What are the recommended treatments for hirsutism?

Treatment of Hirsutism

For most women with hirsutism, start with oral contraceptive pills (OCPs) as first-line pharmacological therapy, and if the response is suboptimal after 6 months, add an antiandrogen such as spironolactone. 1

First-Line Pharmacological Therapy: Oral Contraceptives

OCPs are the recommended initial treatment for the majority of women with patient-important hirsutism 1. They work through multiple mechanisms:

• Suppressing LH secretion (reducing ovarian androgen production)
• Increasing hepatic production of sex hormone-binding globulin (SHGB), which reduces free androgen levels
• Providing contraception (critical given teratogenic potential of antiandrogens)

OCPs containing cyproterone acetate (2 mg) or drospirenone (3 mg) have mild antiandrogenic properties, though all OCPs as a class are superior to placebo 1. The choice between different OCP formulations can be based on availability and side effect profile, as differences in efficacy are relatively small.

Adding Antiandrogens After 6 Months

If hirsutism remains patient-important after 6 months of OCP monotherapy, add an antiandrogen 1. The hierarchy of antiandrogen options:

Spironolactone (First-Line Antiandrogen)

• Dosing: 100-200 mg/day in divided doses (twice daily) 1
• Similar efficacy to other antiandrogens with better safety profile
• Can be used as monotherapy in women who cannot or choose not to use OCPs, but adequate contraception is mandatory 1

Finasteride (Second-Line)

• Dosing: 2.5-5 mg/day 1
• Reduces hirsutism scores by 30-60% 1
• May be slightly less effective than spironolactone with prolonged treatment 1
• Requires strict contraception due to teratogenic effects

Cyproterone Acetate (Where Available)

• Dosing: 50-100 mg/day on cycle days 5-15 with ethinyl estradiol, or 2 mg daily in combined OCP formulation 1
• Not available in the United States
• Similar efficacy to other antiandrogens 1

Flutamide (NOT Recommended as First-Line)

Avoid flutamide due to significant hepatotoxicity risk, including liver failure and death 1. If used despite this risk, use the lowest effective dose (62.5-250 mg/day) with close liver enzyme monitoring 1.

Treatments to AVOID

• Antiandrogen monotherapy without contraception: Absolutely contraindicated due to teratogenic potential 1
• Insulin-lowering drugs (metformin): Not effective for hirsutism treatment 1, 2
• Topical antiandrogens: Limited efficacy 1
• Glucocorticoids: Only for nonclassic congenital adrenal hyperplasia (NCCAH) with suboptimal response to OCPs/antiandrogens 1
• GnRH agonists: Reserved only for severe hyperandrogenemia (e.g., ovarian hyperthecosis) unresponsive to OCPs and antiandrogens 1

Hair Removal Methods

For women desiring additional cosmetic benefit or as an alternative to pharmacotherapy, laser/photoepilation is the preferred direct hair removal method 1.

• Alexandrite and diode lasers are most effective for permanent hair reduction 3
• Eflornithine cream can be added during photoepilation for more rapid initial response 1
• Electrolysis is effective for permanent hair removal in localized areas 3
• Temporary methods (shaving, plucking, waxing) are safe but require ongoing maintenance

Critical Timing and Expectations

All pharmacological therapies require a minimum 6-month trial before adjusting dose, changing medication, or adding additional therapy 1. This is essential because:

• Hair growth cycles are slow
• Existing terminal hairs must complete their growth cycle
• Premature medication changes lead to unnecessary polypharmacy

Lifelong treatment is often necessary for sustained benefit, as hirsutism typically recurs after discontinuation 3.

Common Pitfalls to Avoid

1. Starting antiandrogens without contraception - This is the most dangerous error given teratogenic potential
2. Changing therapy before 6 months - Insufficient time to assess response
3. Using metformin for hirsutism alone - While beneficial for metabolic issues in PCOS, it does not improve hirsutism
4. Prescribing flutamide as first-line - Unacceptable hepatotoxicity risk
5. Underestimating patient distress - Women with subjective complaints of excess hair deserve evaluation and treatment regardless of objective findings 4