Treatment Options for Excessive Hair Growth in PCOS
For PCOS-related hirsutism, a combination approach using both hormonal therapy and direct hair removal methods is most effective, as hirsutism treatment is typically palliative rather than curative. 1
First-Line Pharmacological Treatments
- Combined oral contraceptives (OCPs) are the first-line pharmacological treatment for hirsutism in PCOS, as they suppress androgen excess 2
- OCPs containing ethinyl estradiol increase sex hormone binding globulin (SHBG) and decrease free testosterone levels, reducing the androgens available to stimulate hair follicles 3
- For optimal results, OCPs should be combined with other treatments as hirsutism management typically requires a multi-modal approach 1
Second-Line and Adjunctive Pharmacological Options
- Anti-androgens should be added to OCPs for moderate to severe hirsutism or when OCPs alone provide insufficient improvement 2
- Spironolactone (50-200 mg daily) is commonly used as a peripheral androgen blocker and is most effective when combined with OCPs 4
- Other anti-androgens include flutamide, cyproterone acetate, and finasteride, which block androgen receptors or 5α-reductase activity 4
- Metformin may be considered, particularly in women with insulin resistance, as it can improve hirsutism scores and reduce hair growth velocity while also addressing metabolic aspects of PCOS 5
- Eflornithine hydrochloride 13.9% topical cream can be applied to facial areas to slow hair growth, though it doesn't remove hair 4
Direct Hair Removal Methods
- Laser hair removal provides significant improvement for PCOS-induced hirsutism but requires multiple treatments for optimal results 1
- Electrolysis offers permanent hair removal through destruction of individual hair follicles and can be effective for smaller areas 4
- Temporary methods like shaving, waxing, depilatory creams, and threading provide short-term cosmetic improvement 3
Lifestyle Interventions
- Weight loss of at least 5% of initial body weight can improve hormonal profiles and potentially reduce hirsutism severity in overweight/obese women with PCOS 1, 6
- Regular physical activity, particularly combining aerobic and resistance exercise, enhances insulin sensitivity and may help improve hormonal parameters 6
- Low glycemic index diets and anti-inflammatory food patterns can improve insulin sensitivity and hormonal balance 6
Treatment Algorithm Based on Hirsutism Severity
Mild Hirsutism:
- Start with OCPs plus cosmetic hair removal methods 2
- Consider adding topical eflornithine for facial hair 4
- Implement lifestyle modifications, particularly if overweight/obese 6
Moderate to Severe Hirsutism:
- Combine OCPs with an anti-androgen (spironolactone 100-200 mg daily is most common) 2
- Add laser hair removal or electrolysis for permanent reduction 1, 4
- If OCPs are contraindicated, use anti-androgens with reliable contraception (due to teratogenicity risk) 2
- Consider metformin (1500-2000 mg daily) if insulin resistance is present 5
Important Clinical Considerations
- Laboratory evaluation is recommended for PCOS patients with hirsutism to assess androgen levels and exclude other causes 7
- A typical hormone screening panel should include free and total testosterone, DHEA-S, androstenedione, LH, and FSH 7
- Treatment efficacy should be assessed after at least 6-12 months, as hair growth cycles require time to respond to interventions 2
- Hirsutism treatment addresses the symptom rather than the underlying hormonal cause, so ongoing management is typically required 1
Monitoring Response to Treatment
- Use the modified Ferriman-Gallwey score to objectively assess hirsutism severity before and during treatment 2
- Patient self-assessment of improvement is an important outcome measure 5
- Measure hair growth velocity (mm/day) to quantify treatment response 5
- Monitor for side effects of medications, particularly anti-androgens which may cause liver toxicity or electrolyte disturbances 4