Hello! Welcome back to our study of the clinical aspects of PCOS.
In our last lesson, we identified the three primary clinical signs of hyperandrogenism: hirsutism (male-pattern hair growth), androgenic alopecia (hair loss), and acne. We briefly introduced the idea that hirsutism is assessed using a scoring system to make the evaluation objective.
Today, we will focus entirely on that tool. Our learning outcome is to explain the use of the Ferriman-Gallwey score for the clinical assessment of hirsutism. We will move from simply recognizing hirsutism to learning the standardized method clinicians use to measure its severity. Mastering this is crucial for both diagnosing PCOS and monitoring how well treatments are working.
Why Do We Need a Scoring System?
Hirsutism is a key diagnostic clue for hyperandrogenism, but "excess hair" can be subjective. What one person considers normal, another might find excessive. Furthermore, a clinician needs a way to track changes over time. Is the treatment working? Has the hair growth lessened? To answer these questions objectively, a standardized scoring system is essential.
First, let's refresh our understanding of what kind of hair we are assessing.
Topic 44: Hirsutism and Virilization
The video 'Topic 44: Hirsutism and Virilization' from the Association of Professors of Gynecology and Obstetrics (APGO) provides a clear definition of hirsutism and introduces the concept of the Ferriman-Gallwey scale.
Watch the segment from 00:32 to 01:33. Pay close attention to the distinction between fine, vellus hair and the coarse, dark terminal hair that is assessed in hirsutism. Note how the video introduces the scale as a tool to objectify hair growth.
As the video explains, the Ferriman-Gallwey score was created to provide a semi-quantitative, objective assessment of androgen-dependent hair growth.
The Modified Ferriman-Gallwey (mFG) Score
The original score, developed in 1961, assessed 11 body areas. However, research later showed that terminal hair growth on the forearms and lower legs is not consistently linked to high androgen levels and can be common in women of certain ethnicities without any underlying hormonal disorder.
Therefore, the modified Ferriman-Gallwey (mFG) score is now the universally accepted standard. It focuses on the nine body areas that are most sensitive to androgens.
Guideline No. 444: Hirsutism: Evaluation and Treatment
This clinical practice guideline, 'Hirsutism: Evaluation and Treatment' from the Society of Obstetricians and Gynaecologists of Canada (SOGC), provides an authoritative overview of the mFG score.
Please read the section titled 'DEFINITION AND PATHOGENESIS' (usually on the first page of the document). Focus on the paragraph that begins 'The modified Ferriman-Gallwey (mFG) score...'. This will confirm the nine body areas and establish the mFG score as the preferred method.
The nine androgen-sensitive areas assessed are:
- Upper Lip
- Chin
- Chest
- Upper Abdomen
- Lower Abdomen
- Upper Arms
- Thighs
- Upper Back
- Lower Back
How to Perform the Assessment
For each of these nine areas, hair growth is graded on a scale from 0 to 4:
- Score 0: Absence of terminal hair.
- Score 1: A few scattered terminal hairs.
- Score 2: Light growth of terminal hair.
- Score 3: Moderate growth of terminal hair.
- Score 4: Extensive, dense hair growth, similar to that seen in a typical male (often described as "frankly virile").
The scores from all nine areas are then added together to get a total score, which can range from 0 to 36 (9 areas x 4 points max).
To truly understand how this grading works in practice, it's best to see visual examples.
The 'Ferriman Gallwey score' page from MyEndoConsult offers an excellent interactive guide with pictures that clearly illustrate what each score (1, 2, 3, and 4) looks like for each body area. This is the best way to learn the practical application of the score.
Go through the 'Ferriman-Gallwey Score Calculator' section on the page. You don't need to use the calculator function itself. Instead, carefully examine the images and descriptions for each body area (Upper Lip, Chin, Chest, etc.). Try to understand the visual difference between a score of 1, 2, 3, and 4 for at least three or four of the areas.
Interpreting the Score: What is Clinically Significant?
Once you have a total score, you need to interpret it.
General Threshold
For women of White or Black ethnicity, a total mFG score of ≥8 is generally considered the cut-off for a clinical diagnosis of hirsutism.
Severity Grading
The score can also be used to classify the severity of hirsutism:
- Mild: Score of 8–15
- Moderate: Score of 16–25
- Severe: Score of >25
A Critical Consideration: Ethnic Variation
It is extremely important to recognize that normal hair patterns vary significantly across different ethnic groups. A score that indicates hirsutism in one population may be completely normal in another. This is why using a single cut-off for everyone is inappropriate.
Let's look at the specific recommendations from the SOGC guideline.
Guideline No. 444: Hirsutism: Evaluation and Treatment
We will return to the SOGC guideline to understand the crucial nuances of interpreting the mFG score across different populations.
Find the paragraph that begins 'Scores range from 0 to 4...' This section provides the specific cut-off scores for various ethnicities. Pay close attention to these different thresholds. Also, review Figure 1 and its caption, which provides a classic illustration of the scoring areas.
As you read, note the different thresholds:
- Mexican, Mediterranean, South Asian, Middle Eastern: >9–10
- East Asian (e.g., Chinese, Japanese): >2–3
- Latin American: >6
This highlights that clinical context is everything. A score of 7 might be normal for a Mediterranean woman but would be highly suggestive of hyperandrogenism in a Japanese woman.
Test your understanding!
A 25-year-old woman of South Asian descent is being evaluated. You calculate her mFG score as follows:
- Upper lip: 2
- Chin: 2
- Lower abdomen: 3
- Thighs: 2
- All other areas: 0
What is her total mFG score? Based on the ethnic-specific guidelines, would this score be considered indicative of hirsutism?
Show answer
Her total score is 2 + 2 + 3 + 2 = 9.
Yes, this would be consistent with hirsutism. The guideline suggests a cut-off of >9-10 for South Asian women. A score of 9 is right at that threshold and warrants further investigation for hyperandrogenism. If her score had been 7, it likely would not have met the clinical criteria for hirsutism in her population group.
Limitations of the mFG Score
While the mFG score is the best tool we have, it's not perfect. It has a few important limitations.
- Subjectivity: Although it provides a framework, there can still be some variation between different clinicians' scores.
- Cosmetic Hair Removal: This is the biggest practical challenge. The score can be falsely low if the patient shaves, waxes, plucks, or has had laser hair removal. It is essential to ask the patient about their hair removal methods and timing before scoring.
Hirsutism: Diagnosis, Examination, Management – Gynecology | Lecturio
This short clip from a Lecturio video on Hirsutism highlights this exact practical limitation.
Watch the segment from 03:23 to 03:53. The speaker quickly notes how cosmetic treatments have made the score 'less useful' in some contexts, reinforcing the need to take a good history.
- Patient Perception: As noted in the SOGC guideline, some women with scores as low as 3-5 may experience significant distress from their hair growth. The score is a clinical tool, but the patient's subjective experience is also vital.
Conclusion
Today we took a deep dive into the primary tool for quantifying hirsutism, a cornerstone of the clinical evaluation of PCOS. By moving from a subjective observation to a numerical score, clinicians can diagnose more accurately and track treatment effectiveness over time.
Key Takeaways:
- The modified Ferriman-Gallwey (mFG) score is the standard method for the clinical assessment of hirsutism.
- It involves grading terminal hair growth on a 0-4 scale across nine androgen-sensitive body areas.
- A total score of ≥8 is the common threshold for hirsutism in White and Black women, but this cut-off varies significantly with ethnicity.
- The score is used for initial diagnosis and to monitor response to therapy.
- Its main limitation is the potential for a falsely low score due to cosmetic hair removal, making a thorough patient history essential.
Preview of the Next Lesson:
A clinical sign like hirsutism strongly suggests hyperandrogenism, but a diagnosis requires confirmation with laboratory tests. In our next lesson, we will explore the "biochemical" side of the diagnosis, where you will outline the biochemical investigations used to confirm hyperandrogenism. We will look at which hormones are measured in the blood and what patterns are typically seen in PCOS.