What are the treatment options for hirsutism in Polycystic Ovary Syndrome (PCOS)?

Treatment of Hirsutism in PCOS

The most effective treatment for hirsutism in PCOS is combination therapy with an oral contraceptive pill plus an antiandrogen (spironolactone 50-200 mg daily), alongside concurrent mechanical hair removal methods. 1, 2

First-Line Approach: Combined Medical Therapy

The combination of an antiandrogen with ovarian suppression provides superior results compared to monotherapy for hirsutism management. 1, 2

Oral Contraceptive Pills (OCPs)

• OCPs suppress ovarian androgen secretion and increase sex hormone-binding globulin, reducing free testosterone levels. 2, 3
• They provide the additional benefit of menstrual regulation and endometrial protection. 2
• Any combined OCP formulation is effective, though specific formulations studied include cyproterone acetate 2 mg/ethinylestradiol 35 μg or drospirenone 3 mg/ethinylestradiol 20 μg. 1

Antiandrogen Therapy: Spironolactone

• Spironolactone 50-200 mg daily is the preferred antiandrogen, working best when combined with OCPs. 2
• It decreases testosterone production, competitively inhibits androgen receptor binding, and may inhibit 5α-reductase. 2
• Spironolactone as monotherapy is effective in idiopathic hirsutism but less effective in PCOS patients, where combination with OCPs is necessary. 4
• Common side effects include menstrual irregularities (22-40%, dose-dependent and reduced with OCP co-administration), diuresis (29%), and breast tenderness (17%). 2

Critical Safety Considerations

• Spironolactone is pregnancy category C and must be combined with reliable contraception (OCPs) in sexually active women due to risk of feminization of male fetuses. 2
• Potassium monitoring is required in older patients, those with hypertension, diabetes, chronic kidney disease, or those taking ACE inhibitors, ARBs, or NSAIDs. 2
• Never use spironolactone as monotherapy in patients attempting to conceive. 2

Topical Therapy

• Eflornithine hydrochloride cream is the only FDA-approved topical treatment specifically for hirsutism. 1, 2
• It should be used as adjunctive therapy, not as sole treatment. 1

Mechanical Hair Removal

Medical management must be combined with hair removal techniques for optimal results, as drugs only partially affect terminalized hairs already present. 1, 2, 5

Effective Methods

• Laser photothermolysis and electrolysis are the most effective cosmetic procedures, though effects should not be considered permanent. 5, 6
• Multiple treatments are typically required. 1
• Temporary methods (plucking, shaving, waxing) can be used but require ongoing maintenance. 1
• Electrolysis may be impractical for removing large numbers of hairs. 1

Foundational Lifestyle Modification

Weight loss of just 5% of initial body weight significantly improves androgen levels and hirsutism in PCOS. 2

• Prescribe an energy deficit of 500-750 kcal/day (targeting 1,200-1,500 kcal/day total). 2
• Recommend at least 150 minutes/week of moderate-intensity exercise, which benefits PCOS even without weight loss. 2
• No specific diet type is superior; follow general healthy eating principles. 2

Alternative Antiandrogens

While spironolactone is preferred, other antiandrogens have been studied:

• Flutamide and finasteride are alternatives, though the optimal agent is not definitively established. 1
• These are less commonly used due to side effect profiles or lack of comparative data. 1

Treatment Timeline and Expectations

• Hirsutism treatment is palliative rather than curative, and improvement takes 6-12 months due to hair growth cycles. 1
• Medical therapy must continue long-term to maintain androgen suppression. 1
• Concomitant medical management is necessary even when using mechanical hair removal methods. 1, 2

Common Pitfalls to Avoid

• Do not use antiandrogens without concurrent contraception in women of reproductive potential. 2
• Do not expect rapid results; set realistic expectations about the 6-12 month timeline for visible improvement. 1
• Do not use spironolactone as sole therapy for metabolic dysfunction; add metformin and lifestyle modification. 2
• Do not neglect lifestyle modification as the foundation of all PCOS treatment. 2, 7