A composite clinical photograph illustrating dermatological manifestations of hyperandrogenism, specifically in the context of Polycystic Ovary Syndrome (PCOS). The left image provides a lateral view of the lower face and neck of a female patient, showing inflammatory acne vulgaris characterized by a dense distribution of erythematous papules and pustules along the jawline, mandibular area, and upper neck. Significant hirsutism is also visible, with terminal hair growth in androgen-dependent areas such as the preauricular region and chin. The right image is a frontal view of a female patient exhibiting androgenetic alopecia. Notable features include a receding frontal hairline with temporal sparing, resulting in an 'M' shaped pattern, along with diffuse thinning of the hair on the vertex and mid-scalp. Together, these images demonstrate the cutaneous 'SAHA' syndrome (seborrhea, acne, hirsutism, and alopecia) associated with systemic androgen excess, providing a key educational example for endocrine-related skin disorders.

Clinical photograph of the lower face, neck, and upper chest of a female patient exhibiting signs of hyperandrogenism. The primary clinical finding is hirsutism, characterized by coarse, dark, androgenic terminal hair growth in a male-pattern distribution, specifically along the chin, jawline, and submandibular region of the neck. Accompanying dermatological features include inflammatory acne vulgaris, presenting as erythematous papules and pustules scattered across the neck and upper chest. Additionally, there are multiple pigmented macules and small nevi visible on the neck. The skin on the chin demonstrates a slightly thickened and irregular texture, consistent with follicular stimulation. This visual presentation is a key clinical indicator of endocrine dysfunction, such as that seen in polycystic ovary syndrome (PCOS), Cushing syndrome, or androgen-secreting tumors (e.g., adrenocortical carcinoma), where excess androgens stimulate the conversion of vellus hair to terminal hair in androgen-sensitive areas.

A clinical photograph of a female patient's face and neck in a lateral profile view, demonstrating clinical signs of hyperandrogenism and virilization. The image reveals prominent hirsutism, characterized by coarse, dark hair growth in an androgen-dependent distribution, specifically involving the preauricular (sideburn) area, cheeks, and along the mandibular jawline. Accompanying these findings is an inflammatory acneiform eruption, presenting as erythematous papules and pustules clustered around the jaw and upper neck. This combination of acne and hirsutism is highly suggestive of an underlying hyperandrogenic state. The educational focus of this image is the recognition of physical manifestations of excessive androgen levels in female patients, which may be associated with conditions such as polycystic ovary syndrome (PCOS) or, in this clinical context, pregnancy-related luteoma.

This clinical photograph displays significant dermatological and endocrine-related signs on a female patient, illustrating virilization. The primary finding is androgenic alopecia, characterized by a receding hairline and marked thinning of the hair at the frontal and temporal scalp, following a male-pattern distribution. Additionally, the patient exhibits severe hirsutism, with coarse terminal hair growth visible on the upper lip, chin, and mandibular regions. Notable stubble in these areas suggests recent hair removal efforts. The facial skin appears slightly oily with scattered blemishes on the cheeks, possibly related to hyperandrogenism. These visual features—male-pattern baldness combined with excess facial hair in a female—are classic indicators of hyperandrogenic states, such as those caused by androgen-secreting tumors or severe polycystic ovary syndrome (PCOS).

<table><thead><tr><th>No. Living*</th><th>Type</th><th>Recommendation</th><th>Grade/ Quality</th></tr></thead><tbody><tr><td>1.3.5</td><td>CR</td><td>A modified Ferriman Gallwey score (mFG) of 4–6 should be used to detect hirsutism, depending on ethnicity, acknowledging that self-treatment is common and can limit clinical assessment.</td><td>◊◊◊◊</td></tr><tr><td>1.3.6</td><td>CR</td><td>Healthcare professionals should consider that the severity of hirsutism may vary by ethnicity but the prevalence of hirsutism appears similar across ethnicities.</td><td>◊◊◊</td></tr><tr><td>1.3.7</td><td>PP</td><td>Healthcare professionals should: • be aware that standardised visual scales are preferred when assessing hirsutism, such as the mFG scale in combination with a photographic atlas • consider the Ludwig or Olsen visual scales for assessing female pattern hair loss • note that there are no universally accepted visual instruments for assessing the presence of acne • recognise that women commonly treat clinical hyperandrogenism cosmetically, diminishing their apparent clinical severity • appreciate that self-assessment of unwanted excess hair growth, and possibly acne and female pattern hair loss, has a high degree of validity and merits close evaluation, even if overt clinical signs of hyperandrogenism are not readily evident on examination • be aware that only terminal hairs need to be considered in defining hirsutism, and these can reach > 5 mm if untreated, vary in shape and texture and are generally pigmented • note that new-onset severe or worsening hyperandrogenism, including hirsutism, requires further investigation to rule out androgen-secreting tumours and ovarian hyperthecosis • monitor clinical signs of hyperandrogenism, including hirsutism, acne and female pattern hair loss, for improvement or treatment adjustment during therapy.</td><td></td></tr><tr><td>1.4</td><td colspan="3">Ultrasound and polycystic ovarian morphology</td></tr><tr><td>1.4.1</td><td>EBR</td><td>Follicle number per ovary (FNPO) should be considered the most effective ultrasound marker to detect polycystic ovarian morphology (PCOM) in adults.</td><td>◊◊◊◊ ⊕⊕⊙⊙</td></tr><tr><td>1.4.2</td><td>EBR</td><td>Follicle number per ovary (FNPO), follicle number per cross-section (FNPS) and ovarian volume (OV) should be considered accurate ultrasound markers for PCOM in adults.</td><td>◊◊◊◊ ⊕⊕⊙⊙</td></tr><tr><td>1.4.3</td><td>CR</td><td>PCOM criteria should be based on follicle excess (FNPO, FNPS) and/or ovarian enlargement (OV).</td><td>◊◊◊◊</td></tr><tr><td>1.4.4</td><td>CR</td><td>Follicle number per ovary (FNPO) ≥ 20 in at least one ovary should be considered the threshold for PCOM in adults.</td><td>◊◊◊◊</td></tr><tr><td>1.4.5</td><td>CR</td><td>Ovarian volume (OV) ≥ 10 ml or follicle number per section (FNPS) ≥ 10 in at least one ovary in adults should be considered the threshold for PCOM if using older technology or image quality is insufficient to allow for an accurate assessment of follicle counts throughout the entire ovary.</td><td>◊◊◊◊</td></tr></tbody></table>

A series of clinical photographs documenting a case of severe hirsutism and its response to treatment. Panels (a) and (b) show the patient at presentation, demonstrating dense, dark terminal hair growth on the upper lip, chin, and submandibular region (jawline) extending toward the preauricular area, consistent with a high Ferriman-Gallwey score. Panel (a) also shows evidence of mild inflammatory acne on the cheeks. Panel (c) displays significant terminal hair growth on the abdomen, both supraumbilical and infraumbilical. Panels (d) and (e) provide a follow-up comparison at 6 months after pharmacological intervention, showing a dramatic clinical reduction in facial terminal hair density and improvement in skin texture. This comparison illustrates the visual manifestation of hyperandrogenism and the efficacy of hormonal management in reversing androgen-dependent hair patterns in female patients.

<table> <tr> <th>Table 1. Definition of Terms</th> <th></th> </tr> <tr> <th>Term</th> <th>Definition</th> </tr> <tr> <td>Hirsutism</td> <td>Hirsutism is excessive terminal hair that appears in a male pattern (excessive hair in androgen-dependent areas; <i>i.e.</i>, sexual hair) in women.</td> </tr> <tr> <td>Ferriman–Gallwey score</td> <td>The modified Ferriman–Gallwey score is the gold standard for evaluating hirsutism. Nine body areas most sensitive to androgen are assigned a score from 0 (no hair) to 4 (frankly virile), and these separate scores are summed to provide a hormonal hirsutism score (Fig. 1).</td> </tr> <tr> <td>Local hair growth</td> <td>This is unwanted localized hair growth in the absence of an abnormal hirsutism score.</td> </tr> <tr> <td>Patient-important hirsutism</td> <td>Unwanted sexual hair growth of any degree that causes sufficient distress for women to seek additional treatment.</td> </tr> <tr> <td>Hyperandrogenism</td> <td>Hyperandrogenism (for the purposes of this guideline) is defined as clinical features that result from increased androgen production and/or action.</td> </tr> <tr> <td>Idiopathic hirsutism</td> <td>This is hirsutism without hyperandrogenemia or other signs or symptoms indicative of a hyperandrogenic endocrine disorder.</td> </tr> </table>