What are the treatment options for hirsutism?

Treatment Options for Hirsutism

Combined oral contraceptives (OCPs) are the recommended first-line pharmacological treatment for hirsutism, with spironolactone 100-150 mg daily added if response is inadequate after 6-9 months. 1

Initial Assessment and Workup

Before initiating treatment, specific laboratory evaluation is essential:

• Measure free and total testosterone, DHEA-S, androstenedione, LH, and FSH to identify underlying causes and guide treatment selection 1
• Screen for metabolic abnormalities including fasting glucose and lipid profile, as these guide treatment decisions 1
• Calculate BMI and waist-hip ratio, since obesity significantly impairs treatment efficacy 1
• Total testosterone >200 ng/dL suggests an androgen-secreting tumor requiring urgent imaging 2
• Assess for rapid onset (over months) or virilization signs (clitoromegaly, voice deepening), which indicate high risk for androgen-secreting tumors 3

Treatment Algorithm

Step 1: Lifestyle Modification (All Patients)

Weight loss of just 5% of total body weight significantly improves hirsutism by reducing testosterone levels and improving metabolic parameters 1

• Target an energy deficit of 500-750 kcal/day combined with regular exercise 1
• This approach reduces Ferriman-Gallwey scores by a mean of -1.19 points 1
• In severe obesity with inadequate response to lifestyle modification, bariatric surgery achieves moderate resolution of hirsutism in over 90% of patients by 1 year 1

Step 2: First-Line Pharmacotherapy

Combined oral contraceptives suppress ovarian androgen secretion and increase sex hormone binding globulin 1

• OCPs are the initial pharmacotherapy recommended by the American College of Obstetricians and Gynecologists 1
• Avoid OCPs containing androgenic progestins (norethisterone derivatives or levonorgestrel), as these worsen hirsutism 2
• Continue OCP monotherapy for 6-9 months before assessing response 1, 4

Step 3: Add Antiandrogen Therapy

If response to OCPs alone is inadequate after 6-9 months, add spironolactone 100-150 mg daily 1, 4

• Spironolactone achieves improvement in 85% of patients, with complete remission in 55% 1
• The combination of an antiandrogen with ovarian suppression (OCP) is highly effective 5
• Adequate contraception is mandatory when using antiandrogens due to risk of feminization of male fetuses 6, 7

Alternative antiandrogens if spironolactone is not tolerated:

• Cyproterone acetate 12.5-50 mg/day in reverse sequential regimen is very effective short-term 6
• Flutamide 250-500 mg/day is highly effective but requires hepatic monitoring 6
• Finasteride 5 mg/day is the least effective antiandrogen but has minimal adverse effects 6, 3

Step 4: Insulin Sensitizers (Selected Patients Only)

Metformin monotherapy is recommended only when metabolic abnormalities (insulin resistance or prediabetes) coexist with hirsutism 1

• The American Diabetes Association states metformin has insufficient evidence for hirsutism as the sole indication 1
• Metformin improves metabolic parameters but not hirsutism alone 1, 4

Step 5: Adjunctive Cosmetic Measures

Laser hair removal is an essential adjunct to systemic therapy, not a standalone treatment 1

• Multiple laser treatments are required for optimal results 5
• Laser must be combined with medical management to address underlying androgen excess 1, 5
• Topical eflornithine hydrochloride cream can be used as an adjuvant with systemic medications 4, 3
• Temporary methods (shaving, waxing, plucking) are effective but require frequent repetition 3

Special Populations

For women seeking pregnancy, clomiphene citrate is first-line for ovulation induction, not OCPs 1

In adolescents with PCOS and endocrine comorbidities, early intervention with antiandrogens like finasteride may be beneficial according to the Endocrine Society 2

Women with epilepsy have 10-25% prevalence of PCOS, and certain antiepileptics may trigger or worsen hirsutism 2

Critical Treatment Principles

• All therapies require at least 6 months before switching treatments due to the length of the hair growth cycle 3
• Systemic therapy reduces hair growth in less than 50% of cases, so most women require combined medical and cosmetic approaches 8
• Treatment is palliative rather than curative, requiring long-term management 5, 7
• Continued improvement typically occurs at 12 months beyond the initial 6-month assessment 7