What are the treatment options for hirsutism?

Treatment Options for Hirsutism

The most effective treatment approach for hirsutism is a combination of an antiandrogen medication and an ovarian suppression agent (typically a combined oral contraceptive pill), along with cosmetic hair removal methods. 1

First-Line Pharmacological Treatments

Combined Hormonal Approach

1. Combined Oral Contraceptives (COCs)

   • Suppresses ovarian androgen production
   • Increases sex hormone-binding globulin, reducing free testosterone
   • First choice for non-fertility seeking patients with PCOS-related hirsutism 2

2. Antiandrogen Medications (should be combined with COCs)

   • Spironolactone: 100-150 mg daily

     • Shown to improve hirsutism in 85% of patients, with complete remission in 55% 1
     • Most effective in mild-to-moderate hirsutism

   • Flutamide: Androgen receptor blocker

     • Effective but requires liver function monitoring

   • Finasteride: 1.25-5 mg daily

     • 5α-reductase inhibitor that prevents conversion of testosterone to dihydrotestosterone
     • Particularly effective for scalp hair growth 1, 2

Important Caution

• Antiandrogens must be used with reliable contraception due to risk of feminization of male fetus
• Progestogen-only contraceptives may worsen hirsutism in some cases and should be used with caution 1

FDA-Approved Topical Treatment

• Eflornithine hydrochloride cream (13.9%)
  • Only FDA-approved topical treatment specifically for hirsutism 1
  • Inhibits ornithine decarboxylase in hair follicles
  • Best used as adjunctive therapy with other treatments 3

Additional Pharmacological Options

For PCOS-Related Hirsutism

• Metformin: 500 mg 2-3 times daily
  • Most beneficial in women with PCOS who have insulin resistance
  • Shown to improve Sartorius score in 72% of patients and quality of life in 64% 1
  • Consider for women with features of polycystic ovarian syndrome 2

Limited Efficacy Options

• Isotretinoin
  • Not recommended as primary treatment for hirsutism unless there are concomitant moderate-to-severe acneiform lesions 1
  • Only about 41% of patients show improvement 1

Cosmetic and Mechanical Hair Removal Methods

• Temporary methods:

  • Shaving, waxing, plucking, depilatory creams
  • Inexpensive but require frequent repetition

• Permanent/long-lasting methods:

  • Electrolysis: Effective but time-consuming and may cause scarring
  • Laser hair removal: Most effective for dark hair on light skin
  • Multiple treatments typically required 1
  • Concomitant medical management to reduce androgen levels usually necessary for optimal results

Treatment Algorithm

1. Initial assessment:

   • Determine severity of hirsutism
   • Rule out androgen-secreting tumors and other endocrine disorders
   • Assess for PCOS features (irregular periods, acne, obesity)

2. For mild hirsutism:

   • Start with cosmetic methods
   • If insufficient, add COC with anti-androgenic properties

3. For moderate-to-severe hirsutism:

   • Start with combined therapy: COC + antiandrogen (spironolactone 100-150 mg daily)
   • Add topical eflornithine for facial hirsutism
   • Recommend professional hair removal (laser or electrolysis)

4. For PCOS with insulin resistance:

   • Add metformin 500 mg 2-3 times daily to the above regimen

Important Clinical Considerations

• Treatment expectations: Patients should be counseled that:

  • Visible improvement typically takes 6-12 months
  • Medical therapy reduces hair growth in less than 50% of cases 4
  • Existing terminal hairs will not disappear with medication alone

• Monitoring:

  • Assess response after 6 months before changing therapy
  • For spironolactone: monitor potassium levels
  • For flutamide: monitor liver function
  • For antiandrogens: ensure adequate contraception

• Weight management:

  • Even modest weight loss (5% of initial weight) can improve hormonal parameters and hirsutism in overweight women with PCOS 1, 2

Remember that hirsutism treatment is often palliative rather than curative, and a combination approach using both medical therapy and cosmetic hair removal typically yields the best results.