What are the treatment options for hirsutism?

Treatment of Hirsutism

First-Line Approach: Lifestyle Modification

Weight loss of as little as 5% of total body weight is the initial treatment for hirsutism, particularly in overweight patients, as it significantly reduces testosterone levels and improves 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 difference of -1.19 points 1
• Obesity negatively impacts treatment efficacy, making weight management crucial 1
• Even modest weight reduction improves metabolic and reproductive abnormalities in PCOS-related hirsutism 2

Pharmacological Treatment Algorithm

Step 1: Combined Oral Contraceptives (First-Line Pharmacotherapy)

Combined oral contraceptives are the initial pharmacotherapy for hirsutism, suppressing ovarian androgen secretion and increasing sex hormone binding globulin. 1, 2

• Use third-generation OCPs containing non-androgenic progestins 2, 3
• Avoid OCPs containing androgenic progestins such as norethisterone derivatives or levonorgestrel, as they worsen hirsutism 2
• Long-term use (>12 cycles) cures mild-to-moderate hirsutism and improves severe cases 3
• Short-term use (6 cycles) has restricted effectiveness 3

Step 2: Add Antiandrogen Therapy (If Inadequate Response After 6-9 Months)

Add spironolactone 100-150 mg daily to the OCP regimen if response is inadequate after 6-9 months of monotherapy. 1, 4

• Spironolactone achieves improvement in 85% of patients, with complete remission in 55% 1
• Spironolactone blocks androgen receptors; effectiveness is dose-dependent 3
• High dosages (200 mg/day) are very effective but may cause dysfunctional uterine bleeding, which concomitant OCP use prevents 3
• OCPs are essential when using antiandrogens to provide menstrual cycle control and contraception 3

Alternative Antiandrogen Options

Cyproterone acetate (12.5-50 mg/day in reverse sequential regimen) and flutamide (250-500 mg/day) are the most effective antiandrogens for hirsutism treatment. 3

• Cyproterone acetate inhibits gonadotropin secretion and blocks androgen action; very effective in short-term treatment 3
• Flutamide is a pure antiandrogen that is very effective within 6-12 months 3
• Monitor for hepatotoxicity with flutamide, particularly at high dosages 3
• Finasteride (5 mg/day) is the least effective antiandrogen but has no adverse effects 3
• Pregnancy must be avoided during antiandrogen therapy due to risk of abnormal male fetal development 3, 5

Role of Insulin Sensitizers

Use metformin monotherapy only when metabolic abnormalities such as insulin resistance or prediabetes coexist with hirsutism. 1

• Metformin improves metabolic parameters but has insufficient evidence for hirsutism as the sole indication 1
• Insulin sensitizers are effective for hirsutism in women with hyperandrogenism and insulin resistance, but there is no convincing evidence they are effective for hirsutism alone 4

Essential Adjunctive Treatment

Laser hair removal is an essential adjunct to systemic therapy, requiring multiple treatments for optimal results. 1, 6

• Laser treatment must be combined with medical management to address underlying androgen excess 1, 6
• Multiple laser sessions are typically needed 6
• Concomitant medical management directed at reducing androgen levels is necessary for best outcomes 6
• Topical eflornithine hydrochloride cream can be a useful adjuvant when used with systemic medications or laser therapy 4

Initial Diagnostic Workup

Before initiating treatment, obtain the following laboratory evaluation: 1, 2

• Free and total testosterone, DHEA-S, androstenedione, LH, and FSH 1, 2
• Fasting glucose and lipid profile for metabolic screening 1
• Calculate BMI and waist-hip ratio 1
• Total testosterone or bioavailable/free testosterone >200 ng/dL suggests an androgen-secreting tumor requiring imaging 2

Special Populations

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

• Bariatric surgery may be considered in severe obesity with inadequate response to lifestyle modification 1
• Over 90% of patients achieve moderate resolution of hirsutism by 1 year post-bariatric surgery 1

Critical Pitfalls to Avoid

• Do not use routine endocrinologic testing for mild hirsutism without other signs of hyperandrogenism 2
• Patients with hirsutism plus oligomenorrhea, infertility, clitoromegaly, or truncal obesity warrant full endocrine evaluation 2
• Hirsutism treatment is often palliative rather than curative, requiring a combined approach 6
• Medical therapy reduces hair growth in less than 50% of cases, so cosmetic measures are frequently required 5