Ferriman-Gallwey scoring: A guide to hirsutism

Many women are naturally hairy so it can be difficult to determine just how much hair is a cause for concern. Especially when it’s in certain areas. The Ferriman-Gallwey scoring system is a clinical tool for assessing hirsutism, a condition which is marked by excessive, male-pattern hair growth in women. It evaluates nine areas of your body and assigns a score from 0 to 4 based on the amount of hair in each area

While body hair is entirely normal, certain patterns and distributions can be quite uncomfortable. For example, hair on the chin, upper lip, chest, and lower abdomen. This is usually caused by conditions like polycystic ovary syndrome (PCOS), hormonal imbalances, or other endocrine disorders. 

This article discusses the Ferriman-Gallwey scale and how it is used to determine hirsutism.

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What is hirsutism?

Hirsutism is when there is excessive hair growth in women that follows a male-pattern distribution. It affects areas on your body that are sensitive to androgens, like the upper lip, chin, chest, abdomen, back, and neck.

About 5–15% of women have this condition so it’s a common reason for dermatology visits.

This hair growth involves terminal hairs that are thick, coarse, and long-stranded mostly found on your scalp, eyebrows, eye eyelashes. While vellus hairs are fine, soft, and lightly pigmented, often described as peach fuzz. This terminal hair accounts for around 30% of your surface body hair. 

How Androgens Influence Hair Growth 

During puberty, increasing androgen levels act on sex-specific areas. This causes some vellus hairs to change to terminal hairs. When this change happens excessively in women, it results in hirsutism

Hirsutism is caused by several factors. The most common is polycystic ovary syndrome (PCOS), which leads to increased androgen levels. Other causes include:

• Cushing syndrome, characterised by excess cortisol, which can also stimulate androgen production
• Androgen-secreting tumors, either ovarian or adrena
• Certain medications, such as anabolic steroids, danazol or some hormonal therapies

Ferriman-Gallwey Scoring System: Overview 

The Ferriman-Gallwey scoring system is a clinical tool used to quantify male-pattern hair growth in women. It was originally developed in 1961 by Ferriman and Gallwey and evaluates the extent of hair growth in 11 different body regions. It was later modified to include only 9 body areas, excluding the forearms and lower legs.

This new scale is now known as the Modified Ferriman-Gallwey Score (mFG). The Modified Ferriman-Gallwey (mFG) scale is simple and scores hair growth based on appearance.

Ferriman-Gallwey Scoring System

The Modified Ferriman-Gallwey (mFG) calculator assesses hair growth in nine androgen-sensitive areas of the female body. Each body area is scored from 0 (no terminal hair) to 4 (extensive terminal hair) based on hair appearance. 

The Nine Body Areas Assessed

• Upper Lip- Presence of terminal hair above the lip, ranging from sparse growth to a full moustache pattern.
• Chin-Terminal hair over the chin area, varying from fine strands to dense, beard-like growth.
• Chest- Hair growth between the breasts or around the nipples, similar to male chest hair distribution.
• Upper Back-Terminal hair on the upper region of the back
• Lower Back-Terminal hair on the lower part of the back. 
• Upper Abdomen-Terminal hair between the chest and the navel.
• Lower Abdomen- Terminal hair between the navel and the pubic area, often in a midline pattern.
• Upper Arms- Coarse hair on the upper sections of the arms
• Thighs- Terminal hair on the inner and upper part of the legs.

These locations are selected because they’re sensitive to androgens–the terminal hair development hormone.

How to Use the Modified Ferriman-Gallwey Calculator 

Each area is scored on a scale from 0 (no hair growth) to 4 (extensive hair growth) across the nine specific body regions. The total Ferriman-Gallwey score is calculated by adding all the scores from the nine regions. Scores range from 0 to 36, with a total of 8 or above showing hirsutism. The higher the score, the greater the hair growth showing the effects of androgen activity.

Racial and Ethnic Differences in mFG Scores

Racial variations in terminal hair growth can affect the Modified Ferriman-Gallwey (mFG) scoring outcomes. For example, a study involving Turkish patients, primarily Caucasian, with an mFG score of 8 or above was considered diagnostic for hirsutism.

Among Filipino women, the score for hirsutism was at 7 or above, while in a South Indian population, a score of just 5 or more was sufficient for diagnosis.

In addition to racial variability, research also indicates that certain body regions are more predictive of hirsutism. 

A study identified the chin, thighs, upper lip, and lower abdomen as the most diagnostically relevant areas. Similarly, among Filipino women, the areas that contributed most to the total mFG scores were the upper lip, upper back, upper and lower abdomen, and thighs.

These findings highlight the importance of ethnic background and region-specific scoring emphasis when evaluating hirsutism in women.

Limitations of the mFG Scoring System

While the Modified Ferriman-Gallwey (mFG) scale is affordable, accessible, and easy to apply in clinical settings for scoring hirsutism, it has some limitations such as:

1. Ethnic Variations in Hair Distribution

The scale does not fully account for racial and ethnic differences in terminal hair growth. 

It means there might be a wrong classification leading to under- or over-diagnosis.

2. Need for Full-Body Examination

Assessing the nine body regions means exposing private or sensitive areas. This can be quite embarrassing and uncomfortable.

3. Observer Variability

The scoring is based on individual observations. There may be inter-observer errors leading to different scores among practitioners which affects diagnosis.

4. Time Constraints in Clinical Practice

Evaluating all nine regions can be time-consuming. A high patient load can also affect thorough screening. 

Moving Forward: What You Can Do

While having your mFG assessment, make sure to discuss certain details with your healthcare provider. These can include:

• How visible hair growth makes you feel
  
• Whether it impacts your self-esteem or daily life
  
• Any accompanying symptoms (acne, irregular periods, weight changes)
  
• Next steps like hormone testing or metabolic screening
  

Summary 

The Modified Ferriman-Gallwey (mFG) scoring system is important for evaluating hirsutism in women. Especially due to its ease and accessibility. But, like many diagnostic tools, it has limitations

Ethnicity-specific values should be developed for predicting the accuracy of the mFG scoring system. Although the mFG scale plays an important role in evaluating hirsutism, it’s best combined with other investigations to provide a better diagnosis for women affected by hirsutism.

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