Managing Hirsutism After Bariatric Surgery and on Wegovy
Continue Wegovy (semaglutide) as it supports sustained weight loss which directly improves hirsutism, and initiate combined oral contraceptives as first-line pharmacotherapy, adding spironolactide 100-150 mg daily if inadequate response after 6-9 months. 1
Weight Loss as Primary Therapeutic Intervention
The significant 100-pound weight loss achieved through bariatric surgery and Wegovy represents the most effective intervention for hirsutism, as 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 This patient has far exceeded this threshold, which should translate to substantial improvement in hirsutism symptoms.
Maintaining Weight Loss with Semaglutide
Semaglutide (Wegovy) is particularly valuable in post-bariatric patients, as it is the best-studied anti-obesity medication in this setting and appears similarly well-tolerated and efficacious as in other patients with obesity. 2
Post-bariatric patients typically achieve 7.5-10.3% total weight loss with semaglutide at 6 months, with 61% achieving >5% weight loss at 3 months. 3, 4
Continue semaglutide indefinitely, as pharmacotherapy produces greater weight-loss maintenance than lifestyle alone (difference of 10.3% in clinical trials), and all patients receiving pharmacotherapy must be involved in behavioral modification programs. 2
Pharmacological Management of Hirsutism
First-Line: Combined Oral Contraceptives
Initiate combined oral contraceptives as the initial pharmacotherapy, which suppress ovarian androgen secretion and increase sex hormone binding globulin. 1
OCPs should be started regardless of current hirsutism severity, as they address the underlying hormonal pathophysiology. 1
Second-Line: Add Antiandrogen Therapy
If inadequate response after 6-9 months of OCP therapy, add spironolactone 100-150 mg daily to the OCP regimen. 1
Spironolactone achieves improvement in 85% of patients, with complete remission in 55%. 1
The combination of OCP plus spironolactone is more effective than either agent alone for refractory hirsutism. 1
Metabolic Screening and Monitoring
Measure free and total testosterone, DHEA-S, androstenedione, LH, and FSH to identify underlying causes and guide treatment. 1
Screen for metabolic abnormalities including fasting glucose and lipid profile, as these are essential for guiding treatment and are particularly important in post-bariatric patients. 1
Post-bariatric patients require laboratory monitoring every 3 months in the first year, including complete blood count, electrolytes, glucose, liver and kidney function, and vitamin/mineral status. 2
Adjunctive Cosmetic Treatment
Recommend laser hair removal as an essential adjunct to systemic therapy, with multiple treatments required for optimal results. 1
Laser hair removal must be combined with medical management to address underlying androgen excess, not used as monotherapy. 1
Post-Bariatric Nutritional Support
Ensure daily multivitamin containing recommended daily allowances, along with additional supplementation for high-risk deficiencies including iron, vitamin B12, folate, vitamin D, and calcium. 2
Maintain protein requirements of 60-80 g/day or 1.0-1.5 g/kg ideal body weight to preserve lean body mass. 2
Screen for pre- and post-metabolic and bariatric surgery micronutrient deficiencies (thiamin, vitamin B12, folate, iron, vitamin D, calcium, vitamin A, vitamin E, vitamin K, zinc, and copper). 2
Lifestyle Maintenance
Maintain physical activity >200 minutes per week to sustain weight loss after bariatric surgery, including resistance exercises 2-3 times per week. 2
Promote healthy eating habits including portion control, eating slowly, meeting protein requirements, adequate hydration, and discouraging high-calorie liquid consumption and grazing behavior. 2
Schedule multidisciplinary follow-up visits at 1-2 weeks, then at 1,3,6,9, and 12 months post-surgery, followed by annual visits lifelong. 2
Critical Pitfalls to Avoid
Do not use metformin monotherapy for hirsutism unless metabolic abnormalities such as insulin resistance or prediabetes coexist, as it has insufficient evidence for hirsutism as the sole indication. 1
Avoid discontinuing semaglutide prematurely, as weight regain is common after bariatric surgery (occurring in 20-25% of patients) and can worsen hirsutism. 5, 3
Do not overlook that bariatric surgery itself improves hirsutism, with over 90% achieving moderate resolution by 1 year post-surgery in severe obesity cases. 1
Avoid loss to follow-up after year 3, as this can lead to weight regain and missed complications that may indirectly worsen hirsutism through metabolic deterioration. 2