Unwanted hair growth and persistent acne are more than skin-deep concerns for many teenage girls and young women. New guidance from ACOG is helping doctors take a more thorough, personalized approach — and that’s good news for patients and families navigating these often frustrating conditions.
For many adolescents, acne and unwanted facial or body hair are written off as inevitable rites of passage — something to endure until hormones “settle down.” But for a meaningful number of teenagers, these symptoms aren’t just a byproduct of puberty. They’re signals from the body that something more specific is going on hormonally, and they deserve a thoughtful medical evaluation.
The American College of Obstetricians and Gynecologists (ACOG) has recently updated its guidance on diagnosing and managing hirsutism (excess hair growth in a male-pattern distribution) and acne in adolescents — both of which can be signs of hyperandrogenism, or elevated levels of male-type hormones like testosterone. For patients and families, understanding this updated framework means knowing what to ask for, what to expect from an evaluation, and what treatment options are available.
What’s Actually Causing These Symptoms?
The most common underlying cause of hyperandrogenism in adolescent girls is polycystic ovary syndrome (PCOS). PCOS is a hormonal condition that affects how the ovaries function and is associated with irregular periods, excess androgen production, and often (though not always) the appearance of multiple small follicles on the ovaries on ultrasound. It’s far more prevalent than many people realize — affecting an estimated 1 in 10 women of reproductive age.
That said, PCOS isn’t the only explanation, and diagnosing it in teenagers comes with real complexity. Irregular periods and acne are common in the first few years after puberty even without an underlying condition, which means a diagnosis of PCOS in a young adolescent requires careful consideration and follow-up. Other conditions that can cause similar symptoms include:
- Congenital adrenal hyperplasia (CAH) — a group of inherited disorders affecting the adrenal glands’ hormone production
- Androgen-secreting tumors — rare but important to rule out, particularly when symptoms appear suddenly or are severe
- Cushing syndrome — caused by prolonged exposure to elevated cortisol levels
- Thyroid dysfunction and elevated prolactin levels, which can contribute to hormonal imbalance
Because these conditions have different implications for long-term health, getting the diagnosis right matters — not just for treating symptoms today, but for protecting cardiovascular health, fertility, and metabolic health down the road.
What a Thorough Evaluation Looks Like
ACOG’s updated guidance emphasizes that a good evaluation goes well beyond a quick look at the skin. When a teenager presents with significant acne or hirsutism, her provider should take a detailed history covering menstrual patterns and regularity, the timing of puberty milestones, any hair removal habits (which can mask the true extent of hair growth), prior acne treatments, medications, and family history of hormonal conditions or PCOS.
The physical exam should assess blood pressure and body mass index, look for skin findings associated with hormonal imbalance — such as acanthosis nigricans (velvety darkening in skin folds, often linked to insulin resistance) — and in appropriate cases, evaluate for clitoromegaly, which can indicate significantly elevated androgen levels.
Laboratory testing typically includes measurement of total and free testosterone, DHEAS (a hormone produced by the adrenal glands), and 17-hydroxyprogesterone (to screen for congenital adrenal hyperplasia). Pelvic ultrasound is not a routine first step, but may be warranted if there are signs suggesting a tumor or significant virilization.
Treatment: A Personalized, Layered Approach
One of the most important takeaways from ACOG’s guidance is that there is no single solution for hirsutism or hormonal acne. Effective management typically involves multiple strategies working together, tailored to the individual patient’s symptoms, lab findings, and personal circumstances.
For Hirsutism
Lifestyle modification is the first and often most impactful lever for adolescents with excess weight. Weight loss — even modest amounts — can meaningfully lower androgen levels and improve both hirsutism and menstrual regularity. This is particularly relevant in PCOS, where insulin resistance plays a central role in driving androgen excess.
When medical treatment is appropriate, combined hormonal contraceptives (the pill, patch, or ring) are the most commonly used option. While they aren’t FDA-approved specifically for hirsutism, they work by reducing androgen production from the ovaries and increasing a protein that binds androgens in the bloodstream, making them less active. They are a well-established and effective choice.
Spironolactone, an antiandrogen medication, is another option that can be added for patients who don’t respond adequately to hormonal contraceptives alone. It works by blocking the effect of androgens at the hair follicle level.
For the hair itself, medical treatment will slow new growth but does not make existing hair disappear. Patients should be counseled that it typically takes six months or more to see meaningful improvement — a realistic expectation that helps prevent discouragement and premature discontinuation. In the meantime, hair removal options range from shaving and waxing (both effective and completely acceptable) to longer-lasting solutions like laser hair removal, which is appropriate for motivated adolescents with stable hormone levels.
For Acne
Acne management in adolescents with hyperandrogenism often benefits from collaboration between the gynecologist and a dermatologist, particularly for moderate to severe cases. Treatment is selected based on severity and the presence of hormonal drivers.
Topical therapies remain a cornerstone of care and include benzoyl peroxide, salicylic acid, topical antibiotics, and retinoids — often used in combination to address different aspects of acne formation. For adolescents past their first period whose acne is clearly hormonally driven — worsening around the menstrual cycle, concentrated along the jawline and chin — oral contraceptives are considered an acceptable and effective first-line treatment under ACOG’s guidance.
Oral antibiotics can be added for inflammatory acne that isn’t responding to topical therapy, though they are generally used for limited courses to avoid antibiotic resistance. Isotretinoin (commonly known by the former brand name Accutane) is reserved for severe, scarring, or treatment-resistant acne. It is highly effective but requires strict pregnancy prevention given its serious risk of birth defects — a conversation that requires sensitivity and thoroughness with adolescent patients.
On the topic of diet: despite widespread popular belief, current evidence does not support specific dietary changes as a proven acne treatment. While a healthy, balanced diet supports overall wellbeing, no single food or food group has been shown to reliably improve or worsen acne in clinical studies.
Don’t Overlook the Emotional Side
ACOG’s guidance explicitly acknowledges something that is easy to underemphasize in a clinical setting: hirsutism and acne carry a real psychological burden for adolescents. At a stage of life when self-image is particularly fragile, visible symptoms on the face and body can contribute to anxiety, depression, social withdrawal, and reduced quality of life.
This means that asking about emotional well-being is part of good care — not a soft add-on. Patients who feel heard about how these conditions affect them are also more likely to engage with treatment consistently. When symptoms are severe or psychological distress is significant, referral to mental health support should be part of the care plan.
A Note for Patients and Families
If you or your daughter is dealing with persistent acne, unwanted hair growth, or irregular periods, these symptoms are worth discussing with your OB/GYN — not accepting as “just hormones.” A thoughtful evaluation can identify what’s driving the symptoms, rule out anything that needs attention, and create a treatment plan that’s realistic, effective, and personalized.
At El Camino Women’s Medical Group, we see adolescent and young adult patients across this full spectrum. We’re here to take these concerns seriously, explain what we’re looking for and why, and work with you toward real improvement — in symptoms, in health, and in how you feel day to day.
Have questions about hormonal symptoms in your teen or young adult daughter? We welcome the conversation. Contact our office to schedule an appointment.
El Camino Women’s Medical Group offers the latest Minimally Invasive Solutions for gynecologic problems. Drs. Amy Teng, Erika Balassiano, Pooja Gupta, and Vivian Wan, all members of AAGL (American Association of Gynecologic Laparoscopy), are highly trained and experienced in the field of Minimally Invasive Gynecologic Surgery. Dr. Erika Balassiano has also completed a Minimally Invasive Gynecologic Surgery Fellowship under the supervision of world-renowned Dr. Camran Nezhat. Angel Wong, PA-C, is a physician assistant who sees patients for routine and lower-acuity care.
All of our physicians are El Camino Hospital doctors and operate and deliver at the Mountain View campus.
As part of El Camino Women’s Medical Group’s commitment to comprehensive care for women, we offer in-network mental health services with world-renowned psychiatrist Dr. Rania Awaad and experienced therapist Daniya Ahmed, LMFT. For women seeking to improve their health through a healthier diet, Mariam AlAgha, MS, is an excellent nutritionist with over a decade of success helping women achieve their health goals. Her services are also in network.
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