From the Guidelines
Spironolactone is the first-line medication for controlling hirsutism in Polycystic Ovary Syndrome (PCOS). The medication works by blocking androgen receptors, addressing the underlying hormonal imbalance in PCOS that causes excessive hair growth 1. The typical starting dose is 50-100 mg daily, which can be gradually increased to 200 mg daily if needed. Treatment should continue for at least 6-12 months before assessing full effectiveness, as hair growth cycles are slow to respond. Some key points to consider when treating hirsutism in PCOS include:
- Combined oral contraceptives (COCs) containing ethinyl estradiol with anti-androgenic progestins like drospirenone, cyproterone acetate, or dienogest are also effective, either alone or in combination with spironolactone 1.
- Finasteride (2.5-5 mg daily) and flutamide are second-line options but have more limited evidence.
- These medications work by blocking androgen receptors or reducing androgen production, addressing the underlying hormonal imbalance in PCOS that causes excessive hair growth.
- Patients should be counseled that visible results take 3-6 months to appear, and concurrent cosmetic hair removal methods may be used during treatment.
- For women planning pregnancy, these anti-androgen medications should be discontinued due to potential feminization of male fetuses. It's also important to note that mechanical removal of hair (e.g., plucking, shaving, waxing), electrolysis, and laser vaporization are also used to manage hirsutism, but concomitant medical management directed at reducing androgen levels usually is necessary 1.
From the Research
Medications for Controlling Hirsutism in PCOS
- The following medications are indicated to control hirsutism in Polycystic Ovary Syndrome (PCOS):
- Combined oral contraceptives (COCs) such as ethinyl estradiol and cyproterone acetate 2, 3, 4, 5
- Antiandrogens such as cyproterone acetate, spironolactone, flutamide, and finasteride 4, 5
- Metformin, an oral antihyperglycemic medication, which has been shown to be potentially effective in reducing hirsutism in women with PCOS 2, 6, 3, 5
Mechanism of Action
- COCs work by suppressing ovarian androgen secretion and decreasing free testosterone levels 4
- Antiandrogens work by blocking androgen receptors or inhibiting 5 alpha-reductase activity, which converts testosterone to dihydrotestosterone 4, 5
- Metformin works by reducing hyperinsulinemia, which is thought to contribute to hirsutism in women with PCOS 2, 6
Efficacy and Safety
- The efficacy and safety of these medications vary, and the choice of treatment should be individualized based on the severity of hirsutism, presence of other symptoms, and patient preferences 3, 4, 5
- COCs and antiandrogens are generally effective in reducing hirsutism, but may have side effects such as weight gain, mood changes, and increased risk of thromboembolism 4, 5
- Metformin is generally well-tolerated, but may have gastrointestinal side effects and requires monitoring of renal function and glucose levels 2, 6