What is the treatment approach for women with abnormal facial hair growth due to elevated Dehydroepiandrosterone (DHEA) sulfate levels?

Treatment of Abnormal Facial Hair Growth Due to Elevated DHEA Sulfate in Women

For women with abnormal facial hair growth due to elevated DHEA sulfate levels, the recommended first-line treatment is a combination of an anti-androgen medication (preferably spironolactone) and a combined oral contraceptive, with consideration of low-dose dexamethasone (0.125-0.25mg at bedtime) in cases with significantly elevated DHEA-S levels. 1, 2, 3

Diagnostic Evaluation

Before initiating treatment, confirm the diagnosis and rule out other causes:

• Hormone testing:

  • DHEA sulfate levels (with age-specific reference ranges)
  • Total and free testosterone
  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
  • 17-hydroxyprogesterone (to evaluate for congenital adrenal hyperplasia)
  • Morning cortisol and ACTH (if adrenal tumor suspected) 1

• Imaging studies:

  • Consider adrenal CT or MRI if DHEA-S levels are markedly elevated (>700 μg/dL) to rule out adrenal tumors 4
  • Pelvic ultrasound if PCOS is suspected (especially with LH/FSH ratio >2) 1

Treatment Algorithm

First-line Treatment:

1. Anti-androgen therapy:

   • Spironolactone: 25-100 mg daily, titrated based on response
     • Monitor potassium levels in patients with risk factors for hyperkalemia
     • Can be taken with or without food, but should be consistent 2

2. Combined oral contraceptives:

   • Suppresses ovarian androgen production
   • Increases sex hormone-binding globulin, reducing free testosterone 5, 3

3. For significantly elevated DHEA-S of adrenal origin:

   • Consider low-dose dexamethasone (0.125-0.25 mg at bedtime)
   • Effective dose is typically lower than previously thought
   • 75% of women achieve DHEA-S suppression with ≤0.25 mg daily 6

Adjunctive Treatments:

• Direct hair removal methods:

  • Laser/photoepilation for permanent reduction
  • Temporary methods: shaving, waxing, plucking, depilatory creams 3

• Topical treatments:

  • Eflornithine hydrochloride 13.9% cream can slow facial hair growth 5

Monitoring and Follow-up

• Clinical evaluation every 3-6 months to assess:

  • Improvement in hirsutism
  • Side effects of medications
  • Signs of androgen excess 1

• Hormone measurements:

  • DHEA-S levels every 3-6 months if on glucocorticoid therapy
  • Adjust medication doses based on clinical and biochemical response 1

Important Considerations

• Avoid exogenous testosterone as it would worsen the condition 1

• Glucocorticoid therapy caveats:

  • Use lowest effective dose to minimize side effects
  • Monitor for cushingoid features (weight gain, striae, bruising)
  • Educate patients about stress dosing during illness 1

• Treatment expectations:

  • Improvement typically takes 6-12 months
  • If response to initial therapy is suboptimal after 6 months, consider adding another agent 3

• Contraception:

  • Essential when using anti-androgens due to risk of feminization of male fetus 3

Special Situations

• If PCOS is the underlying cause:

  • Consider insulin-sensitizing agents (metformin) if insulin resistance is present
  • Weight loss if applicable can improve symptoms 1, 5

• If adrenal hyperplasia is diagnosed:

  • Glucocorticoid replacement therapy (hydrocortisone 15-20 mg daily in divided doses)
  • Goal is to normalize adrenal androgens while avoiding cushingoid features 1

The treatment approach should be maintained for at least 6 months before assessing efficacy, as hair growth cycles require time to respond to hormonal interventions 5, 3.