What treatments are available for excessive hair growth due to hormonal imbalances, specifically hirsutism?

Treatment Options for Hirsutism

For women with hirsutism due to hormonal imbalances, a combination of pharmacologic therapy with oral contraceptives and antiandrogens like spironolactone is the most effective treatment approach, along with topical eflornithine for facial hair and physical hair removal methods. 1, 2, 3

Diagnostic Evaluation

Before initiating treatment, proper evaluation is essential:

• Laboratory evaluation is recommended for patients with hirsutism and additional signs of androgen excess 1

  • Testing should include total testosterone, free testosterone, DHEA-S, androstenedione
  • Consider thyroid function tests to rule out thyroid disorders

• Clinical assessment should focus on:

  • Pattern and extent of hair growth (using Ferriman-Gallwey scoring system)
  • Onset and progression (rapid onset over months suggests possible androgen-secreting tumor)
  • Associated symptoms (menstrual irregularities, acne, infertility)
  • Signs of virilization (clitoromegaly, deepening voice, increased muscle mass)

First-Line Pharmacologic Treatments

1. Combined Oral Contraceptives (COCs)

   • Mechanism: Suppress ovarian androgen production and increase sex hormone-binding globulin
   • Dosing: Daily administration of COCs containing ethinyl estradiol with an antiandrogenic progestin
   • Efficacy: Superior to placebo; may take 6-12 months for maximal effect 3, 4
   • Best for: Women with PCOS or other causes of ovarian hyperandrogenism

2. Spironolactone

   • Mechanism: Androgen receptor antagonist
   • Dosing: 50-200 mg daily, divided into two doses
   • Efficacy: 40-50% reduction in hair growth at 6 months
   • Best for: Moderate to severe hirsutism; can be used alone or with COCs 3, 4
   • Caution: Contraindicated in pregnancy; monitor potassium levels

3. Topical Eflornithine 13.9% Cream (Vaniqa)

   • Mechanism: Inhibits ornithine decarboxylase in hair follicles
   • Application: Apply twice daily to affected facial areas
   • Efficacy: Noticeable reduction in facial hair growth within 4-8 weeks
   • Best for: Facial hirsutism, particularly as adjunct to other therapies 5, 2
   • Note: Effects are temporary; hair growth returns upon discontinuation

Second-Line Pharmacologic Options

1. Finasteride

   • Mechanism: 5α-reductase inhibitor, blocks conversion of testosterone to dihydrotestosterone
   • Dosing: 2.5-5 mg daily
   • Efficacy: Moderate effectiveness, particularly for scalp hair
   • Caution: Absolutely contraindicated in pregnancy (Category X) 3, 4

2. Insulin Sensitizers (Metformin)

   • Not recommended as monotherapy for hirsutism
   • May be beneficial as adjunct therapy in women with PCOS and insulin resistance 4

Physical Hair Removal Methods

1. Temporary Methods

   • Shaving, waxing, plucking, threading, depilatory creams
   • Advantages: Immediate results, inexpensive, can be done at home
   • Disadvantages: Temporary, may cause skin irritation, ingrown hairs

2. Permanent/Semi-Permanent Methods

   • Electrolysis

     • Mechanism: Destroys hair follicle with electric current
     • Best for: Small areas, particularly facial hair
     • Limitations: Time-consuming, can be painful, multiple sessions required

   • Laser Hair Removal

     • Mechanism: Targets melanin in hair follicle
     • Best for: Larger areas, dark hair on light skin
     • Limitations: Less effective for light hair or dark skin, multiple sessions required
     • Note: Alexandrite and diode lasers show best evidence for effectiveness 4

Treatment Algorithm

1. Mild Hirsutism:

   • Start with cosmetic methods (shaving, waxing, plucking)
   • Consider topical eflornithine for facial hair
   • If insufficient, add COC (if no contraindications)

2. Moderate Hirsutism:

   • COC + spironolactone (50-100 mg/day)
   • Topical eflornithine for facial hair
   • Consider laser hair removal for accessible areas

3. Severe Hirsutism:

   • COC + spironolactone (100-200 mg/day)
   • Consider adding finasteride if inadequate response after 6 months
   • Aggressive physical hair removal (laser or electrolysis)
   • Topical eflornithine as adjunct therapy

Important Considerations

• Treatment Duration: A minimum trial of 6 months is necessary before assessing efficacy due to the hair growth cycle 4

• Pregnancy Concerns: Most pharmacologic treatments (especially antiandrogens) are contraindicated in pregnancy due to risk of feminization of male fetus

• Monitoring:

  • Spironolactone: Check potassium levels at baseline and periodically
  • COCs: Monitor blood pressure and assess thrombosis risk
  • Finasteride: Liver function tests at baseline and periodically

• Expectations Management: Patients should understand that:

  • Complete hair removal is rarely achieved
  • Existing terminal hairs will not revert to vellus hairs
  • Lifelong therapy may be needed to prevent recurrence 6

Special Populations

• PCOS Patients: May benefit from weight loss (even 5% reduction) and lifestyle modifications in addition to pharmacologic therapy 7

• Patients with Androgen-Secreting Tumors: Require surgical intervention; pharmacologic therapy alone is insufficient 2

• Adolescents: Start with COCs and cosmetic methods; antiandrogens should be used with caution

Remember that hirsutism often causes significant psychological distress and impacts quality of life. Early effective intervention can substantially improve patient outcomes and well-being.