These three get called cosmetic. That word does a lot of quiet work: it puts them last in a ten-minute appointment, and it makes raising them feel like vanity rather than symptom reporting.
They are neither cosmetic nor peripheral. Hyperandrogenism is one of the three Rotterdam criteria, and it can be met clinically — through exactly these signs, with no blood test needing to agree. When you describe them, you are not making conversation; you are reporting diagnostic evidence.
Hirsutism
Coarse, dark, terminal hair growing in a pattern more typical of male distribution — face and jawline, chest, upper abdomen, back, inner thighs. Distinct from the fine, pale vellus hair everyone has everywhere.
Two things make this the strongest of the three as evidence:
It is the most specific. Acne and hair thinning have many causes; this pattern of growth in this distribution has considerably fewer.
It is assessed with an actual scale. The Ferriman–Gallwey system scores hair growth across a set of body areas and produces a number. That it is a subjective assessment, and one where thresholds differ across ethnic groups, is a real limitation — but it is a formal assessment rather than an impression, and it can be repeated and compared.
Which is worth knowing for a specific reason. If you remove hair before an appointment — and most people do, because you have been managing this for years — the assessment cannot be made. Nobody will tell you this in advance. A photograph taken before removal is a legitimate thing to bring, and a great deal easier than arriving unmanaged.
Acne
More weakly evidential than hirsutism, because ordinary acne is extremely common and looks the same.
What is described as more suggestive in this context is adult-onset or adult-persistent acne, and a distribution along the lower face, jawline and neck. Neither is diagnostic on its own; both are worth describing precisely rather than as “my skin’s been bad”.
The useful thing you can contribute here is frequency and timing, because that is what nobody else can observe. “Breakouts on fourteen days of the last thirty, mostly in the week before a period” is a different report from “I get spots” — and the relationship to the cycle is exactly the sort of thing that only shows up in a dated record.
Scalp hair thinning
Androgenic hair loss, typically as diffuse thinning through the crown and a widening part, rather than the receding pattern more familiar from male hair loss. The hairline usually stays.
Of the three this is the one people most often keep entirely to themselves, and it is also the one where time matters most, because hair follicles do not stay responsive indefinitely. If this is happening, it is worth raising at the next appointment you have, rather than the one where you finally feel entitled to bring it up.
Worth knowing: shedding and thinning are not the same thing. A sudden heavy shed a few months after an illness, a major stress, a pregnancy or a significant weight change is a recognised and usually self-limiting pattern with its own name, and it is not the same process as gradual androgenic thinning. Distinguishing them matters, and dates are what distinguish them — which is a genuine argument for writing down when something started rather than reconstructing it later.
Why your bloods can be normal
This is the question that brings people here at 2am, so it deserves a direct answer.
The criterion is hyperandrogenism, and it can be met two ways. Biochemical — a raised measurement. Or clinical — these visible signs. Either one satisfies it. A normal testosterone does not overrule what is visibly happening, and it does not mean you have been imagining it.
There is also a measurement subtlety. Total testosterone can sit inside the reference range while the free androgen index — calculated from total testosterone and SHBG — does not, because SHBG binds testosterone and removes it from circulation. Two people with the same total can have quite different amounts of active hormone. That is why SHBG is on the panel at all, and why “normal testosterone” is a less complete statement than it sounds.
Everything here runs on months
The single most useful thing to know about this whole category: the timescales are long, and they are long for a structural reason.
Hair grows in cycles. A follicle in its growth phase is committed to it; anything aimed at hair growth can only influence follicles entering a new phase. So there is a floor on how quickly any change can become visible, and it is measured in months rather than weeks — with roughly six months being the usual point at which an assessment can meaningfully be made.
This has one important practical consequence. Stopping something at six or eight weeks because nothing has changed is stopping before the question could have been answered. Nothing had time to happen. The same applies to concluding that something worked on the same timescale.
Which makes this the area where a record earns its keep most obviously. Six months is far longer than memory reliably covers, and memory is biased towards the worst weeks — those are the ones that stayed. A count of affected days per month, kept as you go, is the only version of this that can be compared to itself later.
What to bring to the appointment
- Counts, not impressions. Days affected per month, per symptom, kept separately.
- When it started, as precisely as you can, and whether it has changed.
- A photograph, particularly for hirsutism, taken before removal.
- What you have already tried, including things bought over the counter, and for how long.
- Which of the three bothers you most. They are not always treated together, and if the appointment runs out of time, you want the right one to have been discussed.
And one framing worth dropping on the way in: none of this requires justification as a medical concern rather than a cosmetic one. It is one of the three criteria the diagnosis is built on. You are reporting a symptom.