What is the approach to managing hirsutism in women?

Approach to Women with Hirsutism

Begin with lifestyle modification achieving 5% weight loss combined with combined oral contraceptives (COCs) as first-line pharmacological therapy, escalating to antiandrogens (spironolactone 100-150 mg daily) if inadequate response after 6-9 months, while incorporating cosmetic hair removal methods throughout treatment. 1, 2, 3

Initial Assessment and Diagnosis

Laboratory evaluation is essential to identify underlying causes and guide treatment:

• Measure free and total testosterone, DHEA-S, androstenedione, LH, and FSH 2
• Screen for metabolic abnormalities including fasting glucose and lipid profile 3
• Calculate BMI and waist-hip ratio, as obesity negatively impacts treatment efficacy 3, 4

First-Line Treatment Strategy

Lifestyle Modification (All Patients)

Weight loss of as little as 5% of total body weight significantly improves hirsutism through reduction in testosterone levels and improvement in metabolic parameters 1, 2:

• Target energy deficit of 500-750 kcal/day 3
• Combine diet with regular exercise 1
• This approach reduces Ferriman-Gallwey scores by mean difference of -1.19 points 1

Critical caveat: Obesity reduces efficacy of all pharmacological treatments for hirsutism (r = -0.38; P = 0.004), making lifestyle intervention non-negotiable 4

Pharmacological First-Line (Women Not Seeking Pregnancy)

Combined oral contraceptives are the recommended initial pharmacotherapy 3, 5, 6:

• Suppress ovarian androgen secretion and increase sex hormone binding globulin 3
• Antiandrogenic OCPs (containing drospirenone or cyproterone acetate) show slightly superior efficacy compared to neutral OCPs 6
• Significant reduction in Ferriman-Gallwey scores demonstrated across multiple trials 4

Second-Line Treatment (Inadequate Response After 6-9 Months)

Add antiandrogen therapy to the OCP regimen 2, 5:

Spironolactone (First-Line Antiandrogen)

• Dose: 100-150 mg daily 1, 6
• Achieves improvement in 85% of patients, with complete remission in 55% 1
• Must be combined with adequate contraception due to teratogenic risk 7, 6

Alternative Antiandrogens (Second-Line)

• Cyproterone acetate: Effective when combined with ethinyl estradiol 1, 4
• Finasteride 1.25-5 mg daily: Second-line option with demonstrated efficacy 1, 6, 4
• Flutamide: NOT first-line due to hepatotoxicity risk; requires careful liver enzyme monitoring if used 6

Role of Insulin Sensitizers

Metformin monotherapy is NOT recommended for hirsutism alone 6:

• Only use metformin (500 mg 2-3 times daily) when metabolic abnormalities (insulin resistance, prediabetes) coexist with hirsutism 1, 3
• Improves metabolic parameters but insufficient evidence for hirsutism as sole indication 5, 6
• In PCOS patients with features of insulin resistance, metformin provides additional metabolic benefits beyond hirsutism treatment 3

Cosmetic and Physical Modalities

Cosmetic measures are essential adjuncts, as systemic therapy alone reduces hair growth in less than 50% of cases 7:

Laser Hair Removal

• Multiple treatments required for optimal results 2
• Alexandrite and diode lasers most effective for permanent hair reduction 6
• Must be combined with medical management to address underlying androgen excess 2
• Addresses symptom but not hormonal cause 2

Topical Eflornithine

• Useful adjuvant therapy with systemic medications or laser treatment 5, 6
• Can be used as monotherapy for mild hirsutism 6

Electrolysis

• Effective for permanent hair removal in localized areas 6

Treatment Timeline and Expectations

Minimum 6 months required to see pharmacological benefit 6:

• Assess response to OCP monotherapy at 6-9 months before adding antiandrogen 5
• Lifelong treatment often necessary for sustained benefit 6
• Hair growth cycle means visible improvement lags behind hormonal changes 7

Special Populations

Women Seeking Pregnancy

• Clomiphene citrate is first-line for ovulation induction, not OCPs 3
• Discontinue all antiandrogens due to teratogenic risk 7, 6
• Focus on lifestyle modification and metformin if metabolic abnormalities present 3

Obese Women with PCOS

• Bariatric surgery may be considered in severe obesity with inadequate response to lifestyle modification 1
• Over 90% achieve moderate resolution of hirsutism by 1 year post-surgery 1
• Requires contraception for minimum 12 months post-surgery due to pregnancy risks 1

Common Pitfalls to Avoid

• Do not use insulin sensitizers as monotherapy for hirsutism without metabolic indications 6
• Do not rely on laser treatment alone without addressing hormonal cause 2
• Do not prescribe antiandrogens without adequate contraception in reproductive-age women 7, 6
• Do not neglect metabolic screening even in normal-weight PCOS patients 3
• Do not expect rapid results; set realistic expectations for 6+ month timeline 6