androgen index and lower SHBG. That moves the focus away from total testosterone alone and towards the freely available fraction. And there are women with clear skin signs and unremarkable lab results. That is exactly why the clinical assessment stands next to the blood value in the guideline, with equal weight.

Guideline, GRADE What dermatology recommends in 2024

A work group of the American Academy of Dermatology produced a guideline on acne vulgaris in 2024, based on a systematic review with GRADE assessment.

The result is 18 evidence based recommendations and five good practice statements. Strong recommendations apply to benzoyl peroxide, topical retinoids, topical antibiotics and oral doxycycline. Oral isotretinoin is strongly recommended in severe acne, in psychosocial burden, in scarring or when standard therapy has not worked. Conditional recommendations exist among others for topical clascoterone, salicylic acid, azelaic acid as well as for combined oral contraceptives and spironolactone.

For you this means: psychosocial burden is an independent reason for more intensive therapy in this guideline, not just the number of spots.

What you should know about the agents named: apart from benzoyl peroxide these are prescription only medicines. Doxycycline can make the skin sensitive to light and is not used in pregnancy or while breastfeeding. Topical retinoids are likewise not used in pregnancy. Benzoyl peroxide can irritate and it bleaches towels and clothing. If you are pregnant, want to be, or are breastfeeding, please say so actively before anything is prescribed.

Reynolds RV, Yeung H, Cheng CE et al. J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30. PMID: 38300170 · DOI: 10.1016/j.jaad.2023.12.017 [Guideline, Consensus Guideline]

A note that belongs here: isotretinoin is prescription only and harms the unborn child. Treatment with it is medically supervised, with reliable contraception, with pregnancy tests and with monitoring of liver values and blood lipids. The product information also carries a warning that fits this article particularly well: under isotretinoin, depressed mood, a worsening of an existing depression and suicidal thoughts can occur. Further above it said that 30 percent of the women surveyed scored above the clinical cutoff for depression. Together this does not mean that the medicine is wrong. It means that your mood belongs discussed before starting and during treatment, and that you get in touch if you feel worse mentally. That is no argument against the medicine, it is the frame in which it is used.

Why acne arises from the inside and what role the sebaceous gland, insulin and inflammation play is described at length in the article on hormonal acne from the inside. And if skin and gut are both noticeable in your case, it is worth looking at the gut skin axis in acne and rosacea.

Reframe

Adult acne is often treated like adolescent acne: dry it out, scrub it, cover it. That fits the wrong picture, because comedones are the exception here and inflammation is the rule. What sits deep cannot be scrubbed off from the outside.

And now you know why the question about scarring belongs earlier than the question about the next product.

Acanthosis nigricans: the skin sign that speaks about metabolism

Some women discover it by chance. A darker stripe on the neck that you take for dirt. Or a spot in the armpit that feels velvety, almost like fine felt.

You wash at it. It does not go away. And at some point comes the suspicion that you have not looked after yourself properly.

That is not it. That is acanthosis nigricans.

How you recognise it

Four features

Where it sits: In flexural folds: neck, armpits, groin, less often under the breast or on the knuckles of the fingers.
How it looks: The skin appears darker, brownish to grey, with blurred borders. Not like a spot, more like a shadow.
How it feels: Velvety and slightly thickened. More clearly felt with the fingertips than seen.
What it is not: Not dirt, not a fungus, not a consequence of poor hygiene. Scrubbing and bleaching agents achieve nothing and irritate the skin.

A sign, not an emergency. It still belongs mentioned at the next appointment, because it triggers a sensible question about glucose metabolism.

How common it is has been shown by the same two papers from further above. In the dermatology clinic sample of 100 women with PCOS it was found in 30 percent, and in the South Chinese population study it occurred significantly more often in hirsute women. The skin signs rarely come alone.

Here ends what I can support

The mechanism is plausible, but I do not quote it as evidence

The common explanation says that high insulin levels also act on related growth factor receptors of skin cells and drive cell division there, which produces the typical thickening. This explanation is mechanistically understandable and it appears in many textbooks.

For this article I found no cleanly verifiable primary source for it. So it stands here as a plausible assumption and not as an established statement. What is established is the clinical association: acanthosis nigricans goes together with insulin resistance, and that is the reason to take it seriously.

What insulin resistance means in women, how it is measured and why it is so often overlooked is described in the article on insulin resistance and female hormones. Here only one route matters, the one that leads from there to your hair, and that comes next.

Reframe

Most women want to get rid of this sign because it is visible. Understandable. But it is the only one of the four skin findings that hands you information about your metabolism for free. Less a flaw than an indicator.

And now you know why with this finding I do not talk about cream, I talk about fasting insulin.

Two diagnoses that belong ruled out before treatment

Before treatment is discussed, two diagnoses belong ruled out that feel like PCOS and are not. Both are named in the 2018 Endocrine Society guideline.

Late onset congenital adrenal hyperplasia, that is an inherited enzyme deficiency in the adrenal gland. It can cause hirsutism, acne and cycle disturbances just as PCOS does. It is found through an early morning blood value in the first half of the cycle, 17-hydroxyprogesterone.
Cushing syndrome, that is too much cortisol. Thin skin, purple stretch marks, easy bruising, muscle weakness and a central distribution of weight often come with it.

Both are rare. Both change the treatment completely. So it can make sense to simply ask at your next appointment whether this was considered. That includes the question of whether a medication you take can be driving hair growth as well.

The treatment paths and what they honestly deliver

Now the part most women are searching for. I go through it in four blocks, each with the number behind it and with the time it takes.

Two sentences up front that apply to all four. First: each of these options belongs in medical hands, because it carries benefits and risks that have to fit your situation. Second: none of them works faster than your hair cycle.

Block 1: Hormonal contraception

Cochrane meta-analysis, k=31 What the pill can deliver in acne

A team around Arowojolu pooled 31 randomised studies with 12,579 participants, among them six placebo controlled comparisons.

All nine analysable placebo controlled studies showed fewer lesions, lower severity and better self assessment. Concretely: minus 9.98 total lesions with a levonorgestrel pill and minus 9.32 with norgestimate. For a dienogest pill the analysis reports no lesion count but a greater percentage decrease in total lesions, mean difference minus 15.30. That number measures something else and is therefore not comparable with the first two. Between the progestin types only few consistent differences were found.

For you this means: the effect on the skin is real and it is well documented. But it is an improvement by a certain number of lesions and not a clean slate. Whoever expects completely clear skin will be disappointed, and that is not down to the preparation.

What belongs in the same line: combined oral contraceptives are prescription only, and they can raise the risk of blood clots in veins and lung vessels. How strongly can depend on the progestin. On current data, preparations with levonorgestrel sit more favourably than those with dienogest or cyproterone acetate, and it is precisely the latter that often do better on the skin. Smoking, excess weight, migraine with aura, an earlier thrombosis in you or in your family and longer immobilisation shift this calculation further. This is why the question about the skin can never decide on its own which pill suits you. That belongs in a conversation with your physician.

Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Cochrane Database Syst Rev. 2012;2012(7):CD004425. PMID: 22786490 · DOI: 10.1002/14651858.CD004425.pub6 [Systematic Review, Meta-analysis, k=31]

For hirsutism, the 2023 international PCOS guideline places combined oral contraceptives ahead of metformin in recommendation 4.4.1 when an irregular menstrual cycle is present at the same time. The Endocrine Society also recommends them in its 2018 guideline as the entry point for the majority of women.

What it can deliver and what it cannot can be said in one image: it can lower the signal arriving at skin and follicle, among other things by raising SHBG and thereby leaving less free testosterone. It does not change what drives the signal. This is why the skin may return to where it stood before once the pill is stopped. That is no reproach towards gynaecology, it is a description of how it works.

What actually happens in the time after stopping is described in the article on coming off the pill and the post pill phase. And if you are thinking about alternatives anyway, you will find the honest comparison under hormone free contraception. Important: both are reading material for a conversation, not an invitation to change anything about a current prescription. That decision belongs in a discussion with your physician.

Block 2: Antiandrogens

Cochrane meta-analysis, k=9 Spironolactone: the women notice more than the score

A team around Brown included nine studies. Only one of them had acne as an endpoint, all the others hirsutism.

In the two studies with 100 mg spironolactone versus placebo there was a significant difference in the subjective improvement of hair growth, with an odds ratio of 7.18 and a confidence interval of 1.96 to 26.28. For acne vulgaris no evidence of efficacy was found. The authors themselves call the body of studies sparse and small.

For you this means: again the same pattern as with the score. The women notice the difference more clearly than a score reflects it. And the data base is honestly thin, although the agent has been used for decades.

Brown J, Farquhar C, Lee O, Toomath R, Jepson RG. Cochrane Database Syst Rev. 2009;(2):CD000194. PMID: 19370553 · DOI: 10.1002/14651858.CD000194.pub2 [Systematic Review, Meta-analysis, k=9]

The frame that belongs with antiandrogens

Antiandrogens are prescription only, and several of them harm the unborn child. The Endocrine Society explicitly recommends against antiandrogen monotherapy without reliable contraception. In Germany spironolactone is not licensed for this indication, so it is used off label, which belongs explained and supervised by a physician.

With spironolactone something is added that often gets lost: it is a potassium sparing medicine. Potassium in the blood can rise under it, and that can become dangerous with impaired kidney function, under blood pressure medicines of the ACE inhibitor or sartan type, under potassium supplements or under painkillers of the NSAID type. This is why kidney values and potassium belong checked before starting and during treatment. More common and more harmless are cycle irregularities, breast tenderness and increased urination. None of this speaks against the medicine. It only describes why it belongs under medical supervision and not on request.

The same guideline also says when something is added: when the patient relevant burden persists after six months of monotherapy with a contraceptive. The 2023 PCOS guideline likewise names at least six months in 4.6.1. Doses appear in this article only where they are part of a study result. They are literature, not instructions.

Block 3: Topical and local options

On the skin there are two routes that are rarely discussed in German language advice texts. The first is clascoterone, a locally acting antiandrogen that the 2024 AAD guideline lists as a conditional recommendation. It acts locally at the receptor instead of changing the hormonal balance as a whole. Important for you in Germany: this preparation is not licensed in the European Union, so you cannot obtain it here through regular channels. I name it only so that you can place the term if you meet it in English language texts. From the licensing studies, local skin irritation is known, as well as signals of an effect on the adrenal axis and on potassium values. It is not a cosmetic.

The second is eflornithine as a cream, and there is an unusually clean study on it.

RCT, split face controlled, n=31 When every woman is her own control group

A team around Hamzavi treated the entire upper lip with a long pulsed alexandrite laser, every four weeks, up to six sessions. In addition, eflornithine cream was applied on one side and a placebo cream on the other, assigned double blind.

Among 31 analysable participants, 29 of 31, that is 93.5 percent, showed complete or nearly complete hair removal on the eflornithine side, compared with 21 of 31, that is 67.9 percent, on the placebo side, with p equal to 0.021. Both procedures were well tolerated in this study.

What that does not mean: eflornithine cream is prescription only in Germany, and at the treated site it can burn, sting, redden or trigger small inflammations of the hair follicles. It also does not remove hair, it can slow regrowth. If it is stopped, the hair growth usually returns within some weeks. And the laser treatment itself is not free of risk either, more on that in a moment.

For you this means: the design is strong, because every woman was her own control. The numbers are small, it was a single centre, and whether the difference holds beyond six months was not studied.

Hamzavi I, Tan E, Shapiro J, Lui H. J Am Acad Dermatol. 2007;57(1):54-59. PMID: 17270315 · DOI: 10.1016/j.jaad.2006.09.025 [RCT, split face controlled, n=31]

Block 4: Laser and IPL

Cochrane meta-analysis, k=11 What permanent does not mean

A team around Haedersdal pooled eleven randomised studies with 444 people. None had high methodological quality, and the endpoints were too heterogeneous for a pooled analysis.

Alexandrite and diode lasers showed about 50 percent hair reduction up to six months after treatment. For intense pulsed light, neodymium YAG and ruby lasers there was little evidence of an effect. Long term hair removal was not documented for any method. Little was reported about side effects in these studies, and that is not the same as: there are few. Named were pain, redness, swelling, burned hairs and changes in skin pigmentation.

For you this means: the short term effect for alexandrite and diode is documented, IPL stands weaker, and the word permanent is not covered by this analysis. A limitation that belongs with it: the review is from 2006, device technology has developed further since then. That explains the gap but does not fill it. And how high the risk of pigment changes and burns is depends strongly on your skin type and on the device settings. Darker skin needs different parameters. This is why the experience of the person treating you weighs more here than the price per session.

Haedersdal M, Gotzsche PC. Cochrane Database Syst Rev. 2006;2006(4):CD004684. PMID: 17054211 · DOI: 10.1002/14651858.CD004684.pub2 [Systematic Review, Meta-analysis, k=11]

Against that stands the 2023 international PCOS guideline, which explicitly recommends laser and light therapies in recommendation 4.8.1, and does so with an eye on depression, anxiety and quality of life. Both positions are coherent. The Cochrane analysis asks about lasting freedom from hair, the guideline asks about the benefit for the woman sitting in front of you.

Why always six months

Both guidelines name the same interval before switching or adding. The reason is not bureaucratic, it is biological. A follicle whose programme changes today shows it only in the next cycle of its hair. A judgement after six weeks is therefore not a firm judgement, it is a snapshot inside the noise.

Reframe

Many women switch when nothing happens after two months, and land two years later at the fourth option, all of which were tried for too short a time. The strongest lever in this topic is unspectacular: stay with one route long enough to be able to judge it. Photos in the same light, the same distance, every three months. That beats any memory.

And now you know why at the first appointment I ask about the calendar and not about the desired date for the result.

The route I take in addition, and where it honestly ends

Up to here nothing has been written that could not also be said in a dermatology or gynaecology consultation. That is intentional. This workup is the foundation, and it stays that way.

What I do in addition is not an alternative to it. It is a second question alongside: what is carrying the free testosterone up there in the first place?

This question needs time, and time is the scarcest resource in every consultation, in mine just as much. I have decided to make my appointments long, and I use that for the layer underneath. That is a decision about priorities and not a verdict on other practices.

The best founded lever: insulin and SHBG

SHBG is a transport protein from the liver. It binds sex hormones in the blood. What is bound does not arrive at the receptor.

A metaphor: picture SHBG as a taxi fleet. As long as enough taxis are on the road, testosterone sits inside and gets driven around. If the number of taxis drops, the share travelling on foot rises, and that share gets in everywhere. The total value in the lab can stay entirely unchanged.

Cell study, in vitro In cell culture, insulin lowered the liver cell's SHBG production

A team around Plymate studied the human liver cell line Hep G2 in culture in 1988, with 72 hour incubations in serum free medium, comparing insulin, prolactin, estradiol, thyroxine and testosterone.

In the control, SHBG production was 65.0 nmol per million cells, under insulin 46.8 and under prolactin also 46.8, each with p less than 0.01. Insulin additionally inhibited the SHBG production that estradiol and thyroxine had increased.

For you this means: this is the mechanism behind the sentence that lowering insulin may raise SHBG. It was shown in cells, not in humans. That is exactly how it belongs read.

Plymate SR, Matej LA, Jones RE, Friedl KE. J Clin Endocrinol Metab. 1988;67(3):460-464. PMID: 2842359 · DOI: 10.1210/jcem-67-3-460 [In vitro, Cell culture]

In humans the picture looks more modest, and that belongs here just as much.

Cochrane meta-analysis, k=15 Lifestyle moves the free androgen index, but not by much

A team around Lim pooled 15 randomised studies with 498 participants, ten of them on physical activity and five on combined interventions.

The free androgen index fell by 1.11 points compared with minimal or no intervention, confidence interval minus 1.96 to minus 0.26, at a heterogeneity of 71 percent and low quality of evidence. That one figure, however, does not rest on all 15 included studies, but on six of them with 204 women in total. Weight fell by 1.68 kg, BMI by 0.34.

For you this means: the effect is measurable and it is small. And more importantly: endpoints on skin and hair were not recorded in this analysis at all. Anyone promising you a specific improvement in hair growth through lifestyle goes beyond these data.

Lim SS, Hutchison SK, Van Ryswyk E et al. Cochrane Database Syst Rev. 2019;3(3):CD007506. PMID: 30921477 · DOI: 10.1002/14651858.CD007506.pub4 [Systematic Review, Meta-analysis, k=15]

The counter position, written out

The guideline advises against relying on blood sugar alone

The Endocrine Society advises against insulin lowering medication as the sole treatment of hirsutism in its 2018 guideline. There it is a weak recommendation at low quality of evidence, not a prohibition. The reasoning is sound: in the systematic reviews the effect on hair growth was too small and too uncertain, while contraceptives and antiandrogens performed better.

A 2020 Cochrane analysis with 44 randomised studies and 2,253 women supports this. At a BMI between 25 and 30, metformin possibly performed more weakly than the pill, mean difference 1.92 at low quality of evidence, otherwise the effect remained uncertain. Metformin alone and the pill alone were each weaker than the combination. Severe gastrointestinal side effects occurred more often under metformin, Peto odds ratio 6.42.

My objection is not that the guideline is wrong. It is that the guideline answers a different question. It asks about hair growth in six to twelve months. I additionally ask about metabolism over decades, and there blood sugar is no side stage. Both belong next to each other and not against each other. And both are prescription matters. With metformin there is more to it: in Germany it is not licensed for PCOS. It is therefore used outside its licence, which belongs explained medically and touches the question of who pays. Sufficient kidney function is a precondition, so kidney values belong checked before and during treatment. Gastrointestinal complaints are common, and very rarely an acidification of the blood can occur. Whether metformin, a contraceptive or a combination fits you is decided and supervised medically, not after a blog article.

Fraison E, Kostova E, Moran LJ et al. Cochrane Database Syst Rev. 2020;8(8):CD005552. PMID: 32794179 · DOI: 10.1002/14651858.CD005552.pub3 [Systematic Review, Meta-analysis, k=44]

What that means in practice is not written here, but where it belongs: avoiding blood sugar spikes describes order, combination and timing, and nutrition, hormones and blood sugar places that in the larger context.

There is one study on the blood sugar route and the skin that I still want to name, because it keeps being quoted incorrectly.

In this context it is often cited as if it applied to women. A team around Smith found a decrease of 23.5 lesions over twelve weeks on a diet with a low glycaemic load compared with 12.0 in the control group, alongside improved insulin sensitivity and weight loss that could not be separated from the diet effect. The decisive point: this study was conducted exclusively in young men. It works as a pointer to the general link between glycaemic load and lesion count, not as evidence for women with PCOS. Smith RN et al. Am J Clin Nutr. 2007;86(1):107-115. PMID: 17616769 · DOI: 10.1093/ajcn/86.1.107 [RCT, n=43, male participants only]

Zinc: one study, not a field

RCT, double blind, n=48 A clear effect on the objective score

A team around Jamilian randomised 48 women with PCOS to 220 mg zinc sulfate, corresponding to 50 mg elemental zinc, or placebo over eight weeks.

The modified Ferriman Gallwey score fell by 1.71 plus minus 0.99 points compared with 0.29 plus minus 0.95 under placebo, with p less than 0.001. Hair loss decreased in 41.7 percent compared with 12.5 percent, p equal to 0.02. Hormone profiles and inflammatory cytokines did not change significantly.

For you this means: this is the only clear effect on an objective hirsutism score that I found in the functional area for this article. And it is 48 women, eight weeks, one centre, with unchanged hormone values. One study is not a body of evidence.

Jamilian M, Foroozanfard F, Bahmani F et al. Biol Trace Elem Res. 2016;170(2):271-278. PMID: 26315303 · DOI: 10.1007/s12011-015-0480-7 [RCT, double blind, n=48]

The amount named is the study dose and not a recommendation, and it is high. For orientation: the European authority EFSA derives a tolerable upper intake level of 25 mg for total daily zinc intake, and the German Federal Institute for Risk Assessment recommends at most 6.5 mg per day in food supplements. The study dose sits well above that. Zinc at this level over longer periods can disturb copper balance and through that affect the blood count and the nervous system. So this is not something you put together for yourself after reading an article, and it belongs under medical supervision. Where it sits within the wider micronutrient picture is described in the article on micronutrients, zinc and vitamin D.

Spearmint: the hormones move, the score does not

RCT, 30 days, n=42 Spearmint tea, read honestly

Grant conducted a two centre randomised controlled trial over 30 days, with 42 randomised volunteers. Spearmint tea twice daily was compared against a placebo herbal tea.

Within the spearmint group, free and total testosterone fell significantly over the 30 days, LH and FSH rose, and the self reported burden went down. A clean comparison against the placebo group is not reported for the hormone values in the abstract. The objective Ferriman Gallwey score did not differ between the groups, with p equal to 0.12. The author explains this with the study duration being too short.

For you this means: the hormone values move measurably and the women feel some relief. The visible hair growth did not change measurably in 30 days. That is no contradiction, it is a question of the hair cycle we already know from above.

Grant P. Phytother Res. 2010;24(2):186-188. PMID: 19585478 · DOI: 10.1002/ptr.2900 [RCT, n=42]

The prior history is thinner still. A team around Akdogan gave 21 women with hirsutism tea from Mentha spicata twice daily for five days, without a control group. Free testosterone fell significantly, total testosterone and DHEA-S did not change. Five days, 21 women, no control: a pointer, not evidence. Both details on preparation come from the studies and are not a recommendation. Where plant based options realistically stand is placed in context by the article on chasteberry and plant based hormone helpers.

Inositol: the lab moves, skin and hair have not been studied

On inositol there is a 2023 meta-analysis with 26 randomised studies and 1,691 patients. It reports changes in laboratory values and in cycle regularity. I deliberately do not repeat those figures here, because in Germany inositol is a food supplement and I may not make disease related claims for a food. What I can say: clinical endpoints on skin and hair were not analysed in that review at all. If the topic interests you, it is a question for the consultation and not one for the shopping basket.

This is why the international PCOS guideline places metformin first in recommendation 4.7.2 and words 4.7.1 cautiously. Both are true at the same time: the lab moves, and what that does to skin and hair is open. The same guideline states in 4.7.5 that regulation and quality control of supplements differ from those for medicines and that dose and quality can vary. And because metformin appears in this paragraph: it is a prescription medicine. Whether it fits you, whether it stays and whether something is added belongs in a conversation with your physician and is not started, changed or stopped on your own.

Environment: the part this article exists for

Now the layer many women ask me about. Why is there a search for mould, heavy metals and endocrine disruptors here when this is about hair? The honest answer starts with what is established. And that is little.

Case-control, cross sectional, n=171 Bisphenol A and androgens in PCOS

A team around Kandaraki examined 71 women with PCOS and 100 healthy women at a university hospital, matched for age and BMI.

Bisphenol A in blood was 1.05 plus minus 0.56 compared with 0.72 plus minus 0.37 nanograms per millilitre, p less than 0.001. The associations were weak: r equal to 0.192 for testosterone, r equal to 0.257 for androstenedione and r equal to 0.273 for insulin resistance within the PCOS group. The authors speak of a possible role, not of a cause, and consider the relationship potentially bidirectional, because androgens can influence the breakdown of the substance.

For you this means: there is a documented association between this substance and the androgen balance in PCOS. It is weak. And it proves no cause, not even the direction.

Kandaraki E, Chatzigeorgiou A, Livadas S et al. J Clin Endocrinol Metab. 2011;96(3):E480-E484. PMID: 21193545 · DOI: 10.1210/jc.2010-1658 [Case-control, Cohort, n=171]

The sentence that has to stand here

It does not follow that every hormonal disorder has an environmental cause. The associations in this literature are weak, the direction is often open, and a large part of the convincing data comes from cell culture and animal models, not from intervention studies in humans.

In the background of the same paper it is mentioned that in laboratory animals an early exposure to this substance produced a picture in adulthood resembling PCOS. That is an animal finding. It justifies a question, not a conclusion about you.

Why I look anyway: if a layer acts mechanistically on the same levers we are working on regardless, namely insulin, SHBG and inflammation, then it is a sensible question. Not more, but also not less. Which everyday sources exist is described in the article on xenoestrogens in everyday life. Zearalenone, a mould toxin whose oestrogenic activity is documented in cell culture and animal models, is described in the article on zearalenone and hormones. And when a heavy metal measurement makes sense and when it does not is placed in context by the article on heavy metals in blood or urine.

Two further layers belong to the same question: silent inflammation and chronic stress. Which values make sense for the assessment and when they are measured is described under hormone testing in women. And because the liver processes both SHBG and oestrogen breakdown, the article on oestrogen and the liver fits alongside.

And now the most important paragraph of this article

There is a point where this topic tips over, and I see it often. Do you remember the numbers from the questionnaire study? 67 percent checked constantly in the mirror, 76 percent by touching. That is no marginal finding, that is the majority.

Whoever starts measuring, avoiding and checking everything only moves the problem. Hair growth becomes a control task, food becomes an exam, your own body becomes an opponent. Environmental topics are especially prone to this, because in theory there is always something else that could be left out.

How you notice that observing is taking up too much room

The mirror becomes an appointment. You no longer check in passing but on a schedule, several times a day, in a particular light.
The list gets longer, never shorter. Every week something is added that you avoid, and nothing ever comes back.
Going out becomes negotiable. You cancel things because today you do not want to face being seen.
Eating becomes an exam. A meal is no longer good or bad in taste, but right or wrong.
Numbers no longer reassure. A good value only holds until the next question.

If you find several of these points in yourself, that is no failure and no character flaw. It is a known side effect of a topic you can see. The article on eating disorders between body and mind describes how this spiral arises and where support makes sense. It is worth raising early and not only when nothing else works any more.

If you are feeling very bad right now

You do not have to wait until your next appointment. In Germany the Telefonseelsorge is reachable free of charge around the clock on 0800 111 0 111 and 0800 111 0 222, and also on 116 123. In acute danger please call 112. That is not a sign of weakness, it is the right number at the right time.

Reframe

The functional part of this article is deliberately the smallest. Not because it matters little to me, but because the data on it are small.

What is large is the order. First the workup, then the documented routes with their timeline, then the layer underneath. Whoever starts at the bottom loses years.

And now you know why in the consultation I first ask whether the gynaecological and dermatological workup is in place, before I talk about insulin, environment and inflammation.

Frequently asked questions

At what Ferriman Gallwey score do we speak of hirsutism?

The 2023 international PCOS guideline recommends a range of 4 to 6 points on the modified Ferriman Gallwey score, depending on ethnicity. The cutoff of 8 that was taught for decades is no longer the benchmark. In population studies the calculated cutoffs were 3 in a US sample of 633 women, 5 in a South Chinese sample of 2,988 women and 6 in a Colombian sample of 323 women. One thing still matters: the score is an orientation, not a verdict on how much this burdens you.

My score is low, but I suffer a lot. Am I imagining it?

No, and the guideline says so. The 2023 international PCOS guideline states in recommendation 1.3.4 that the reported burden from unwanted hair growth and female pattern hair loss should be considered important, regardless of the apparent clinical severity. In the US population study, 69.3 percent of women scoring 3 or above considered themselves hairy, practically the same as the 70.0 percent scoring 8 or above. Between 3 and 8 points sits a large group of women who fall through the old cutoff and are burdened all the same.

Why does hair grow on my chin while the hair on my head gets thinner?

Because the hair follicle itself decides how it answers androgens. A 2007 review describes this explicitly as a biological paradox with opposite effects depending on body site. The difference was measured in a separate 1997 tissue study in 24 people: frontal scalp follicles in women contained around 40 percent fewer androgen receptors and six times the amount of aromatase compared with men, plus three to three and a half times less 5 alpha reductase. On the chin, androgen can lengthen the growth phase. On the crown, it can shorten it.

Is hair loss in PCOS reversible, and how long does it take?

The most honest number comes from a study without a control group in 80 women on oral antiandrogens over at least twelve months: 44 percent showed regrowth, 44 percent showed no recognisable change, 12 percent kept losing hair. Oral antiandrogens are prescription only and several of them cause birth defects, so they are an option only with medical supervision and secure contraception. For topically applied minoxidil, a Cochrane analysis of 47 studies and 5,290 participants found a risk ratio of 1.93 for a moderate to marked increase in hair growth compared with placebo, at moderate quality of evidence. The same analysis also reports adverse events. Typical are irritation and itching of the scalp, unwanted hair growth elsewhere and in the first weeks often increased shedding. In pregnancy and while breastfeeding minoxidil is not used, and minoxidil in tablet form is a different matter that belongs exclusively in medical hands. The timeline runs from months into years, because the hair cycle sets the pace. Before six months an effect can barely be judged. And if your hairline is receding, your eyebrows are thinning, the scalp burns or itches or round bald patches appear, please do not wait but have it looked at promptly.

Why do I have hair loss even though I am on the pill?

Because hair loss in women can have several causes at the same time. The Androgen Excess and PCOS Society stated in 2019 that isolated female pattern hair loss with normal androgen levels does not count as a sign of androgen excess. The same task force recommends looking at vitamin D, iron, zinc, thyroid hormones and prolactin as well. Whether an existing prescription still fits belongs in a conversation with your physician and is not changed on your own.

Why does my acne persist on the pill, and why does it come back after stopping?

A Cochrane analysis of 31 studies and 12,579 participants shows that combined oral contraceptives can measurably lower the number of lesions, by about 9.98 lesions with a levonorgestrel pill and by 9.32 with norgestimate. That is an improvement, not a clean slate. The point of action also sits at the signal and not at what drives the signal. This is why the skin may return to where it stood before once the pill is stopped. Important alongside this: combined oral contraceptives are prescription only and they can raise the risk of blood clots in veins and lung vessels, to a different degree depending on the progestin. Smoking, excess weight, migraine with aura and earlier thromboses shift that calculation further. So the question about the skin can never decide on its own which pill fits. Both starting and stopping are discussed with your physician and not decided alone.

Does PCOS acne really sit typically on the chin and the jawline?

Here you have to be more precise than the internet usually is. A study of 280 adults with acne found the cheek as the most common site at 81 percent, then the chin at 67 percent and the jaw area at 58.3 percent, plus 55 percent inflammatory forms and only 6 percent comedonal acne. That separates adult acne from adolescent acne. A comparison study with 186 women with PCOS and 113 women without PCOS, however, found no difference in severity, location and type. So the distribution says something about age, not about the diagnosis.

What are the dark, velvety patches on my neck and armpits?

That is probably acanthosis nigricans, a velvety thickened, darker looking skin in flexural folds such as the neck, armpits and groin. In a dermatology clinic sample of 100 women with PCOS it was found in 30 percent. In the South Chinese population study it occurred significantly more often in hirsute women. It counts as a skin sign that goes together with insulin resistance, and it is a good reason to have your glucose metabolism looked at medically. It cannot be scrubbed away, and attempts with bleaching agents only irritate the skin.

How do I lower testosterone naturally, and how much of that is realistic?

The best founded path runs through insulin and through SHBG, the transport protein for sex hormones. In cultured human liver cells, insulin lowered SHBG production from 65.0 to 46.8 nmol per million cells. In humans, a Cochrane analysis found a reduction of the free androgen index by 1.11 points under lifestyle change. That one figure rests on six randomised studies with 204 women in total, at low quality of evidence. Endpoints on skin and hair were not recorded there at all. So a measurable but small shift is realistic, and it does not replace medical treatment.

Does spearmint tea do anything for unwanted hair?

In a randomised study over 30 days with 42 randomised participants, free and total testosterone fell significantly within the spearmint group, and the self reported burden went down. A clean comparison against the placebo group is not reported for the hormone values. The objective Ferriman Gallwey score did not differ between the groups after 30 days, with p equal to 0.12. The author attributes this explicitly to the short study duration. The preceding study from Turkey ran only five days in 21 women without a control group. That is a signal, not a body of evidence, and it does not replace medically supervised treatment.

Can zinc contribute anything in PCOS hair loss and hirsutism?

In a randomised, double blind study in 48 women over eight weeks, the modified Ferriman Gallwey score fell by 1.71 points under zinc compared with 0.29 under placebo. Hair loss decreased in 41.7 percent compared with 12.5 percent. The hormone profiles did not change. That is one study, one centre, eight weeks, and the mechanism remains unclear. One study is not a body of evidence. The study dose is also high: EFSA derives a tolerable upper intake level of 25 mg for total daily zinc intake, and the German Federal Institute for Risk Assessment recommends at most 6.5 mg per day in food supplements. Zinc at higher doses over longer periods can disturb copper balance and through that affect the blood count and the nervous system, which is why something like this belongs under medical supervision and is not put together by yourself.

What is better for heavy hair growth, laser or IPL, and does it last?

A Cochrane analysis of eleven studies and 444 people found about 50 percent hair reduction up to six months after treatment for alexandrite and diode lasers. For intense pulsed light, neodymium YAG and ruby lasers there was little evidence of an effect. Long term hair removal was not documented for any method. Little was reported about side effects in these studies; named were pain, redness, swelling, burned hairs and changes in skin pigmentation. How high that risk is depends strongly on skin type and on the device settings. This review is from 2006, device technology has developed further since then, which explains the gap but does not close it. The 2023 PCOS guideline recommends laser and light therapies all the same, explicitly also because of depression, anxiety and quality of life.

When can I judge whether a treatment is doing anything?

Six months is the usual lower limit. The Endocrine Society guideline recommends adding an antiandrogen only once the patient relevant burden persists after six months of monotherapy with a contraceptive. The 2023 international PCOS guideline also names at least six months in recommendation 4.6.1. The reason lies in the hair cycle: a hair that is programmed differently today looks different only months later. For hair loss, the observation window in the antiandrogen study was at least twelve months. Antiandrogens are prescription only and partly cause birth defects, so secure contraception and medical supervision always belong with them.

Why am I being checked for mould, heavy metals and endocrine disruptors when I came about my hair?

Because there is an additional layer that rarely gets time, and because it acts measurably on the same levers: insulin, SHBG, inflammation. So far little of it is established. In a case control study with 71 women with PCOS and 100 controls, bisphenol A in blood was 1.05 compared with 0.72 nanograms per millilitre, with correlations to testosterone of r equal to 0.192 and to androstenedione of r equal to 0.257. Those are weak associations, and the authors speak explicitly of a possible role, not of a cause. It does not follow that every hormonal disorder has an environmental cause. The gynaecological and dermatological workup remains the foundation, the environmental perspective comes on top of it and not in its place.

Where this topic connects to the rest

Skin and hair never stand alone in PCOS. They hang on glucose metabolism, on iron and thyroid, on the question of contraception and on how much room observing is given. Depending on where you stand right now, one of these routes leads onward.

If you want to understand the diagnosis first

Polycystic ovary syndrome: causes and symptoms

The overview of criteria, causes and the integrative route, of which this article deepens only one section.

If skin is your main topic

Hormonal acne from the inside

The mechanism behind hormonal acne, independently of PCOS, with sebaceous gland, insulin and inflammation interacting.

If you want to understand the blood sugar lever

Insulin resistance and female hormones

The axis between blood sugar, insulin and the female hormones, meaning the layer underneath free testosterone.

If you want the enzyme route in detail

DHT, hair loss and testosterone

How 5 alpha reductase and DHT act at the follicle, described there explicitly from a male perspective.

If the hair loss may not be hormonal at all

Iron deficiency and hair loss

Which ferritin value hair needs, and why this value so often disappears into a subordinate clause in routine labs.

If skin and hair appear together with fatigue

Thyroid and female hormones

The second axis behind the same symptoms, and why the professional society recommends looking at it too.

If you want to know what else I look for

Xenoestrogens in everyday life

Endocrine disruptors in daily life, with an honest account of what the data support and what they do not.

If you are thinking about stopping

Coming off the pill and the post pill phase

What happens in the months afterwards, and why skin and hair often react first. Meant as a basis for a conversation.

If you want to change something tomorrow

Avoiding blood sugar spikes

Order, combination and timing while eating, practical instead of theoretical, without a list of bans.

If observing turns into compulsion

Eating disorders between body and mind

When control over appearance and food tips over, and where support sensibly starts, before things get tight.

If the diagnosis is not settled yet

Diagnosing PCOS: Rotterdam and the phenotypes

The Rotterdam criteria, the four phenotypes and the exclusion work that often gets skipped.

If a testosterone value is in question

Testosterone in women

Too much, too little, and why measuring in the low female range is so difficult.

If the values look normal

SHBG: the overlooked value

The transport protein that explains why two women with the same testosterone can experience very different things.

If you want to understand the engine

PCOS and insulin resistance

How insulin keeps androgens up and SHBG down, and what each measurement actually shows.

Shukri Jarmoukli

Physician · Area of focus: integrative medicine · ViveCura Berlin

I work in my private practice at the intersection of conventional medicine, functional medicine and Clinical Psychoneuroimmunology. In PCOS, beyond the diagnosis, what interests me above all is the question of what carries free testosterone so high, meaning insulin and SHBG, inflammation, micronutrients and environmental factors.

On skin and hair I am more reserved than you might expect from an integrative practice. The documented routes run through contraceptives, antiandrogens, topical agents and laser, and they need time. What I look at in addition has an honestly small data base, and I write it down exactly that way. This article does not replace medical advice and does not replace a gynaecological or dermatological workup. It is meant to help you ask better questions at your next appointment.

ViveCura, Privatpraxis Shukri Jarmoukli, Skalitzer Straße 137, 10999 Berlin

Scientific sources

Teede HJ, Tay CT, Laven J, Dokras A, Moran LJ, Piltonen TT et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Hum Reprod. 2023;38(9):1655-1679. PMID: 37580037 · DOI: 10.1093/humrep/dead156 [Guideline, Consensus Guideline]
Martin KA, Anderson RR, Chang RJ, Ehrmann DA, Lobo RA, Murad MH et al. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(4):1233-1257. PMID: 29522147 · DOI: 10.1210/jc.2018-00241 [Guideline, Consensus Guideline]
Carmina E, Azziz R, Bergfeld W, Escobar-Morreale HF, Futterweit W, Huddleston H et al. Female Pattern Hair Loss and Androgen Excess: A Report From the Multidisciplinary Androgen Excess and PCOS Committee. J Clin Endocrinol Metab. 2019;104(7):2875-2891. PMID: 30785992 · DOI: 10.1210/jc.2018-02548 [Guideline, Systematic Review]
Reynolds RV, Yeung H, Cheng CE, Cook-Bolden F, Desai SR, Druby KM et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30. PMID: 38300170 · DOI: 10.1016/j.jaad.2023.12.017 [Guideline, Consensus Guideline]
Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab. 1961;21:1440-1447. PMID: 13892577 · DOI: 10.1210/jcem-21-11-1440 [Original paper, Basis for reviews]
DeUgarte CM, Woods KS, Bartolucci AA, Azziz R. Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. J Clin Endocrinol Metab. 2006;91(4):1345-1350. PMID: 16449347 · DOI: 10.1210/jc.2004-2301 [Cross-sectional, Cohort, n=633]
Zhao X, Ni R, Li L, Mo Y, Huang J, Huang M et al. Defining hirsutism in Chinese women: a cross-sectional study. Fertil Steril. 2011;96(3):792-796. PMID: 21762890 · DOI: 10.1016/j.fertnstert.2011.06.040 [Cross-sectional, Cohort, n=2,988]
Rios X, Vergara JI, Wandurraga EA, Rey JJ. Clinical assessment of body hair in Colombian women: determining the cutoff score that defines hirsutism. Biomedica. 2013;33(3):370-374. PMID: 24652172 [Cross-sectional, Cohort, n=323]
Randall VA. Hormonal regulation of hair follicles exhibits a biological paradox. Semin Cell Dev Biol. 2007;18(2):274-285. PMID: 17379547 · DOI: 10.1016/j.semcdb.2007.02.004 [Mechanism Review, Narrative Review]
Sawaya ME, Price VH. Different levels of 5alpha-reductase type I and II, aromatase, and androgen receptor in hair follicles of women and men with androgenetic alopecia. J Invest Dermatol. 1997;109(3):296-300. PMID: 9284093 · DOI: 10.1111/1523-1747.ep12335779 [Cohort, Tissue samples, n=24]
Keen MA, Shah IH, Sheikh G. Cutaneous Manifestations of Polycystic Ovary Syndrome: A Cross-Sectional Clinical Study. Indian Dermatol Online J. 2017;8(2):104-110. PMID: 28405549 · DOI: 10.4103/2229-5178.202275 [Cross-sectional, Cohort, n=100]
Feng JG, Guo Y, Ma LA, Xing J, Sun RF, Zhu W. Prevalence of dermatologic manifestations and metabolic biomarkers in women with polycystic ovary syndrome in north China. J Cosmet Dermatol. 2017;17(3):511-517. PMID: 28940857 · DOI: 10.1111/jocd.12387 [Case-control, Cohort, n=299]
Khunger N, Kumar C. A clinico-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78(3):335-341. PMID: 22565434 · DOI: 10.4103/0378-6323.95450 [Cross-sectional, Cohort, n=280]
Lipton MG, Sherr L, Elford J, Rustin MHA, Clayton WJ. Women living with facial hair: the psychological and behavioral burden. J Psychosom Res. 2006;61(2):161-168. PMID: 16880018 · DOI: 10.1016/j.jpsychores.2006.01.016 [Cross-sectional, Cohort, n=88]
Dokras A, Clifton S, Futterweit W, Wild R. Increased prevalence of anxiety symptoms in women with polycystic ovary syndrome: systematic review and meta-analysis. Fertil Steril. 2012;97(1):225-230.e2. PMID: 22127370 · DOI: 10.1016/j.fertnstert.2011.10.022 [Meta-analysis, Systematic Review]
Plymate SR, Matej LA, Jones RE, Friedl KE. Inhibition of sex hormone-binding globulin production in the human hepatoma (Hep G2) cell line by insulin and prolactin. J Clin Endocrinol Metab. 1988;67(3):460-464. PMID: 2842359 · DOI: 10.1210/jcem-67-3-460 [In vitro, Cell culture]
Lim SS, Hutchison SK, Van Ryswyk E, Norman RJ, Teede HJ, Moran LJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2019;3(3):CD007506. PMID: 30921477 · DOI: 10.1002/14651858.CD007506.pub4 [Systematic Review, Meta-analysis, k=15]
Fraison E, Kostova E, Moran LJ, Bilal S, Ee CC, Venetis C, Costello MF. Metformin versus the combined oral contraceptive pill for hirsutism, acne, and menstrual pattern in polycystic ovary syndrome. Cochrane Database Syst Rev. 2020;8(8):CD005552. PMID: 32794179 · DOI: 10.1002/14651858.CD005552.pub3 [Systematic Review, Meta-analysis, k=44]
Greff D, Juhasz AE, Vancsa S, Varadi A, Sipos Z, Szinte J et al. Inositol is an effective and safe treatment in polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials. Reprod Biol Endocrinol. 2023;21(1):10. PMID: 36703143 · DOI: 10.1186/s12958-023-01055-z [Systematic Review, Meta-analysis, k=26]
Brown J, Farquhar C, Lee O, Toomath R, Jepson RG. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev. 2009;(2):CD000194. PMID: 19370553 · DOI: 10.1002/14651858.CD000194.pub2 [Systematic Review, Meta-analysis, k=9]
Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2012;2012(7):CD004425. PMID: 22786490 · DOI: 10.1002/14651858.CD004425.pub6 [Systematic Review, Meta-analysis, k=31]
van Zuuren EJ, Fedorowicz Z, Schoones J. Interventions for female pattern hair loss. Cochrane Database Syst Rev. 2016;2016(5):CD007628. PMID: 27225981 · DOI: 10.1002/14651858.CD007628.pub4 [Systematic Review, Meta-analysis, k=47]
Sinclair R, Wewerinke M, Jolley D. Treatment of female pattern hair loss with oral antiandrogens. Br J Dermatol. 2005;152(3):466-473. PMID: 15787815 · DOI: 10.1111/j.1365-2133.2005.06218.x [Cohort, Uncontrolled intervention study, n=80]
Haedersdal M, Gotzsche PC. Laser and photoepilation for unwanted hair growth. Cochrane Database Syst Rev. 2006;2006(4):CD004684. PMID: 17054211 · DOI: 10.1002/14651858.CD004684.pub2 [Systematic Review, Meta-analysis, k=11]
Hamzavi I, Tan E, Shapiro J, Lui H. A randomized bilateral vehicle-controlled study of eflornithine cream combined with laser treatment versus laser treatment alone for facial hirsutism in women. J Am Acad Dermatol. 2007;57(1):54-59. PMID: 17270315 · DOI: 10.1016/j.jaad.2006.09.025 [RCT, split face controlled, n=31]
Grant P. Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. A randomized controlled trial. Phytother Res. 2010;24(2):186-188. PMID: 19585478 · DOI: 10.1002/ptr.2900 [RCT, n=42]
Akdogan M, Tamer MN, Cure E, Cure MC, Koroglu BK, Delibas N. Effect of spearmint (Mentha spicata Labiatae) teas on androgen levels in women with hirsutism. Phytother Res. 2007;21(5):444-447. PMID: 17310494 · DOI: 10.1002/ptr.2074 [Cohort, Uncontrolled, n=21]
Jamilian M, Foroozanfard F, Bahmani F, Talaee R, Monavari M, Asemi Z. Effects of Zinc Supplementation on Endocrine Outcomes in Women with Polycystic Ovary Syndrome: a Randomized, Double-Blind, Placebo-Controlled Trial. Biol Trace Elem Res. 2016;170(2):271-278. PMID: 26315303 · DOI: 10.1007/s12011-015-0480-7 [RCT, double blind, n=48]
Smith RN, Mann NJ, Braue A, Makelainen H, Varigos GA. A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr. 2007;86(1):107-115. PMID: 17616769 · DOI: 10.1093/ajcn/86.1.107 [RCT, n=43, male participants only]
Kandaraki E, Chatzigeorgiou A, Livadas S, Palioura E, Economou F, Koutsilieris M et al. Endocrine disruptors and polycystic ovary syndrome (PCOS): elevated serum levels of bisphenol A in women with PCOS. J Clin Endocrinol Metab. 2011;96(3):E480-E484. PMID: 21193545 · DOI: 10.1210/jc.2010-1658 [Case-control, Cohort, n=171]

Transparency on the evidence: where the data are thin

The origin of the score can only partly be checked. No abstract is available in PubMed for the 1961 paper. So no sample size and no description of the sample of that time appears here. What is documented is the origin in the United Kingdom and the later modification by Hatch, via the Colombian paper, which reports it verbatim.
The widespread sharpened claim that the score was developed only in white women cannot be supported that way. The US population study explicitly found no difference between black and white women, and the guideline states that prevalence appears similar across ethnicities. What is supported is the criticism of a single cutoff set too high, no more than that.
The tissue study on receptors and enzymes covers 24 people. It explains a pattern, it does not test a treatment, and everyone involved already had androgenetic alopecia.
The frequency figures for skin signs come from a dermatology clinic sample. 78 percent hirsutism and 30 percent acanthosis nigricans describe women who came because of skin problems. As population prevalence these numbers do not work.
The mechanism of acanthosis nigricans stands here without a citation. For the common explanation via related growth factor receptors on skin cells, no cleanly verifiable primary source was found in this research. It therefore stands explicitly as a plausible assumption.
In the spironolactone analysis the abstract is internally inconsistent at one point. This is why only the odds ratio of 7.18 for subjective improvement and the finding that no evidence of efficacy was found for acne appear here. The weighted mean difference to the objective score, also given there, is deliberately not quoted.
The figure of 44 percent regrowth comes from a study without a control group. Part of this result might have turned out the same way without treatment. The authors themselves call for a placebo controlled study.
The laser analysis is from 2006. None of the eleven included studies had high methodological quality. Device technology has changed since then, which explains the missing long term documentation but does not replace it. Newer robust data were not reviewed for this article.
Zinc and spearmint each rest on one small study. 48 women over eight weeks, and 42 women over 30 days respectively. The hormone values did not move for zinc, the objective score did not move for spearmint. Both are a pointer and not a body of evidence.
The insulin SHBG link was shown in liver cells in culture. What is documented in humans is only that the free androgen index fell by 1.11 points under lifestyle change, at low quality of evidence and without endpoints on skin and hair.
The study on glycaemic load was conducted exclusively in young men. It appears here only with that label and is not evidence for women with PCOS.
The environmental finding is a single case control study with weak correlations between 0.19 and 0.27, with the direction unclear. It does not follow that every hormonal disorder has an environmental cause. The mentioned finding in laboratory animals is an animal finding and not human evidence.
On inositol a further meta-analysis was reviewed and not quoted, because its author group includes a connection to a company that sells such preparations. The analysis quoted here is independent of that.
No figures are given here for inositol, deliberately. In Germany inositol is a food supplement. Disease related claims may not be made for a food, so the meta-analysis cited here appears without its result figures.
What deliberately does not appear here. No personal dosing recommendation, no treatment protocol, no product names and no sources of supply. And no sentence suggesting that you change, reduce or stop an existing medication on your own, or postpone a recommended gynaecological, dermatological or surgical workup. Every adjustment belongs under medical supervision. What I describe from my own consultation is labelled as an observation and is not a study result.

PCOS on Skin and Hair: Hirsutism, Acne and Hair Loss

What awaits you here

Why skin and hair of all things weigh so heavily

The four signs this is about

The paradox: less above, more below

Why the hair follicle gives its own answer

What these numbers do not say

Hirsutism: the score, its limits and what you carry

Three countries, three cutoffs

What the 2023 guideline made of it

No, the score does not simply measure past white women

Hair loss in women: pattern, regrowth, timeline

Why the hairline usually stays

Does it grow back?

Acne in PCOS: why it behaves differently than at sixteen

A location on the chin does not prove PCOS

Acanthosis nigricans: the skin sign that speaks about metabolism

Four features

The mechanism is plausible, but I do not quote it as evidence

The treatment paths and what they honestly deliver

Block 1: Hormonal contraception

Block 2: Antiandrogens

Block 3: Topical and local options

Block 4: Laser and IPL

The route I take in addition, and where it honestly ends

The best founded lever: insulin and SHBG

The guideline advises against relying on blood sugar alone

Zinc: one study, not a field

Spearmint: the hormones move, the score does not

Inositol: the lab moves, skin and hair have not been studied

Environment: the part this article exists for

And now the most important paragraph of this article

How you notice that observing is taking up too much room

Frequently asked questions

Where this topic connects to the rest

Polycystic ovary syndrome: causes and symptoms

Hormonal acne from the inside

Insulin resistance and female hormones

DHT, hair loss and testosterone

Iron deficiency and hair loss

Thyroid and female hormones

Xenoestrogens in everyday life

Coming off the pill and the post pill phase

Avoiding blood sugar spikes

Eating disorders between body and mind

Diagnosing PCOS: Rotterdam and the phenotypes

Testosterone in women

SHBG: the overlooked value

PCOS and insulin resistance

Shukri Jarmoukli

Scientific sources

Have questions or want to book an appointment?