When I was first diagnosed with polycystic ovary syndrome (PCOS), the gynecologist made the diagnosis based solely on my lack of a period and the visible dark hairs on my upper lip. For years, I waged war against those pesky dark hairs, found on my upper lip, chin, and lower belly, and excess hair growth is a common struggle for women with PCOS. It's also often a cause of shame, embarrassment, and reduced self-esteem. Sadly, most doctors don't realize the potential damage of these seemingly benign symptoms, and they rarely provide tools to help.

Fortunately, there are a lot of natural options out there!

This article will first define what exactly hirsutism is. Then we'll talk about the root cause of hirsutism in women with PCOS. Lastly, and most importantly, we'll talk about effective ways to reduce unwanted hair growth.

WHAT IS HIRSUTISM?

Hirsutism is the technical term for a more masculine pattern of hair growth on the face and body, and PCOS is the most common cause of hirsutism. Hirsutism involves the production of "terminal hairs." A terminal hair is coarse and dark, like the hairs commonly associated with men's beards. In contrast, "vellus hairs" are shorter, softer, and not pigmented. These hairs are often called "peach fuzz." Vellus hair growth is largely genetic, although peach fuzz can be elevated in people with higher stress hormones or those who are underweight. Terminal hairs can have a genetic component, but they are also driven by high levels of androgens.

Why Do Women with PCOS Experience Hirsutism (Unwanted facial and body hair)?

Hirsutism in women with PCOS (and other women) is driven by high androgen levels (aka excess male hormones), specifically free testosterone. Most of the testosterone in a well-functioning female body will be bound up by sex hormone-binding globulin (SHBG) and albumin. When testosterone is bound up, it can’t contribute to more masculine characteristics like unwanted facial hair.

Most women with PCOS have insulin resistance, during at least some part of their menstrual cycle. When we have insulin resistance, our bodies need to pump out more and more insulin to stabilize blood sugar levels.

In the presence of excess insulin, the ovaries excrete higher levels of testosterone while SHBG levels decrease, resulting in more unbound testosterone, known as free testosterone. There is some evidence that women with PCOS have ovaries that are especially sensitive to higher insulin levels.

These high testosterone levels then act on androgen receptors in the body, causing excessive growth of hair where you don’t want it.

Many women with PCOS will also experience hair loss from places they do want it (primarily your head!), which is also a result of high androgen production.

Common Treatment Options for excessive facial and body hair growth

Just live with it. Some people are totally cool with the hairs, and if this is you, keep on doing you!
Take hormonal birth control pills with lower androgenic progestins like Drospirenone. Talk to your healthcare provider about potential risks and side effects.
Use simple hair removal methods like tweezing, shaving, threading, waxing, or hair removal creams - I think these are relatively self-explanatory ways to remove those hairs, and if you're reading this, I bet you're already doing at least one of these things! Ingrown hairs and time are likely the biggest challenges with these methods.
Get laser hair removal. In theory, laser hair removal is permanent hair removal that works by damaging the hair follicles, but in reality, changes to your hormones may cause new hairs to form. This was my experience. Laser hair removal is also most effective on dark hair and coarse hair on people with light skin. It is less effective for those with light hair or darker skin tones. It is also very expensive! And can cause skin irritation.
Take spironolactone. This is a prescription often provided alongside a PCOS diagnosis. Spironolactone blocks testosterone receptors and reduces male-pattern hair growth. However, this medication can also have side effects (as I experienced!).

Less Common, but Effective Options that Address the Underlying Cause of Hirsutism (All discussed further below)

Use time-restricted eating (aka, fasting) or shift more of your calories earlier in the day.
Add in spearmint tea.
Take a probiotic supplement.
Take magnesium.
Get more vitamin D (through sunshine, food, or supplements - be careful with supplements!)
Use diet to address your insulin resistance. Following a ketogenic diet or a low glycemic index/load diet has been shown to improve insulin resistance in women with PCOS. I also love working one-on-one with clients to help personalize their diet plans.
Use carb-cycling if just following a low glycemic index diet alone doesn't fully resolve your hirsutism. See the lists of carbs below and learn about menstrual cycle tracking here.

Time Restricted Eating to Lower Testosterone

Time-restricted eating often, although not always, has been shown to improve insulin sensitivity. With insulin resistance being a primary underlying factor for the elevated free testosterone underlying hirsutism, it makes intuitive sense that improving insulin sensitivity would also improve reproductive hormone levels and PCOS symptoms.

To test this theory, Li et al. (2021) recruited 18 women with PCOS between the ages of 18 and 31 who were anovulatory (did not have naturally occurring periods) and had BMIs of at least 24. All participants were outpatients at the Department of Endocrinology at the Shengjing Hospital of China Medical University.

During the first week of the study, participants ate as they normally did and kept track of their food consumption. They also weighed themselves each day, and the researchers took a variety of baseline measurements.

During the next five weeks of the study, all participants were asked to fast for 16 hours and eat within an 8-hour window, from 8 a.m. to 4 p.m. each day. They were asked not to adjust their diet in any other way (in terms of total calories or macronutrient composition) relative to their baseline diets.

In terms of insulin sensitivity, participants experienced a 21% reduction in fasting insulin, a 28% improvement in their handling of an oral glucose drink, and a 21% reduction in HOMA-IR (a measure of insulin resistance). All of these changes are substantial improvements.

As we might expect from an increase in insulin sensitivity, participants experienced an average of a 9% reduction in total testosterone, a 19% increase in sex-hormone binding globulin (which we want to see increase to reduce free testosterone), and a 26% decrease in free androgen index. These changes would all help to address PCOS symptoms like acne and hirsutism.

While not the subject of this article, participants also experienced substantial weight loss, despite not adjusting their total calories.

Altering Caloric Timing to Reduce Testosterone Levels

While we often think about fasting as a way to improve insulin sensitivity and manage PCOS, simply shifting the distribution of your caloric intake may yield benefits. For many women, the idea of fasting can be daunting and/or create feelings of restriction that may cause undo anxiety (this is the case for me!). So, I love that there is an easier way to achieve the hormonal benefits of fasting!

Jakubowicz et al. (2013) recruited 60 women, ages 25 to 39, with BMIs less than 23.7 who had previously been diagnosed with PCOS. The majority of the women were sedentary and were asked to maintain their status quo level of exercise throughout the intervention.

All women consumed diets consisting of 1800 calories per day, which was determined to be an amount of calories that should maintain body weight. Mealtime windows were as follows:

Breakfast: 6AM - 9AM
Lunch: 12PM - 3PM
Dinner: 6PM - 9PM

The participants were given meal plans that used the following macronutrient quantities:

Carbohydrates: 124g
Protein: 191g
Fat: 62g

However, consumption differed based on the timing of calories consumed. Half of the women were assigned to the “breakfast diet” with calories as follows:

Breakfast: 980 calories (54%)
Lunch: 640 calories (35%)
Dinner: 190 calories (11%)

The “dinner diet” reversed these amounts:

Breakfast: 190 calories (11%)
Lunch: 640 calories (35%)
Dinner: 980 calories (54%)

The women followed these diets for 12 weeks. Among the breakfast diet participants, average fasting glucose decreased by 8%, and average fasting insulin decreased by 53%. Measures of insulin resistance, HOMA-IR and HOMA-B, decreased by 56% and 35% respectively, while a measure of insulin sensitivity, ISI, increased by 135%. These are substantial improvements in the participants’ blood sugar management! The dinner diet experienced no statistically significant changes in any of these measurements. These impacts are substantially larger than those found for time-restricted eating, although this study was also longer than the time-restricted eating study, which may explain the different magnitudes of findings.

Among breakfast diet participants, their sex hormone binding globulin doubled on average, while free testosterone decreased by 50%, DHEA-S decreased by 35%, total testosterone by 47%, and free androgen index by 78%. All these changes imply that the diet shift likely had significant effects on pesky PCOS symptoms like excessive body and facial hair growth, acne, and male-pattern baldness. The only statistically significant change experienced by the dinner diet group was a 35% increase in one of the forms of estrogen studied.

Why does timing matter?

Melatonin can interfere with insulin sensitivity, with the degree of interference in part determined by genetics (Garaulet et al. 2020).

It can take up to five hours for your body to digest and absorb the food you’ve eaten (Tobias and Sadiq 2022), and your body starts producing melatonin when it senses the onset of darkness (Masters et al. 2014).

If the sun sets where you are around 8 pm, (assuming you’re not staring at bright screens) your body will start secreting melatonin around this time. If you’ve consumed dinner at 7 pm, you may have up to 4 more hours of digestion after melatonin has been released. If you consume even moderate amounts of carbohydrates at dinner, your body may have a hard time regulating your blood sugar due to the circulating melatonin, which will cause your pancreas to secrete high levels of insulin in its attempt to bring your blood sugar back down. This will exacerbate any existing insulin resistance that you have.

When I’ve consumed carbohydrates closer to bedtime while wearing a continuous glucose monitor, I’ve observed my blood sugar spiking higher overnight than the same food would have done if consumed earlier in the day. And when these spikes have occurred, my blood sugar has remained dysregulated, with peaks and dips occurring for hours. Shifting most of my caloric consumption earlier in the day would reduce the impacts of melatonin-induced insulin resistance.

Spearmint Tea for Hirsutism

Spearmint tea is a classic recommendation for women with PCOS. In fact, this tea has anecdotally eliminated all PCOS symptoms in some women. I don't think it is a miracle tea for most women with PCOS, but there is solid evidence that it can help with PCOS symptoms.

The first of two respectable studies using spearmint tea to treat excess androgens occurred in Turkey and recruited 21 women who experienced hirsutism, 12 of whom had also been diagnosed with PCOS (Akdogan et al. 2007). Twice daily for five days, the women consumed spearmint tea. The tea was prepared with 1 tsp (5 grams) of dried leaves with 1 cup of boiling water which steeped for 5 to 10 minutes. Levels of relevant hormones were tested both before and after the 5-day intervention period. They found about a 40% reduction in free testosterone, although no change in total testosterone was found. This suggests a possible increase in sex hormone-binding globulin, although this hormone was not measured. They also found a 27% increase in luteinizing hormone (LH), a 17.5% increase in follicle-stimulating hormone (FSH), and a 36.4% increase in estradiol (the most common form of estrogen). Note that most women with PCOS usually have an elevated LH to FSH ratio (Saadia 2020), so while spearmint tea may reduce free testosterone, it may exacerbate existing imbalances between LH and FSH. The relative levels of these hormones are critical for ovulation.

A second study sought to replicate the original study, and also explicitly considered the impact on hirsutism (Grant 2010). This study recruited 42 women with PCOS, half of whom were assigned to the treatment group to consume spearmint tea, twice per day, for 30 days; the other half consumed chamomile tea, which has no impact on androgen hormones. Like the original study, this study measured hormone levels before and after the intervention period. Unlike the previous study, they also specifically measured and compared changes in hirsutism, as measured by the Ferriman-Galway ratings of hirsutism. While they found similar impacts on hormones at the conclusion of the study (29% reduction in free testosterone, 23% reduction in total testosterone, 38% increase in LH, 19% increase in FSH), they found no statistically significant difference in their objective measure of hirsutism. However, the women in the treatment group assessed their own hirsutism as improved, while the control group did not. This suggests that objective measures of hair growth may not be able to capture all of the nuances of hair growth that women can observe on their own bodies. If you’ve ever carefully tweezed each rogue hair, you know how familiar you can get with your hair patterns, so I’m inclined to trust the women’s observations.

It should be noted that the average growth cycle for facial hair is about four months (Matheson and Bain 2019), so neither study lasted long enough to capture all of the impacts of the intervention on hirsutism.

Probiotics and Hirsutism

There are several studies on the use of probiotics to address various PCOS symptoms and health markers. One study specifically considered the effects of probiotics on hirsutism. This study by Arab et al. (2020) recruited 99 women with PCOS from the Arash Women's Hospital in Tehran, Iran. Participants were aged 19 to 37 years old, with body mass indexes of 25 or higher (associated with being overweight or obese). 50 of the participants were randomly assigned to the probiotic group. This group consumed:

2 capsules per day, which contained 7 strains of beneficial bacteria, including
- Lactobacillus acidophilus (ATCC: 4357) 3 × 10^10 colony-forming units (CFU)
- Lacticaseibacillus casei (ATCC: 393) 3 × 10^9 CFU
- Lactobacillus bulgaricus (ATCC: 11842) 5 × 10^8 CFU
- Lacticaseibacillus rhamnosus (ATCC: 7469) 7 × 10^9 CFU
- Bifidobacterium longum (ATCC: 15697) 1 ×10^9 CFU
- Bifidobacterium breve (ATCC: 15700) 2 × 10^10 CFU
- Streptococcus thermophilus (ATCC: 19258) 3 × 10^8 CFU)
- 21 mg inulin, a prebiotic that can support beneficial gut bacteria

The control group took two placebo capsules each day which contained 250 mg starch and 250 mg maltodextrin.

Each group took their respective capsules for 12 weeks.

The probiotic group did not experience any changes in total testosterone levels, sex hormone-binding globulin, or free androgen index. The placebo group experienced an increase in their levels of total testosterone and free androgen index and decreases in sex hormone binding globulin. In this sense, if the probiotic helped the probiotic group prevent worsening hormonal imbalances, then we could consider this a benefit of probiotic supplementation, even though they did not experience changes themselves. Both groups experienced an increase in DHEAS, which is another androgen hormone.

The placebo group also experienced small changes in the percentage experiencing different levels of hirsutism, while the placebo group did not. After the intervention, the probiotic group had a larger percentage with no hirsutism and smaller percentages with mild or moderate hirsutism. The percentage with severe hirsutism did not change.

Pre- and post-intervention hirsutism (excessive facial and/or body hair growth) severity for women with polycystic ovary syndrome (PCOS) taking either a probiotic supplement or a placebo for 12 weeks. Results compiled from Arab et al. (2020).

It is quite interesting that this study did not find beneficial effects of probiotics on lab-measured hormone levels, but did observe positive effects of probiotic supplementation in terms of the symptoms of PCOS. This suggests that a healthy gut may play a role in symptoms, regardless of hormone levels. It also suggests that more studies of women with PCOS should measure symptoms, and not just lab values.

Magnesium and Hirsutism

Magnesium has been studied in the context of several women's health challenges, and one study specifically included hirsutism measurements for women with PCOS.

Shokrpour and Asemi (2019) recruited 60 women with PCOS. Half were given a daily supplement of 250 mg of magnesium and 400 mg of vitamin E per day. The other half received a placebo. Fasting blood samples were taken at the start of the study and after 12 weeks of administration of the supplement/placebo. They found that within the group of women receiving the supplement, sex-hormone binding globulin increased (a positive change because it helps to neutralize excess androgens), an index of free androgens decreased, and hirsutism decreased. None of these changes were observed among the control group.

Vitamin D and Menstrual Cycle Regularity

Lastly, among the supplement options, Vitamin D supplements have become quite trendy in recent years. One study considered the use of vitamin D among women with PCOS who were deficient in vitamin D.

Irani et al. (2015) recruited 68 females with PCOS who were also deficient in vitamin D.

Of these participants, 45 were randomly assigned to supplement with vitamin D and consumed:

One capsule of 50,000 IU of vitamin D each week.

23 were randomly assigned to the control group, and they consumed:

One capsule filled with lactose monohydrate powder, which looked similar to the vitamin D capsule.

Both groups consumed their respective capsules weekly for 8 weeks.

As expected, the group consuming the placebo experienced no changes in any marker of health.

The treatment group experienced a 21% decrease in the Ferriman-Gallway score, which is a marker of hirsutism. Interestingly, despite these in overt symptoms of excess androgen hormones, no changes in any reproductive hormones occurred. These findings are similar to the effects of probiotic supplementation. It should be noted that these findings may not occur in women with sufficient vitamin D levels! Always consult your healthcare provider before starting supplements.

Using Diets to Improve Hirsutism

Past posts have discussed the ketogenic diet and the low glycemic index and/or load diets. I'm a big fan of following the low glycemic load diet, and it has definitely improved hirsutism both in myself and in my clients. The ketogenic diet is not always sustainable long term, so I am less likely to recommend this diet. However, if it works for you, use it! Both of these diets are covered extensively in the links above, so I won’t go into to them further here.

Carbohydrate Cycling and Hirsutism

When I saw my gynecologist after quitting hormonal birth control, I discussed the lingering dark hairs on my chin. She immediately suggested that I try Spironolactone, which blocks the effects of testosterone, without actually addressing the root cause of why it is being produced.

There was no discussion of the underlying causes of the high testosterone that was causing the excessive hair growth.

I tried Spironolactone for a few days. The drug is also used to manage high blood pressure. As someone whose blood pressure is usually right about 90 over 60, I don’t really need a medication that further lowers blood pressure. And indeed, when I tried weightlifting on Spironolactone, I got horribly lightheaded.

I had no intentions of quitting weightlifting, so I quit the Spironolactone instead and just kept on tweezing the pesky, rogue hairs. I also tried laser hair removal, which helped a bit, but my ever-wobbling androgen hormones seemed to continuously create new hair growth, so laser therapy felt a bit like whack-a-mole, and I abandoned that costly strategy.

By wearing a continuous glucose monitor, I learned that I am quite insulin-resistant in the 10 days before my period. As mentioned above, high insulin levels increase the production of testosterone and… cause those pesky dark hairs to sprout where I don’t want them. While my blood tests showed normal testosterone levels, I strongly suspect that this snapshot didn’t accurately capture the hormonal changes that occur across my entire menstrual cycle.

When I consistently adjust carbohydrate consumption during the last 10 days of my cycle for 2 - 3 cycles in a row, I notice significant improvements in my excess facial hair growth. During this interval, I focus on eating low glycemic index and low glycemic load carbohydrates such as: asparagus, bell pepper, broccoli, Brussel sprouts, cabbage, cauliflower, carrots, cucumbers, eggplant, fennel, green beans, kohlrabi, lettuce, kale, mushrooms, onion, radishes, spinach, summer squash, Swiss chard, tomatoes, zucchini.

During the rest of my cycle, I eat: all of the vegetables listed above as well as acorn squash, beets, butternut squash, pumpkin, rutabaga, boiled sweet potatoes, and turnips; fruits including apples, avocados, blackberries, blueberries, fresh figs, grapefruit, kiwi, mandarins, nectarines, oranges, plums, raspberries, strawberries, and tangerines; occasional grains including black wild rice (sometimes labeled forbidden rice) and quinoa; and legumes including black beans, cannellini beans, chickpeas, fava beans, great northern beans, green peas, hummus, lentils, mung beans, red beans, and soybeans.

(Not sure how to know where you are in your cycle? Check out my post on using basal body temperature to track your cycle.)

I haven't seen studies looking specifically at this strategy, so I can't say it will work for everyone. But it does work for me!

Also, remember that the average hair cycle is about four months, so you might not see immediate results with this strategy (or any of the above-mentioned holistic strategies), but stick with it for a few months to see if it works for you.

Take-home points

There are many strategies that you can experiment with to reduce male-pattern hair growth! And unlike conventional approaches, holistic strategies have little to no side effects.

Tackling insulin resistance through diet (and exercise and stress reduction!) will reduce hirsutism.

It may take a few months for any strategy to cause a noticeable reduction in hair growth due to hair’s natural growth cycle.

Always consult with a trusted healthcare professional before starting any supplement plan.

About the Author

Kelly Grogan, Ph.D., NTM, is a holistic nutrition therapist who is passionate about helping females with PCOS. She currently manages her own PCOS with nutrition and lifestyle tools that she developed through extensive review of the scientific literature on PCOS interventions.

references

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