Nexplanon is NOT an effective treatment for hirsutism
Nexplanon (etonogestrel implant) should not be used as a treatment for hirsutism, as there is no evidence supporting its efficacy for this indication, and progestin-only contraceptives lack the anti-androgenic properties necessary to reduce excess hair growth.
Why Nexplanon is Inappropriate for Hirsutism
Mechanism of Action Does Not Address Hirsutism
- Nexplanon is a progestin-only contraceptive that does not contain estrogen or anti-androgenic components needed to suppress androgen production or block androgen receptors 1
- The etonogestrel in Nexplanon is a metabolite of desogestrel, which while less androgenic than some progestins, does not possess the anti-androgenic activity required to treat hirsutism 2
- Hirsutism requires suppression of ovarian androgen production and/or blockade of androgen receptors at the hair follicle level, which progestin-only methods cannot achieve 3
Evidence-Based First-Line Treatments for Hirsutism
Combined oral contraceptives (COCs) with anti-androgenic properties are the recommended first-line therapy:
- OCPs containing ethinyl estradiol combined with anti-androgenic progestins (cyproterone acetate, drospirenone) or neutral progestins (desogestrel) are effective for mild to moderate hirsutism 1, 3
- COCs work by suppressing ovarian androgen production through gonadotropin suppression and increasing sex hormone-binding globulin (SHBG), which reduces free testosterone 2
- Treatment with desogestrel-containing OCPs (150 mcg desogestrel + 30 mcg ethinyl estradiol) reduced hair growth significantly over one year, with 10 of 15 patients reporting definite improvement 2
- Two-year treatment with low-dose estrogen OCCs containing either desogestrel or cyproterone acetate reduced hirsutism scores from 11.8 to 4.7, nearly reaching control levels 4
Anti-androgen medications are indicated for moderate to severe hirsutism:
- Spironolactone 100 mg daily is more effective than placebo (mean difference -7.69 on Ferriman-Gallwey score) and is the first-line anti-androgen 5, 6
- Flutamide 250 mg twice daily showed significant reductions in hirsutism scores (mean difference -7.60 compared to placebo), though hepatotoxicity risk requires monitoring 5, 6
- Finasteride 5 mg daily showed inconsistent results across studies and cannot be firmly recommended as first-line therapy 6
- Anti-androgens should be combined with OCPs if monotherapy with OCPs is insufficient after 6-9 months 3
Treatment Algorithm for Hirsutism
Mild hirsutism:
- Start with combined OCPs containing anti-androgenic or neutral progestins 3, 5
- Add topical eflornithine as adjunctive therapy 3, 5
- Consider cosmetic measures (laser hair removal, electrolysis) 5
Moderate to severe hirsutism:
- Initiate combined OCPs with anti-androgenic progestins 1, 3
- If insufficient improvement after 6-9 months, add spironolactone 100 mg daily 3, 5
- Alternative anti-androgens (finasteride, cyproterone acetate) can be considered as second-line 5
- Minimum 6 months of pharmacotherapy required to see benefit; lifelong treatment often necessary 5
Special considerations:
- Metformin is ineffective for hirsutism alone and should not be used unless insulin resistance is present 5, 6
- Weight loss of 5% can improve metabolic and reproductive abnormalities in obese women with PCOS-related hirsutism 1
- Laboratory evaluation should include total or free testosterone, DHEAS, and assessment for underlying causes (PCOS, adrenal disorders, tumors) 1
Common Pitfalls to Avoid
- Do not prescribe progestin-only contraceptives (including Nexplanon) for hirsutism treatment - they lack the estrogen component necessary to increase SHBG and suppress ovarian androgens 3, 2
- Avoid OCPs containing androgenic progestins (norethisterone derivatives, levonorgestrel), as these can worsen hirsutism 7
- Do not expect rapid results - pharmacological treatment requires at least 6 months to demonstrate clinical benefit 5
- Ensure contraception is in place when using anti-androgens due to teratogenic risk 3