What treatments help manage hirsutism in patients with Polycystic Ovary Syndrome (PCOS)?

Management of Hirsutism in PCOS

For patients with PCOS, the most effective treatment approach for hirsutism is a combination of an antiandrogen medication (such as spironolactone 100 mg daily) with an ovarian suppression agent (such as combined oral contraceptives), along with cosmetic hair removal methods. 1

First-Line Pharmacological Treatments

Combined Oral Contraceptives (COCs)

• COCs are recommended as first-line therapy for hirsutism in PCOS patients 1, 2
• They work by:
  • Suppressing gonadotropins and ovarian androgen production
  • Increasing sex hormone-binding globulin (SHBG), which reduces free testosterone
  • Providing endometrial protection
• Third-generation COCs containing newer progestogens are effective for mild-to-moderate hirsutism with long-term use (>12 cycles) 3

Antiandrogens

• Spironolactone 100 mg daily is recommended by the Endocrine Society for hirsutism management 1
  • Visible improvement typically takes 6 months
  • Works by blocking androgen receptors
  • Dosage-dependent effectiveness (higher doses of 200 mg/day may be more effective but cause more side effects) 3
• Other antiandrogens include:
  • Flutamide: Very effective within 6-12 months but carries risk of hepatotoxicity 3
  • Finasteride: 5 mg/day can decrease hirsutism with minimal side effects 3
  • Cyproterone acetate: Effective when used in COCs or reverse sequential regimen 3

⚠️ Important: All antiandrogens must be used with effective contraception due to risk of fetal abnormalities in male fetuses 1, 3

Combination Therapy Approach

Research shows that combination therapy with COCs plus spironolactone is more effective than either treatment alone 4:

• Results in greater reduction in Ferriman-Gallwey hirsutism scores
• Higher patient satisfaction rates
• Treatment requires at least 6 months, with continued improvement over time 4

Alternative Approaches

Metformin

• May be effective for hirsutism in PCOS patients with insulin resistance 5, 2
• Works by reducing hyperinsulinemia rather than directly affecting androgen levels 5
• Can be particularly useful when COCs are contraindicated due to metabolic comorbidities 2
• Should be combined with lifestyle modifications 2

GnRH Agonists

• Reserved for severe cases of ovarian hyperandrogenism with hyperinsulinemia 3
• Requires "add back" therapy with estrogen-progestogen to avoid estrogen deficiency
• More complicated and expensive treatment option 3

Treatment Algorithm Based on Hirsutism Severity

1. Mild Hirsutism:

   • COCs + cosmetic hair removal methods 2

2. Moderate to Severe Hirsutism:

   • COCs + antiandrogen (preferably spironolactone 100 mg daily) 1, 2
   • If COCs contraindicated: antiandrogen + alternative contraception method 2
   • Consider metformin if insulin resistance present 5, 2

3. All Patients:

   • Maintain treatment for at least 6-12 months 2, 4
   • Monitor for improvement using modified Ferriman-Gallwey score 4

Cosmetic Approaches

• Should be used alongside pharmacological treatments 1
• Options include:
  • Temporary methods: shaving, waxing, depilatory creams
  • Permanent methods: electrolysis, laser hair removal
  • Topical eflornithine can slow facial hair growth

Common Pitfalls and Caveats

• Expecting immediate results: Visible improvement typically takes at least 6 months 1, 4
• Discontinuing treatment too early: Continued improvement occurs with longer treatment duration 4
• Failing to provide contraception with antiandrogens: Essential to prevent fetal abnormalities 3
• Neglecting metabolic aspects: Address insulin resistance when present 5, 2
• Not considering patient distress: Treatment should address the psychological impact of hirsutism 2

Predictors of Treatment Success

• Higher initial Ferriman-Gallwey score and sex hormone-binding globulin (SHBG) levels independently predict successful therapy with COCs plus spironolactone 4