When should I consider referring a patient with hirsutism to an endocrinologist or dermatologist?

Refer a patient with hirsutism to an endocrinologist urgently (within 2 weeks) if there is suspicion of an underlying adrenal or ovarian neoplasm, especially if there is sudden onset or rapid progression of hair growth, signs of virilization (such as voice deepening, increased muscle bulk, clitoromegaly), or a pelvic/abdominal mass. Also urgently refer if serum testosterone is raised above 4 nmol/L, particularly if above 6–7 nmol/L, or if 17-hydroxyprogesterone levels are elevated. Consider referral to endocrinology if another endocrine disorder is suspected that requires secondary care diagnosis or management, or if investigations return abnormal results. Refer to dermatology if the patient has facial hirsutism and topical eflornithine treatment in primary care has been ineffective after 4 months, or if combined oral contraceptives (COCs) are contraindicated or ineffective after 6 months, for specialist treatment options. Referral to dermatology may also be appropriate if hirsutism significantly impacts quality of life and requires specialist hair removal or anti-androgen therapies.