Can Slynd (drospirenone) help with excessive hair growth due to Polycystic Ovary Syndrome (PCOS)?

Slynd for Hirsutism in PCOS

Slynd (drospirenone 4 mg progestin-only pill) is not recommended for treating excessive hair growth in PCOS, as progestin-only contraceptives may worsen hirsutism. 1 Instead, combined oral contraceptives containing drospirenone with ethinyl estradiol are highly effective for this indication and should be your first-line hormonal choice if the patient also desires contraception. 1

Why Slynd Is Not Appropriate for PCOS Hirsutism

• Progestin-only formulations consistently worsen acne and hirsutism because they lack the estrogen component necessary to suppress ovarian androgen production and increase sex hormone-binding globulin (SHBG). 1, 2

• The American Academy of Dermatology explicitly advises against prescribing progestin-only contraceptives for androgen-related conditions. 2

• While drospirenone itself has antiandrogenic properties (approximately 30% the potency of cyproterone acetate), these benefits are insufficient without estrogen to create the net antiandrogenic effect needed for hirsutism management. 3

What You Should Prescribe Instead

First-Line: Combined Oral Contraceptives with Drospirenone

For women with PCOS-related hirsutism who desire contraception, prescribe ethinyl estradiol 30 mcg/drospirenone 3 mg (Yasmin) or ethinyl estradiol 20 mcg/drospirenone 3 mg (Yaz). 2, 4

• Combined drospirenone/ethinyl estradiol formulations reduce hirsutism scores by 67% at 6 months and 78% at 12 months, with the most prominent improvement on the chest and abdomen, followed by upper lip and chin. 5

• These formulations work through multiple mechanisms: decreasing ovarian androgen production, increasing SHBG (which binds free testosterone), reducing 5α-reductase activity, and blocking androgen receptor activation. 1, 2

• Drospirenone-containing COCs demonstrate superior efficacy compared to other progestins (norgestimate, chlormadinone acetate) in reducing Ferriman-Gallwey scores, androstenedione levels, and total testosterone levels. 2, 6

Timeline Expectations

• Counsel patients that visible improvement requires 6-12 months of continuous therapy, with statistically significant changes typically evident by 6 months. 1, 5

• The beneficial effect is most obvious after six cycles and continues thereafter at a slower rate. 5

• Concomitant mechanical hair removal (plucking, shaving, waxing, laser, electrolysis) is usually necessary during the initial treatment period and may be continued long-term. 1

Combination Therapy for Optimal Results

If hirsutism is moderate to severe, combine the drospirenone-containing COC with spironolactone 50-100 mg daily after 3-6 months if response is inadequate. 1, 2

• ACOG guidelines indicate that the combination of an antiandrogen (spironolactone) and ovarian suppression (COC) appears most effective for PCOS-related hirsutism. 1

• This combined approach addresses both ovarian androgen excess and peripheral androgen receptor blockade. 7

Alternative for Women Not Desiring Contraception

• If the patient does not want contraception, spironolactone 50-100 mg daily is the preferred first-line treatment, with 66% of women achieving clear or markedly improved outcomes. 2

• Metformin combined with lifestyle modifications (5-10% weight loss) can serve as a second-line option for reducing androgen secretion, particularly in patients with insulin resistance or metabolic comorbidities. 7

Safety Considerations for Drospirenone-Containing COCs

• Absolute contraindications include: renal dysfunction, adrenal insufficiency, current/history of VTE or PE, breast cancer, hepatic dysfunction, uncontrolled hypertension, smoking if ≥35 years, and migraine with aura. 2

• VTE risk with drospirenone-COCs is approximately 10 per 10,000 woman-years (compared to 3-9 for standard COCs and 1-5 for non-users). 2

• Despite drospirenone's mild potassium-sparing effects, routine potassium monitoring is not required in young, healthy women without kidney, liver, or adrenal disease. 2

• Obtain baseline blood pressure, pregnancy test, and consider baseline potassium if risk factors exist; recheck potassium at 4-6 weeks if indicated. 2

Foundational Lifestyle Interventions

All PCOS patients should begin with lifestyle modification targeting 5-10% weight loss through a 500-750 kcal/day energy deficit and at least 250 minutes/week of moderate-intensity exercise. 8, 9

• Weight loss of as little as 5% improves metabolic and reproductive abnormalities in PCOS, including androgen levels. 1, 9

• Exercise benefits PCOS even without weight loss and should be prescribed regardless of BMI. 1, 9

Common Pitfalls to Avoid

• Do not prescribe Slynd or any progestin-only contraceptive (pills, injections, implants, or IUDs) for hirsutism management, as they may worsen the condition. 1, 2

• Do not expect rapid results; explicitly counsel patients at initiation that visible improvement takes 6-12 months to prevent premature discontinuation. 1, 5

• Do not neglect metabolic screening (fasting glucose, lipid profile) even in normal-weight PCOS patients, as metabolic abnormalities are common. 8