What are the treatment options for managing excessive body and facial hair, particularly in cases related to hormonal imbalances such as polycystic ovary syndrome (PCOS)?

Management of Excessive Body and Facial Hair

For patients with excessive body and facial hair, particularly in cases related to hormonal imbalances like PCOS, a combination of pharmacological treatments and mechanical hair removal methods is recommended, with oral contraceptives being the first-line medical therapy. 1

Diagnostic Evaluation

Before initiating treatment, proper diagnosis is essential:

• Hormonal assessment:

  • Measure total testosterone and free testosterone levels 1
  • Check DHEA-S levels to assess adrenal androgen production 1
  • Measure 17-hydroxyprogesterone to evaluate for non-classical congenital adrenal hyperplasia 1
  • Assess LH/FSH ratio (>2 suggests PCOS) 1
  • Consider fasting glucose, insulin levels, and lipid profile 2

• Imaging:

  • Pelvic ultrasound if PCOS is suspected 1
  • Adrenal CT or MRI if significantly elevated androgens to rule out adrenal tumors 1

Treatment Options

First-Line Pharmacological Treatments

1. Combined Oral Contraceptives (COCs):

   • Suppress ovarian androgen production
   • Increase sex hormone-binding globulin (SHBG)
   • Reduce free testosterone levels 1
   • Recommended as first-line treatment by the American Academy of Dermatology 1

2. Anti-androgens:

   • Spironolactone: 25-100 mg daily

     • Blocks androgen receptors and inhibits androgen production
     • Monitor for hyperkalemia, especially in patients with renal impairment 1
     • Clinical studies show regression of hirsutism within two months, with maximal effect at six months 3

   • Other options:

     • Flutamide
     • Finasteride
     • Cyproterone acetate (not available in all countries) 2

3. Insulin-sensitizing agents:

   • Metformin - particularly useful when PCOS and insulin resistance are present 2
   • Improves ovulation and may help reduce androgen levels 2

4. Topical treatments:

   • Eflornithine hydrochloride 13.9% cream (FDA-approved)
     • Slows facial hair growth
     • Can be used as adjuvant therapy with systemic medications 4

Mechanical Hair Removal Methods

1. Temporary methods:

   • Shaving
   • Plucking
   • Waxing
   • Depilatory creams 5

2. Permanent/semi-permanent methods:

   • Electrolysis:

     • Destroys individual hair follicles with electric current
     • May be impractical for large areas 2
     • Multiple treatments needed 2

   • Laser hair removal:

     • Most effective for dark hair on light skin
     • Multiple treatments required
     • Results depend on practitioner skill, laser type, skin type, and hair color 5
     • Offers fastest method of hair reduction 5

Treatment Algorithm

1. For mild hirsutism:

   • Start with mechanical hair removal methods
   • Consider topical eflornithine for facial hair

2. For moderate to severe hirsutism:

   • Start with COCs with anti-androgenic properties
   • If inadequate response after 6-9 months, add an anti-androgen (spironolactone) 4
   • Combine with mechanical hair removal methods
   • Consider topical eflornithine as adjuvant therapy

3. For hirsutism with PCOS and insulin resistance:

   • Add metformin to the treatment regimen 2
   • Weight loss if overweight/obese (5% weight loss can improve symptoms) 2

Special Considerations

• Pregnancy planning: Anti-androgens are contraindicated during pregnancy due to risk of fetal virilization 1
• Monitoring: Clinical assessment every 3-6 months to evaluate treatment efficacy 1
• Treatment expectations: Improvement typically takes 6-12 months; existing terminal hairs won't disappear but new growth can be prevented 4
• Family history: Idiopathic hirsutism often has a strong familial component 6

Pitfalls and Caveats

• Anti-androgens should not be used without adequate contraception in women of reproductive age due to risk of fetal virilization
• Spironolactone can cause hyperkalemia; monitor potassium levels
• Hirsutism treatment is typically long-term; patients should be counseled about realistic expectations
• Asian women may have less prevalent hirsutism despite androgen excess 6
• Treatment efficacy should be assessed after at least 6 months, as hair growth cycles are slow

By combining pharmacological approaches with mechanical hair removal methods, most patients with hirsutism can achieve satisfactory results, though treatment typically needs to be continued long-term for sustained benefits.