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Case Report | DOI: https://doi.org/10.31579/2767-7370/158
1 Professor of Maternal and Newborn Health Nursing, Faculty of Nursing, Beni-Suef University, Egypt.
2 PhD Student in Maternal and Newborn Health Nursing, Faculty of Nursing, Beni-Suef University, Egypt.
3 Professor of Maternal and Newborn Health Nursing, Faculty of Nursing, Menoufia University, Egypt.
*Corresponding Author: Hanan Elzeblawy Hassan, Professor of Maternal and Newborn Health Nursing, Faculty of Nursing, Beni-Suef University, Egypt.
Citation: Hanan E. Hassan, Abd-ELhakam FH, Ali Kasem EK, (2025), Hirsutism among Infertile Women: Impact of Lifestyle Modifications, J New Medical Innovations and Research, 6(5); DOI:10.31579/2767-7370/158
Copyright: © 2025, Hanan Elzeblawy Hassan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 29 May 2025 | Accepted: 16 May 2025 | Published: 20 May 2025
Keywords: hirsutism; lifestyle; modifications; infertile women
Background: Hirsutism, or excessive terminal hair growth with a masculine pattern distribution, affects 60–70% of PCOS patients
Aim: evaluate the effect of lifestyle modification intervention on hirsutism among infertile overweight and obese women with PCOs.
Subjects and Methods: A quasi-experimental research design was used to study 116 infertile women at gynecological and infertility outpatient and inpatient clinics and specialized medical center for the treatment of infertility and delayed childbearing affiliated with Beni-Suef University Hospital in Egypt. The study utilized modified Ferriman-Gallwey (mFG) to determine the degree of Hirsutism.
Results: prior to the intervention, 51.7% of the study group exhibited significant hair growth in the upper abdomen and lower abdomen, but 58.6% of the study group had no visible terminal hair. 45% and 30% of the study group had moderate and severe hirsutism, respectively, before the intervention, compared to 23% and 11% after the intervention, respectively. Statistically significant association between hirsutism levels and lifestyle dietary habits after program implementation was found (p<0.05). Statistically significant association between physical activity level was observed after program implementation (p<0.05).
Conclusion: Lifestyle modification interventions have a significant positive effect on hirsutism levels for infertile overweight and obese women.
Recommendations: As counselors, nurses should offer advice and support as well as teach infertile overweight women about lifestyle change, since it presents a significant challenge in the modern society.
Since 1990, various diagnostic standards have been used to categorize PCOS. In 1990, the National Institutes of Health (NIH) established its criteria. A new diagnostic standard known as the Rotterdam criteria was developed in 2003 at a workshop in Rotterdam. The Androgen Excess Society (AES) updated the diagnostic standards and announced new standards in 2006. Another significant factor to take into account is the psychological health of the patient due to the impact of PCOS on physical appearance such as Hirsutism (Deswal et al., 2020; Hassan et al., 2019b; Mohamed & Hassan, 2020; Hassan & Farag, 2019).
Women with PCOS have been reported to have intrinsic theca cell malfunction, which results in excessive androgen synthesis and overexpressed luteinizing hormone (LH) receptors that are unaffected by endocrine or paracrine regulation (Zeng et al., 2020; Hassan et al., 2025). Additionally, androgens promote lipolysis, which raises the levels of free fatty acids in the blood, which leads to the development of insulin resistance and the development of abdominal obesity, particularly visceral obesity, which is frequent in women with PCOS. The effects of too much androgen on pertinent tissues; acne, male pattern baldness, and hirsutism are among other signs of hyperandrogenism (Di Lorenzo, et al., 2023; Mohamed et al., 2024; Hassan et al., 2015; Emem & Hassan, 2017).
Hirsutism, or excessive terminal hair growth with a masculine pattern distribution, affects 60–70% of PCOS patients (Kamenov & Gateva, 2020). The modified Ferriman-Gallwey (mFG) is the most widely used visual assessment technique to evaluate terminal hairs, which are pigmented, medullated hairs that would grow longer than 5 mm if unmolested (Willis et al., 2020; Hassan, 2019a; Nady et al., 2018a; Gamel et al., 2019).
In Egypt, there were 27.4% of women who had PCOS. Infertile women had a prevalence of 37.5%, whereas fertile women had a prevalence of 14%. Infertile patients with POCS had ovulatory disorders, hirsutism, and PCO in proportions of 73.3%, 60.4%, and 79.4%, respectively. PCOS prevalence and elevated BMI were significantly correlated (Sanad, 2014; Sheha et al., 2018; Nady et al., 2018b; Mohammed et al., 2018).
The modified Ferriman-Gallwey (mFG) evaluates the presence of terminal hair in nine areas of the body that are predominantly masculine: the upper lip, chin, and neck; the upper chest (excluding the nipples), upper abdomen (above the umbilicus), lower abdomen, thighs (front and/or back), upper back and upper arms. Each area is visually scored from zero (no terminal hair visible) to four (terminal hair consistent with a well-developed male) (John, 2021). A total score of zero denotes the absence of hirsutism, six to fifteen denotes mild hirsutism, and greater than fifteen denotes moderate to severe hirsutism. (Kamenov & Gateva, 2020; Hassan, 2020a).Treatment options for PCOS underlined are pharmacological, surgical intervention, and non-pharmacological interventions (Lifestyle interventions).
a) Glucocorticoids: They can aid in preventing and managing hirsutism and enabling ovulatory cycles in patients with classic congenital adrenal hyperplasia when their usage is best justified (Davariya et al., 2022).
c) Gonadotropin-releasing hormone agonist (GnRHa): It improves hirsutism, inhibits pituitary hormones, and increases estradiol output while decreasing androgen (Calcaterra, et al., 2023).
a) Direct hair removal therapy: For many years, the standard method was to get rid of extra hair in PCOS. It operates by inserting a small needle with an electrical current into the hair follicle. Although laser treatment is more expensive, less uncomfortable, and produces results much more quickly, the adverse effects are more severe (Davariya, et al., 2022).
b) Eflornithine hydrochloride: It is an inhibitor of the enzyme ornithine decarboxylase in human skin and has been approved for topical application in hirsutism (Rashid, et al., 2022).
Laparoscopic ovarian drilling, Bariatric surgery, and Assisted Reproductive Technology
The majority of PCOS patients said that they rarely obtain lifestyle recommendations from their therapists, although the majority of physicians support lifestyle changes for the management of PCOS (Nemchikova & Frontoni, 2022; Mostafa et al., 2018; Hassan, 2020b; Nady et al., 2017; Hassan, 2016).
Aim of the study:
This study was conducted to evaluate the effect of lifestyle modification intervention on hirsutism among infertile overweight and obese women with PCOs.
Study hypotheses:
Infertile overweight and obese women who will receive lifestyle modification interventions will experience an improvement and decrease hirsutism level.
Subject and methods:
Research design: A quasi-experimental design.
Study setting: The study was conducted at gynecological and infertility outpatient and inpatient clinics and specialized medical center for the treatment of infertility and delayed childbearing affiliated with Beni-Suef University Hospital.
Sample type and size:
A purposive sample 116 infertile overweight and obese women who attended the previously mentioned sitting will be selected, and fulfilled the following criteria:
Tools of data collection: Arabic Structured interviewing questionnaire divided into two parts:
Part I. Basic data and sociodemographic characteristics as telephone number, age, residence, marital status, employment, length in centimeters, weight in kilograms, waist circumference, and thigh circumference
Part II. Questions about Hirsutism; in the nine predominantly masculine body areas (androgen-dependent), such as the upper lip, chin and neck, upper chest (excluding the nipples), upper abdomen (above the umbilicus), lower abdomen, thighs (front and/or back), upper back, lower back, and upper arms, the presence of terminal hair (hairs that would grow >5mm in length if left unmolested, are typically pigmented, and are medullated) was assessed (Kahraman & Erdoğan, 2021).The participants' level of hirsutism was assessed using the modified Ferriman-Gallwey (mFG), which rates the nine mainly masculine body locations for terminal hair. Visual scores ranging from one (little unseen hair development) to four (extremely thick hair) were applied to each place (Kahraman & Erdoğan, 2021).
Scoring system: The total score was adopted from Kahraman & Erdoğan (2021) and assessed by summation of sub-scores in the nine areas:
Ethical Considerations:
Official approval will be obtained from ethical and research counsels that were approved by the Faculty of Nursing, Menoufia University Counsel. Informed oral consent was obtained from all women after an explanation of the nature and purpose of the study.
Field Work:
The study aimed to evaluate the impact of a lifestyle modification intervention on hyper-androgenic infertile overweight and obese women. The research involved a comprehensive review of literature, including textbooks, articles, journals, and websites. The study also involved interviews and assessments to assess socio-demographic characteristics, lifestyle habits, and baseline measures related to hyper-androgenism. The intervention was implemented in training halls, aiming for a 5-10% weight loss or a BMI < 29>
Statistical Analysis: -
Data was entered and analyzed using SPSS (version 25). Graphics were done using the excel program as well as the SPSS package. The level of significance was set at a P value of <0>
Figure 1 showed that while 48.3% of women with polycystic ovarian syndrome had no apparent terminal hair, 26% of infertile, overweight, and obese women had severe upper lips. According to the study, 58.6% of the control group had moderate hirsutism both before and after the intervention, compared to 29.3% of the study group who had severe hirsutism in their neck and chin. Before the intervention, 67.2% of the study and control groups, excluding the nipples, had no terminal hair visible on the upper chest; after the intervention, this number increased to 77.6%.
Figure 1: hirsutism among the Studied Infertile Overweight and Obese Women with Polycystic Ovary Syndrome
Furthermore, prior to the intervention, 51.7% of the study group exhibited significant hair growth in the upper abdomen (above the umbilicus) and lower abdomen, but 58.6% of the study group had no visible terminal hair, and 67.2% and 75.6% of the study groups, respectively, had no terminal hair visible on the thighs (front and/or back) before and after the intervention. Furthermore, before and following the intervention, there was no discernible terminal hair on the upper back, lower back, or upper arms in 75.9% and 86.2% of the research groups, respectively.
Table 1 shows the shows the total hirsutism levels among the studied infertile, overweight, and obese women with polycystic ovary syndrome. It presents that 45% and 30% of the study group had moderate and severe hirsutism, respectively, before the intervention, compared to 23% and 11
Figure 1 showed that while 48.3% of women with polycystic ovarian syndrome had no apparent terminal hair, 26% of infertile, overweight, and obese women had severe upper lips. According to the study, 58.6% of the control group had moderate hirsutism both before and after the intervention, compared to 29.3% of the study group who had severe hirsutism in their neck and chin. Before the intervention, 67.2% of the study and control groups, excluding the nipples, had no terminal hair visible on the upper chest; after the intervention, this number increased to 77.6%.
Figure 1: hirsutism among the Studied Infertile Overweight and Obese Women with Polycystic Ovary Syndrome
Furthermore, prior to the intervention, 51.7% of the study group exhibited significant hair growth in the upper abdomen (above the umbilicus) and lower abdomen, but 58.6% of the study group had no visible terminal hair, and 67.2% and 75.6% of the study groups, respectively, had no terminal hair visible on the thighs (front and/or back) before and after the intervention. Furthermore, before and following the intervention, there was no discernible terminal hair on the upper back, lower back, or upper arms in 75.9% and 86.2% of the research groups, respectively.
Table 1 shows the shows the total hirsutism levels among the studied infertile, overweight, and obese women with polycystic ovary syndrome. It presents that 45% and 30% of the study group had moderate and severe hirsutism, respectively, before the intervention, compared to 23% and 11
The current study findings revealed that nearly half and more than one-third of the study and control groups had moderate hirsutism before the intervention, respectively. After the intervention, about two-thirds of the study group had no terminal hair visible. Meanwhile, there were no statistically significant differences between study and control groups, neither before nor after the intervention.
These findings came in agreement with Niranjani et al. (2022), who studied "Effectiveness of cinnamon, exercise, and counseling on hyperandrogenic symptoms and level of anxiety among young girls with olycystic ovarian syndrome." They revealed that on the Modified Ferriman Gallwey scale (Hirsutism), during Pre-test through Post-test 2, the non-interventional group showed no improvement in score, whereas group A and group B showed a 1 score decrease.
On the contrary, these findings were inconsistent with those of Pramod et al. (2023), who studied dietary and physical activity patterns in PCOS women and found that less than one-quarter of respondents had dark hair growth. These differences might be attributed to the different populations in their study on overweight and obese women with PCOS.
The current study findings revealed that there is an improvement in lifestyle and daily habit levels among the studied hyper-androgenic infertile overweight and obese women. It reveals that most of the study and control groups had poor habits before the intervention, which improved to most of the study, and less than one-third of the control group had good habits after the intervention, respectively.
These results came in agreement with These findings came in agreement with Eleftheriadou et al. (2015), who study “Dietary Habits in Adolescent Girls with Polycystic Ovarian Syndrome" and found that poor eating habits were demonstrated in this group of adolescent PCOS patients, and this may contribute to the development of obesity in later life. Increased body weight increases long-term health risks and should be tackled with lifestyle interventions early in life.
Regarding total physical activity levels among the studied hyper-androgenic infertile overweight and obese women. The current study findings revealed that there is an improvement in total physical activity. Most of the study and control groups had mild physical activity (sedentary lifestyle) before the intervention, compared to two-thirds of the study group after the intervention having moderate physical activity. There is a statistically significant difference between the study and control groups after the intervention.
But in disagreement with the current study, Zhang et al. (2018) did not find differences in physical activity between the PCOS and control groups. Also, the current study is supported by Mutsaerts et al. (2013), who revealed that women with PCOS did not show a different change in lifestyle and moderate to vigorous physical activity compared with non-PCOS obese controls. This disagreement may be attributed to the type and intensity of physical activity.
The current study findings revealed that there is a statistically significant association between hyper-androgenic features (Hirsutism, acne, and alopecia) improvement and lifestyle habits in the study group of hyper-androgenic infertile overweight and obese women.
A meta-analysis indicated that hirsutism and menstruation dysfunction were the two aspects of quality of life most affected by PCOS; however, a more recent systematic review discovered that infertility and weight issues were the two factors most detrimental to HRQoL (Naumova et al., 2021). In addition, a recent study found that women with PCOS are 40% more likely to attempt suicide and are more likely to have personality disorders, schizophrenia, or bipolar illness (Farajzadegan et al., 2023).
Significant improvements in hirsutism can be achieved with lifestyle changes (diet and exercise) that result in a small to moderate weight loss of about 5%-10% (Cowan & Moran, et al., 2023).
Lifestyle modification interventions have a significant positive effect on hirsutism levels for infertile overweight and obese women.
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To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
