What are the first-line treatment recommendations for adolescents with Polycystic Ovary Syndrome (PCOS) and hirsutism according to the European Society of Human Reproduction and Embryology (ESHRE) guidelines?

First-Line Treatment for Adolescents with PCOS and Hirsutism

For adolescents with Polycystic Ovary Syndrome (PCOS) and hirsutism, the first-line treatment should be combined oral contraceptives (COCs) along with lifestyle modifications focusing on weight management and regular physical activity. 1

Treatment Algorithm for PCOS with Hirsutism in Adolescents

Step 1: Lifestyle Interventions

• Dietary approach:

  • Energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day)
  • Focus on low glycemic index foods and anti-inflammatory diet patterns
  • Adequate magnesium and zinc intake
  • Limit calories from fat to 25-30%, saturated fat to <7%, and avoid trans fats 1

• Physical activity:

  • At least 60 minutes of moderate to vigorous activity daily
  • Include weight training 3 times per week
  • Target 5-10% weight reduction for significant clinical improvements 1

Step 2: Pharmacological Management of Hirsutism

• First-line medication: Combined oral contraceptives (COCs)

  • COCs reliably improve both menstrual abnormalities and hyperandrogenism 1
  • They work by suppressing ovarian androgen production and increasing sex hormone-binding globulin, which reduces free testosterone levels

• Anti-androgen therapy:

  • Consider adding an anti-androgen (such as spironolactone) if response to COCs alone is inadequate 2, 1
  • Note: Anti-androgens should always be used with effective contraception due to potential teratogenic effects

Step 3: Additional Treatments for Hirsutism

• Topical treatments:

  • Eflornithine hydrochloride cream for facial hirsutism 2

• Mechanical hair removal methods:

  • Temporary methods: shaving, plucking, waxing
  • Permanent methods: electrolysis, laser hair removal 2

Important Considerations

Monitoring

• Evaluate menstrual cycles every 3-6 months
• Assess metabolic parameters annually
• Screen for cardiovascular risk factors and mental health concerns 1

Cautions and Limitations

• COCs may not be appropriate for adolescents with certain conditions (history of thrombosis, migraine with aura, etc.)
• Mechanical hair removal methods may require multiple treatments and concomitant medical management to reduce androgen levels 2
• Visible improvement in hirsutism typically takes 6-12 months due to hair follicle cycle

Addressing Comorbidities

• For insulin resistance: Consider metformin (starting at 500 mg/day with gradual increase) 1
• For psychological concerns: Address anxiety, depression, and body image issues that commonly accompany PCOS 1

The combination of an anti-androgen with COCs appears to be the most effective treatment approach for hirsutism in PCOS, though the optimal specific combination has not been definitively established 2. Treatment should be continued for at least 6-12 months before assessing full efficacy due to the slow turnover of hair follicles.