Grading of hirsutism: a practical approach to the modified Ferriman-Gallwey scoring system

Abstract

Introduction:
The modified Ferriman-Gallwey (mFG) scale is accepted as a useful clinical scoring system in the evaluation of hirsutism.

Aim:
To prevent overlooking hirsutism diagnoses and facilitate patient examinations in ongoing pandemic conditions by simplifying the mFG score.

Material and methods:
This study included 227 patients who were diagnosed with hirsutism and had mFG scores of ≥ 8. Hair distribution and hair growth intensity of nine different body regions in the mFG score were examined.

Results:
Among our patients with hirsutism, terminal hair was present on the chin in 97.4% (n = 221), thighs in 96.5% (n = 219), upper lip in 94.7% (n = 215), and lower abdomen in 92.1% (n = 205), and this was significantly higher compared with the remaining five regions (p < 0.001 for each comparison). Terminal hair growth scored as ≥ 1 was found in 89% of the patients (n = 202) for the combination of the chin, thighs, and upper lip, and in 87.2% (n = 198) for the combination of the chin, thighs, and lower abdomen. When the chin and thighs were evaluated together, 75.3% (n = 171) of the patients had ≥ 2 terminal hair growth.

Conclusions:
In addition to the chin and thighs being the main regions of terminal hair growth, examination of the upper lip or lower abdomen can sufficiently help predict hirsutism. During the ongoing pandemic conditions when we need to follow social distancing rules, a practical approach to the mFG scoring system will facilitate the work of many physicians, including dermatologists, and will shorten the patient's stay in the clinic.

Full text

Advances in Dermatology and Allergology 1
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Original paper
Address for correspondence: Filiz Cebeci Kahraman Assoc. Prof., Department of Dermatology, Istanbul Medeniyet University, Göztepe
Prof. Dr. Süleyman Yalçın City Hospital, Dr. Erkin Street, Kadıköy, 347134 Istanbul, Turkey, phone: +90 5373724722, fax: +90 2122340419,
e-mail: cebeciliz@yahoo.com
Received: 25.05.2021, accepted: 22.06.2021.
Grading of hirsutism: a practical approach to the
modied Ferriman-Gallwey scoring system
Filiz Cebeci Kahraman1, Sevil Savaş Erdoğan2
1Department of Dermatology, Istanbul Medeniyet University, Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Istanbul, Turkey
2
Department of Dermatology, University of Health Sciences, Sultan 2. Abdulhamid Han Training and Research Hospital, Istanbul,
Turkey
Adv Dermatol Allergol
DOI: https://doi.org/10.5114/ada.2021.108455
Abstract
Introduction: The modied Ferriman-Gallwey (mFG) scale is accepted as a useful clinical scoring system in the
evaluation of hirsutism.
Aim: To prevent overlooking hirsutism diagnoses and facilitate patient examinations in ongoing pandemic condi-
tions by simplifying the mFG score.
Material and methods: This study included 227 patients who were diagnosed with hirsutism and had mFG scores
of ≥ 8. Hair distribution and hair growth intensity of nine dierent body regions in the mFG score were examined.
Results: Among our patients with hirsutism, terminal hair was present on the chin in 97.4% (n = 221), thighs in
96.5% (n = 219), upper lip in 94.7% (n = 215), and lower abdomen in 92.1% (n = 205), and this was signicantly
higher compared with the remaining ve regions (p < 0.001 for each comparison). Terminal hair growth scored as ≥ 1
was found in 89% of the patients (n = 202) for the combination of the chin, thighs, and upper lip, and in 87.2%
(n =198) for the combination of the chin, thighs, and lower abdomen. When the chin and thighs were evaluated
together, 75.3% (n = 171) of the patients had ≥ 2 terminal hair growth.
Conclusions: In addition to the chin and thighs being the main regions of terminal hair growth, examination of the
upper lip or lower abdomen can suciently help predict hirsutism. During the ongoing pandemic conditions when
we need to follow social distancing rules, a practical approach to the mFG scoring system will facilitate the work of
many physicians, including dermatologists, and will shorten the patient’s stay in the clinic.
Key words: Ferriman-Gallwey score, hair growth, hirsutism.
Introduction
Hirsutism is dened as the overgrowth of male-type
terminal hair in the androgen-sensitive areas of women
[1]. Approximately 5–10% of women of reproductive age
have hirsutism [2]. More than 80% of women with hirsut-
ism have polycystic ovary syndrome (PCOS), and approxi-
mately 10% have idiopathic hirsutism [3]. Therefore, the
body examination of patients presenting with excessive
hair growth, acne, androgenetic alopecia, and menstrual
irregularities should not be neglected to detect hirsutism.
The methods used for the clinical evaluation of hir-
sutism include photographic evaluation, microscopic
measurements of hair diameters, and computer-based
measurement of photographed hair [4]. However, grad-
ing of hair growth according to the modied Ferriman-
Gallwey (mFG) scale is a simpler and widely used stan-
dard method based on a visual scoring system [1]. The
original system was based on the scoring of the presence
of hair in 11 regions, which was then modied to include
nine regions [5].
Although the mFG scale is simpler than other meth-
ods, it involves the evaluation of the amount of terminal
hair in nine androgen-sensitive body regions: the upper
lip, chin, chest, upper and lower back, upper and lower
abdomen, upper arm, and thighs. The ongoing pandemic,
which is present all over the world, has brought about
certain difficulties in patient examinations, especially
concerning methods that require full undressing. The
evaluation of all these nine regions is challenging for
both physicians and patients in dermatology outpatient
clinics where time is limited and patient density is high.
The purpose of this study was to shorten the duration
of contact with the patient during the examination and

Advances in Dermatology and Allergology2
Filiz Cebeci Kahraman, Sevil Savaş Erdoğan
to simplify examinations for the detection of hirsutism
in socioculturally conservative countries, such as Turkey.
The examination of these nine regions, which present
with higher hair density, can provide rapid assessment,
reduce contact with the patient, and prompt physicians
to examine other regions if necessary.
Aim
Therefore, we aimed to identify a more practical
method that could be used in screening women sus-
pected of having hirsutism by revealing the body regions
where hair growth was clustered.
Material and methods
The study group consisted of 227 women aged 18–45
years who presented to our dermatology outpatient
clinic and were diagnosed with hirsutism. The study was
conducted according to the principles of the Declaration
of Helsinki and approved by the local ethics committee.
Women with an mFG score of ≥ 8 and diagnosis of id-
iopathic hirsutism or PCOS were included in the study,
retrospectively. The diagnosis of idiopathic hirsutism
was made according to the presence of hirsutism, regu-
lar menstrual cycle, and normal serum androgen prole
[6]. The diagnosis of PCOS was made according to the
revised Rotterdam diagnostic criteria based on the pres-
ence of at least two of the following three criteria: oligo-
or anovulation; clinical and/or biochemical signs of hy-
perandrogenism; and polycystic ovaries and exclusion of
other related disorders [7]. Pregnant or lactating patients,
those who used drugs such as oral contraceptives, corti-
costeroids, cyclosporine or spironolactone within the last
three months, and those with chronic diseases, thyroid
hormone dysfunction, congenital adrenal hyperplasia,
adrenal or ovarian tumours and other endocrine disor-
ders were excluded from the study.
According to the mFG scoring system, each region
was separately evaluated in terms of the rate of terminal
hair growth and scored from 0 (absence) to 4 (excessive).
The total score was calculated, and an mFG score of ≥ 8
was accepted as hirsutism [1, 5]. The severity of hirsutism
was classied as mild if the mFG score was 8–16, moder-
ate if 17–24, and severe if above 24 [1]. The details of the
mFG scores and age were retrospectively obtained from
the les of the patients. The presence and intensity of
hair growth in all regions were determined separately by
a single physician.
Statistical analysis
The SPSS v. 15.0 for Windows software package was
used for statistical analyses. Descriptive statistics are giv-
en as numbers and percentages for categorical variables,
and mean, standard deviation, minimum, maximum,
median and interquartile range for numerical variables.
Scores were compared using the Friedman test in more
than two dependent groups. Subgroup analyses were
performed using the Wilcoxon test. The comparison of
rates between more than two dependent groups was
undertaken using Cochran’s Q test. Subgroup analysis
was performed using the McNemar’s test. The results
were interpreted using Bonferroni correction in subgroup
analyses of more than two groups. The rates between
the independent groups were compared using the c2 test.
The comparisons of numerical variables in independent
groups were performed using the Mann-Whitney U test
because the conditions of normal distribution were not
met. The statistical signicance level of a was accepted
as p < 0.05.
Results
In this study, 227 patients with hirsutism were evalu-
ated. The mean age of the women with hirsutism was
25.4 ±6 (range: 18–45) years. The mean total mFG score
was 12.9 ±4.2 (range: 8–35), and 80.6% (n = 183) of the
patients had mild, 18.5% (n = 42) moderate, 0.9% (n = 2)
severe hirsutism. The average hair growth scores by
regions were 2.85 ±1.08 for the chin, 2.86 ±1.15 for the
thighs, 1.99 ±1.10 for the lip, 2.08 ±1.04 for the lower ab-
domen, 1.48 ±0.99 for the chest, 0.77 ±1.08 for the lower
back, 0.35 ±0.70 for the upper abdomen, 0.35 ±0.68 for
the arm, and 0.19 ±0.62 for the upper back (Table 1).
Table 1 shows the percentages of hair growth scores
for the nine regions included in the mFG scoring system
among the women in our study group (Figure 1). Terminal
hair was present on the chin in 97.4% (n = 221) of the
patients, thighs in 96.5% (n = 219), upper lip in 94.7%
(n = 215), and lower abdomen in 92.1% (n = 205) (Figure 2).
The rates of the presence of terminal hair on the chin,
upper lip, lower abdomen, and thighs (i.e., grade 1) were
statistically signicantly higher when compared with the
remaining regions (chest, upper abdomen, lower back,
upper back, and upper arm) (p < 0.001 for each compari-
son; p < 0.001 for the subgroup analysis with the Bonfer-
roni correction).
Table 2 shows the distribution of patients with hair
growth scores of ≥ 2, ≥ 3, and 4 by region. Accordingly,
the hair growth score was 2 or above for the chin region in
88.1% of the patients (n = 200), thighs in 85.9% (n = 195),
lower abdomen in 72.2% (n = 164), upper lip in 62.1% (n =
141), and chest in 48% (n = 109) (Figure 3). The presence
of terminal hair scored as ≥ 2 on the chin, upper lip, chest,
lower abdomen, and thighs were statistically signicantly
higher when compared with the remaining regions (upper
abdomen, lower back, upper back, and upper arm) (p <
0.001 for each comparison and p < 0.001 for the subgroup
analysis with Bonferroni correction) (Table 2).
When we evaluated the regions according to the
highest presence of hair growth, the rate of patients
with terminal hair scored as ≥ 1 was 89% (n = 202) for

Advances in Dermatology and Allergology
Grading of hirsutism: a practical approach to the modied Ferriman-Gallwey scoring system
3
the combination of the chin, thigh, and lip regions and
87.2% (n = 198) for the combination of chin, thigh, and
lower abdomen regions. The most common regions
with ≥ 2 terminal hair growth scores in our patients
were the chin and thighs. The proportion of patients
with terminal hair growth score ≥ 2 on both chin and
thighs 75.3% (n = 171).
Discussion
In this study, we examined the distribution and den-
sity of terminal hair in nine body regions, and the results
showed that the chin, thighs, upper lip, and lower abdo-
men were the regions that most contributed to the total
body hair growth score in the Turkish population. Given
that our study group comprised only patients with hirsut-
ism and we observed less frequency and intensity of hair
growth in the upper abdomen, lower back, upper back
and upper arm in these patients, we can easily state that
these four regions can be disregarded when using the
mFG scoring system in Turkish patients.
Table 1. Hair growth scores by body region
Body region Hair growth score
Mean ± SD Median (IQR) 0 1 2 3 4
Chin 2.85 ±1.08 3 (2–4) n621 52 70 78
% 2.6 9.3 22.9 30.8 34.4
Thigh 2.86 ±1.15 3 (2–4) n 8 24 47 60 88
% 3.5 10.6 20.7 26.4 38.8
Upper lip 1.99 ±1.10 2 (1–3) n 12 74 74 39 28
% 5.3 32.6 32.6 17.2 12.3
Lower abdomen 2.08 ±1.04 2 (1–3) n 18 45 80 69 15
% 7.9 19.8 35.2 30.4 6.6
Chest 1.48 ±0.99 1 (1–2) n39 79 74 31 4
% 17.2 34.8 32.6 13.7 1.8
Lower back 0.77 ±1.08 0 (0–1) n126 59 18 17 7
% 55.5 26.0 7.9 7.5 3.1
Upper abdomen 0.35 ±0.70 0 (0–1) n169 42 11 41
% 74.4 18.5 4.8 1.8 0.4
Arm 0.35 ±0.68 0 (0–1) n169 42 12 31
% 74.4 18.5 5.3 1.3 0.4
Upper back 0.19 ±0.62 0 (0–0) n 201 16 5 3 2
% 88.5 7.0 2.2 1.3 0.9
SD – standard deviation, IQR – interquartile range. Subgroup analysis with Bonferroni correction, p < 0.001.
Figure 1. Distribution of hair growth scores according to
the body region
Chin Thigh Upper Lower Chest Lower Upper Arm Upper
lip abdomen back abdomen back
Score 4
Score 3
Score 2
Score 1
Score 0
100
90
80
70
60
50
40
30
20
10
0
Percentage
Figure 2. Distribution of patients with a hair growth score
of ≥ 1 according to the body regions
Chin
Thigh
Upper lip
Lower abdomen
Chest
Lower back
Upper abdomen
Arm
Upper back
0 20 40 60 80 100
Percentage
97.4
96.5
94.7
92.1
82.8
44.5
25.6
25.5
11.5

Advances in Dermatology and Allergology4
Filiz Cebeci Kahraman, Sevil Savaş Erdoğan
Since a score of 2 in the chest region contributes
to the diagnosis of hirsutism in approximately half of
all the patients, its presence is signicant and cannot
be neglected. However, the inspection of this region in
conservative societies is not easy. A smaller-scale study
from Turkey yielded similar results to our findings. In
a study including 65 patients with hirsutism, Hassa et al.
reported a low eect of the upper abdomen, upper arm,
and upper back on the total FG score and suggested that
these regions could be ignored [8].
Studies have been conducted in dierent countries to
examine women with hirsutism using the mFG scoring sys-
tem. Regions of more prominent involvement were deter-
mined as the upper lip, chin, lower abdomen, and thighs in
Dutch women [9]; lower abdomen, thigh, upper lip, and up-
per arm in Chinese women [10]; lower abdomen, upper lip,
chin, and thighs in Iraqi women [11]; face, chest, and lower
abdomen in Pakistani [12] and Indian [13] women; and face,
lower abdomen, chest, and thighs in Iranian women [14].
In all these societies and our population, hair growth was
concentrated in similar localizations, except for the upper
arm in Chinese women.
Based on the fact that approximately 90% of patients
in our study had a terminal hair score of ≥ 1 in each of the
chin, thigh, upper lip or chin, thigh, lower abdomen combi-
nations, the examination of these three regions is useful
in estimating that the total mFG score is above 8. In our
study, 89% of the patients were determined to reach a score
accepted as hirsutism (i.e., 8 and above) with the combina-
tion of the chin, thigh, and lip regions, and 87.2% with the
combination of the chin, thigh, and lower abdomen regions.
When we examined the average score of hair growth in-
tensity in these regions, it was 2.85 for the chin, 2.86 for
the thighs, 1.99 for the lip, and 2.08 for the lower abdomen,
conrming this nding. This shows that in our population,
examining the chin and thigh regions is sucient to reach
a total mFG score of 6, and when the upper lip or lower ab-
domen is added to this evaluation, a score of 8 and above
can be reached in approximately 90% of patients. Thus, in
addition to the chin and thighs, which are the main regions
Table 2. Distribution of patients according to hair growth scores by body region
Body region Score ≥ 1 Score ≥ 2 Score ≥ 3 Score = 4
Absent Present Absent Present Absent Present Absent Present
Chin n6221 27 200 79 148 149 78
% 2.6 97.4 11.9 88.1 34.8 65.2 65.6 34.4
Thigh n8219 32 195 79 148 139 88
% 3.5 96.5 14.1 85.9 34.8 65.2 61.2 38.8
Upper lip n12 215 86 141 160 67 199 28
% 5.3 94.7 37.9 62.1 70.5 29.5 87.8 12.3
Lower abdomen n18 209 63 164 143 84 212 15
% 7.9 92.1 27.8 72.2 63.0 37.0 93.4 6.6
Chest n39 188 118 109 192 35 223 4
% 17.2 82.8 52.0 48.0 84.6 15.4 98.2 1.8
Lower back n126 101 185 42 203 24 220 7
% 55.5 44.5 81.5 18.5 89.4 10.6 96.9 3.1
Upper abdomen n169 58 211 16 222 5 226 1
% 74.4 25.6 93.0 7.0 97.8 2.2 99.6 0.4
Arm n169 58 211 16 223 4 226 1
% 74.4 25.6 93.0 7.0 98.2 1.8 99.6 0.4
Upper back n201 26 217 10 222 5 225 2
% 88.5 11.5 95.6 4.4 97.8 2.2 99.1 0.9
Subgroup analysis with Bonferroni correction, p < 0.001.
Figure 3. Distribution of patients with a hair growth score
of ≥ 2 according to the body regions
Chin
Thigh
Upper lip
Lower abdomen
Chest
Lower back
Upper abdomen
Arm
Upper back
0 20 40 60 80 100
Percentage
88.1
85.9
62.1
72.2
48.0
18.5
7.0
7.0
4.4

Advances in Dermatology and Allergology
Grading of hirsutism: a practical approach to the modied Ferriman-Gallwey scoring system
5
for this evaluation, the lip and lower abdomen regions can
contribute equally to the total score.
A few studies have been conducted in dierent popula-
tions with the aim of simplifying the mFG score, as in our
study. In a study conducted in Alabama, Knochenhauer
et al. found that the examination and scoring of hair growth
on the chin or lower abdominal region alone were highly
sensitive predictors for the diagnosis of hirsutism. They de-
termined all women with an FG score of ≥ 2 in any of these
body regions and a total score of ≥ 8 [15]. In an epidemio-
logic study from China, it was suggested that scores of ≥ 2
on the lower abdomen, thighs, and upper lip, which are the
regions that make the strongest contribution to hirsutism,
could be used to predict hirsutism at high sensitivity and
specicity [10]. Cook et al., carrying out a two-centre study in
Alabama and Los Angeles, determined that the best predic-
tor of the total mFG score was the upper abdomen, lower
abdomen, and chin combination or the upper abdomen,
lower abdomen, and thigh combination [16]. More recently,
in a study from Iran, the authors concluded that evaluat-
ing terminal hair growth on the chin or lower abdomen to
predict hirsutism seemed to be an acceptable screening
method [17]. The body regions we found to be prominent
in the diagnosis of hirsutism were similar to those reported
by previous studies evaluating dierent populations, except
for the upper abdomen.
Even though mFG scoring is a subjective hair examina-
tion method, it is more dicult to overlook ≥ 2 hair growth
intensity, but grade 1 hair growth may be overlooked ac-
cording to the region and the evaluation may dier among
physicians. Therefore, a score of ≥ 2 appears to indicate con-
siderable hair growth intensity. In our study, the hair growth
intensity score was ≥ 2 in 75.3% of the patients when the
chin and thighs were evaluated together. The prominence
of the same regions also in this evaluation strengthened
our ndings.
Conclusions
We propose that four regions including the chin, thighs,
upper lip, and lower abdomen stand out in simplifying the
mFG scale, and that the remaining four regions including
the upper abdomen, lower back, upper back and upper arm
can be disregarded in Turkish patients. The thigh and chin
regions seem to be the rst locations that should be exam-
ined to predict hirsutism. We can easily reach this conclu-
sion based on our results from the large-scale study we
conducted with the Turkish population.
At a time when we need to follow social distancing
rules in daily life, including the hospital environment,
a practical approach to the mFG scoring system will fa-
cilitate the work of many physicians, including dermatolo-
gists. We consider that this practical approach will shorten
the patient’s duration of stay in the outpatient clinic and
reduce transmission. Thus, dermatologists will be able to
provide health services that minimize transmission risk
during the ongoing pandemic by also screening hirsutism
when evaluating patients with other dermatologic condi-
tions such as acne and androgenetic alopecia.
Acknowledgments
We would like to thank Dr. Zübeyde Arat, who con-
tributed to obtaining the statistical data and creating
the gures for the study.
Conict of interest
The authors declare no conict of interest.
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