Hirsutism and Endometriosis: Are They Linked? Symptoms, Tests, Treatment

Chin hairs and brutal period pain showing up at the same time mess with your head. Are they connected or just bad luck? Short answer: they can overlap, but usually for reasons that sit next to, not inside, each other. This guide spells out what actually links the two, how doctors sort it out, and the moves that ease both hair growth and pelvic pain without making one worse.

TL;DR

• Hirsutism signals higher androgen activity; endometriosis is an estrogen-driven, inflammatory pain condition. They’re different, but can co-exist.
• The typical bridge is PCOS or another hyperandrogenic issue, not endometriosis itself (Endocrine Society 2018; International PCOS Guideline 2023).
• Start with a clean workup: menstrual history, pelvic ultrasound for endometriomas, and labs for androgens and thyroid/adrenal screens.
• Treatment can help both: certain combined pills, targeted progestins, and antiandrogens (with contraception) plus laser/electrolysis for hair.
• Red flags: suddenly worsening hair growth, voice deepening, clitoromegaly, or severe, escalating pelvic pain-see a doctor fast.

What actually links, and separates, these two conditions

Let’s make the terms clear. Hirsutism is coarse, male-pattern hair growth on the face, chest, stomach, back, or thighs in people with ovaries. It usually points to androgen excess or increased skin sensitivity to androgens. Endometriosis is when endometrium-like tissue grows outside the uterus, driving inflammation and pain, and sometimes fertility trouble. Different engines under the hood.

So why do they show up together for some? Two big reasons:

• Co-existing hyperandrogenism, most often PCOS. PCOS is common and can bring hirsutism, acne, irregular cycles, and polycystic ovaries (Rotterdam criteria; International PCOS Guideline 2023). You can also have pelvic pain from endometriosis at the same time.
• Medication effects. Old-school danazol can shrink endometriosis lesions but often worsens hair growth and acne-one reason it’s used less now. Some progestins can nudge acne or hair in susceptible people, while others help.

What the science says. Endometriosis tends to be estrogen-dominant with progesterone resistance and immune activation (ESHRE 2022; Zondervan et al., 2020). Hirsutism is about androgen biology-ovarian (PCOS), adrenal (nonclassical CAH), rare tumors, or “idiopathic” when labs are normal but hair follicles are extra sensitive (Endocrine Society 2018). Cohort and surgical series report a co-occurrence of PCOS and endometriosis in a minority of patients-uncommon but not rare in specialty clinics. The takeaway: if you have both pain and new coarse hair, check for PCOS or other androgen sources rather than pinning it all on endometriosis.

Shared threads are real but indirect. Early menarche, family history, and environmental factors show up in both conditions, but through different pathways. Insulin resistance drives androgen excess in many with PCOS, which fuels hirsutism; it isn’t a core feature of endometriosis. Immune and inflammatory signaling is active in endometriosis; that doesn’t raise testosterone by itself.

Practical framing you can use:

• If cycles are irregular or spaced out and hair growth is increasing, think PCOS or another androgen condition, even if pelvic pain suggests endometriosis too.
• If cycles are regular, pain is the main story, and labs are normal, endometriosis plus idiopathic hirsutism is possible.
• Fast, dramatic hair changes or virilization (deepening voice, clitoromegaly) point to adrenal/ovarian tumors-urgent workup needed.

Numbers frame the risk: hirsutism affects around 5-10% of reproductive-age women (Endocrine Society 2018). Endometriosis affects about 10% (ESHRE 2022). Both are common; overlap happens, but biology explains it better than one causing the other. If you remember one line, remember this: hirsutism and endometriosis can share a person, not a cause.

How to check for overlap: a simple, doctor-ready plan

You don’t need to guess. A clean, stepwise workup saves time and avoids wild-goose chases.

Step 1: Track the right details for 6-8 weeks.

• Cycles: first day of bleeding, length, spotting, missed periods.
• Pain: timing (before, during, after period), location, painkiller doses that actually help, bowel/bladder pain, pain with sex.
• Hair map: new coarse hair areas and how often you need to shave/wax. Note acne and scalp hair loss.
• Other: weight changes, headaches, galactorrhea (milk-like breast discharge), new muscle bulk, voice changes.
• Family history: endometriosis, PCOS, diabetes, thyroid, adrenal issues.

Step 2: See your GP with a shortlist of questions:

• Could this be PCOS, endometriosis, both, or something else?
• What’s the plan to rule out adrenal/thyroid/tumor causes?
• Which treatments help pain without worsening hair growth?
• If I want pregnancy soon, how does the plan change?

Step 3: Expect these tests (timed when possible in the early follicular phase, unless urgent):

• Total and free testosterone (or free androgen index), SHBG.
• DHEAS to screen adrenal androgen output.
• 17-hydroxyprogesterone (morning) to rule out nonclassical CAH.
• TSH and prolactin (thyroid and pituitary checks).
• Fasting glucose or HbA1c and lipids if PCOS suspected.
• Luteinizing hormone and follicle-stimulating hormone if cycles are irregular (contextual).
• Pelvic ultrasound to look for endometriomas and ovarian morphology. No blood test diagnoses endometriosis; imaging can hint, surgery confirms (ESHRE 2022).

Step 4: Differentiate with a tight decision tree.

• Irregular or absent periods + elevated androgens ± polycystic ovaries: likely PCOS (International PCOS Guideline 2023). Treat both hair and metabolic risks.
• Severe cyclic pain ± endometrioma on ultrasound, normal androgens: likely endometriosis; manage pain and inflammation first line.
• Normal labs, steady cycles, but bothersome hair: idiopathic hirsutism-treat the hair and consider antiandrogens with contraception.
• Very high androgens or virilization: urgent imaging for adrenal/ovarian tumors and endocrine consult.
• Persisting severe pain with negative imaging: you can still have endometriosis; empirical treatment or diagnostic laparoscopy may be discussed (ACOG 2021; ESHRE 2022).

Two quick examples to make it concrete:

• Case A: 27, regular 29-day cycles, crippling cramps, pain with sex, clean androgen labs, ultrasound shows a 4 cm endometrioma. That’s endometriosis. Hair on the chin popped up recently but labs are normal-idiopathic hirsutism is likely. Treat pain/endometriosis directly, tackle facial hair cosmetically and, if needed, with medical therapy.
• Case B: 32, cycles every 45-60 days, chin/chest hair growth, acne, ultrasound with polycystic ovarian morphology, mildly elevated free testosterone, pelvic pain around periods. That’s PCOS plus suspected endometriosis. Manage androgens and metabolism, and treat pain; a gyne plan for endometriosis runs alongside.

Red flags you shouldn’t ignore:

• Rapid hair growth over months with voice deepening or clitoromegaly.
• Severe, escalating pelvic pain, fever, or pain that wakes you at night.
• Unexplained weight loss, easy bruising, or purple stretch marks (screen for Cushing’s if clinical picture fits).

Evidence notes you can trust: The Endocrine Society’s 2018 hirsutism guideline outlines testing and treatment options; ESHRE’s 2022 endometriosis guideline supports ultrasound as first-line imaging and emphasizes shared decision-making on surgery; the 2023 international PCOS guideline updates diagnostic criteria and treatment, including metabolic care. These are the playbooks most clinicians use in 2025.

Treatment that helps both-without backfiring

The goal is simple: dial down pain and inflammation, reduce hair growth, and protect future fertility if that matters to you. Small levers, stacked right, beat one big lever that backfires.

Hormonal options you’ll hear about:

• Combined oral contraceptives (COCs): reduce ovarian androgen production and thin the endometrium, easing cramps. Drospirenone- or cyproterone-containing pills reduce acne/hirsutism for many (choose carefully in those at VTE risk; cyproterone has dose-related meningioma risk at high cumulative doses-regulatory safety notices since 2020).
• Progestin-only strategies: levonorgestrel IUD, dienogest, or norethindrone acetate can suppress endometriosis pain well. Some progestins may be neutral or slightly negative on skin/hair; many do fine on them.
• GnRH agonists/antagonists with add-back therapy: strong pain control for refractory endometriosis; side effects (hot flushes, bone loss risk) require add-back estrogen/progestin. Not first-line for hair, and usually reserved for tough pain cases (ESHRE 2022).
• Danazol: shrinks lesions but commonly worsens hirsutism/acne and affects lipids. Often avoided when hair is a concern.

Antiandrogens (used only with reliable contraception because of fetal risk):

• Spironolactone: blocks androgen receptors; improves facial/body hair over 3-6 months. Watch potassium and blood pressure.
• Finasteride: blocks conversion to dihydrotestosterone; option if spironolactone isn’t tolerated.
• Flutamide: effective but liver toxicity risk-rarely first choice now.

Non-hormonal hair treatments:

• Laser hair removal: longer-term reduction on dark hair/light skin; multiple sessions; touch-ups needed. Works regardless of the cause of hirsutism.
• Electrolysis: permanent hair destruction, best for light or grey hairs or small areas.
• Eflornithine cream: slows facial hair growth; pairs well with laser.

Metabolic and lifestyle levers (matter most if PCOS is in the mix):

• Weight management and resistance training can improve insulin sensitivity and reduce androgen drive in PCOS (International PCOS Guideline 2023).
• Sleep and stress routines steady cortisol and appetite signals-small but real effects on symptoms.
• Diet: a steady, high-fiber, minimally processed pattern helps metabolic health; for endometriosis, some find benefit from anti-inflammatory patterns and limiting alcohol-evidence is moderate but worth a trial if it’s sustainable.

Pain care that respects daily life:

• NSAIDs around menses for cramp control.
• Pelvic floor physio when pain involves muscle guarding.
• Heat, TENS units, and paced activity for flare management.

Fertility plans change the playbook:

• If you want pregnancy soon: avoid antiandrogens. For endometriosis pain, non-contraceptive options or surgery may be considered. For PCOS-related ovulation issues, letrozole is first-line for ovulation induction (PCOS Guideline 2023).
• If pregnancy is a later goal: symptom control now with reversible methods is fine, and may protect fertility by calming inflammation and preventing cyst complications.

Smart pitfalls to avoid:

• Chasing “hormone detoxes” instead of screening for real androgen or thyroid problems.
• Starting antiandrogens without contraception-serious birth defect risk.
• Stopping endometriosis therapy that works because of mild skin changes-often you can switch progestin type or add skin-targeted care and keep pain controlled.

Good rules of thumb:

• If hair is the main bother and labs point to PCOS, combine a skin-friendly COC with spironolactone; add laser for speed.
• If pain is the main bother and labs are normal, lead with an IUD or dienogest; if hair bothers you, pair with cosmetic options and revisit labs annually.
• Any sudden change in hair pattern or voice: pause and re-test-don’t assume it’s just PCOS or endometriosis.

FAQ, quick checklists, and your next moves

FAQ

• Does endometriosis raise testosterone? No. Endometriosis is driven by estrogen and inflammation. If your testosterone is high, look for PCOS or adrenal causes.
• Can you have PCOS with regular periods? Yes. You can meet PCOS criteria with clinical/biochemical hyperandrogenism and polycystic ovaries even if cycles look regular (PCOS Guideline 2023).
• Is AMH a PCOS test? AMH can reflect follicle count, but it isn’t a stand-alone diagnostic. Use it in context.
• Will laser fix the cause of hirsutism? No. It reduces hair. If androgens stay high, new hairs can appear. Best results happen when hormones are controlled too.
• Do supplements help? Myo-inositol can support ovulation and metabolic health in PCOS. For endometriosis, data on supplements is mixed; omega‑3s may help pain for some. Always check interactions with your clinician.
• Can pregnancy “reset” endometriosis? Symptoms may settle during pregnancy for some, but it’s not a cure. Plan management before and after.

Doctor-ready checklist (print this):

• 3 months of cycle dates and pain scores.
• List of hair growth areas and how often you remove hair.
• All meds/supplements, including doses and start dates.
• Family history of endometriosis, PCOS, diabetes, thyroid/adrenal disorders.
• Your top two goals (e.g., less pain, less facial hair, pregnancy within 1 year).

Testing cheat-sheet:

• Core labs: total/free testosterone (or FAI), SHBG, DHEAS, 17‑OHP, TSH, prolactin.
• Metabolic: fasting glucose or HbA1c, fasting lipids.
• Imaging: pelvic ultrasound for endometriomas and ovarian morphology; MRI only for complex cases.
• Consider cortisol testing if Cushing’s features show up (easy bruising, proximal muscle weakness, purple striae).

Next steps by scenario:

• Hirsutism + irregular cycles, pain manageable: prioritize PCOS workup; start a COC that helps skin; add spironolactone if needed; use NSAIDs/heat for cramps; reassess pain in 2-3 cycles.
• Severe pain + normal labs, regular cycles: treat as suspected endometriosis with an IUD or progestin; add pelvic physio; revisit hair with cosmetic measures; consider antiandrogens only if contraception is secured.
• Planning pregnancy in 6-12 months: avoid antiandrogens; use non-hormonal pain tools; discuss surgery for endometriosis if pain or cysts are significant; consider early referral for fertility counseling if cycles are irregular.
• On treatment but hair worsened: review meds for androgenic side effects; switch progestin type or add skin-directed therapy; re-check androgens.

When to escalate care:

• No relief after 3-6 months of guideline-based therapy.
• Red-flag androgen signs or rapidly enlarging ovarian cysts.
• Fertility goals with age-related urgency or prior surgery.

Why this approach works: it treats the person, not a label. Hirsutism flags androgen biology. Endometriosis flags pain and inflammatory biology. Sometimes they ride together; often they don’t. Either way, you deserve a plan that explains your symptoms and gives you agency-clear tests, clear choices, and a fallback if Plan A doesn’t stick.