What are the treatment options for hirsutism?

Treatment Options for Hirsutism

First-Line Approach: Weight Loss and Lifestyle Modification

Weight loss of as little as 5% of total body weight significantly improves hirsutism through reduction in testosterone levels and improvement in metabolic parameters, reducing Ferriman-Gallwey scores by a mean difference of -1.19 points. 1

• Target an energy deficit of 500-750 kcal/day combined with regular exercise 1
• Obesity negatively impacts treatment efficacy, making weight management critical before or alongside pharmacotherapy 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 post-surgery 1

Pharmacological Treatment Algorithm

Initial Pharmacotherapy: Combined Oral Contraceptives

Combined oral contraceptives (COCs) are recommended as the initial pharmacotherapy, suppressing ovarian androgen secretion and increasing sex hormone binding globulin. 1

• Third-generation COCs containing new progestogens or cyproterone have restricted effectiveness in the short term (6 cycles) but cure mild-to-moderate hirsutism with long-term use (>12 cycles) 2
• COCs decrease free testosterone levels and may also decrease adrenal androgen production 2
• Monotherapy with oral contraceptives that have antiandrogenic activity is recommended as first-line treatment for the majority of women 3

Second-Line: Adding Antiandrogen Therapy

Adding antiandrogen therapy, such as spironolactone 100-150 mg daily, to the OCP regimen is recommended for inadequate response after 6-9 months. 1, 3

• Spironolactone achieves improvement in 85% of patients, with complete remission in 55% 1
• High dosages (200 mg/day) are very effective but may cause dysfunctional uterine bleeding; concomitant use of a COC prevents these adverse effects 2
• Cyproterone acetate (12.5-50 mg/day in a reverse sequential regimen) is very effective, especially when used alone or in association with COCs 2
• Flutamide (250-500 mg/day) is very effective within 6-12 months, though dry skin is frequent and hepatotoxicity is possible at high dosages 2
• Finasteride (5 mg/day) is the least effective antiandrogen but decreases hirsutism without adverse effects 2

Critical caveat: Pregnancy must be avoided during therapy with antiandrogens because of the possible risk of abnormal development of a male fetus. 2

Role of Insulin Sensitizers

Metformin monotherapy is recommended 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
• In women with hirsutism, hyperandrogenism, and insulin resistance, insulin sensitizers are effective for hirsutism as well as hyperinsulinemia and infertility, but there is no convincing evidence they are effective for hirsutism alone 3

Adjunctive Physical and Cosmetic Modalities

Laser Hair Removal

Laser hair removal is recommended 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 1
• While laser treatment significantly improves hirsutism, it addresses the symptom rather than the underlying hormonal cause 4
• Photoepilation and electrolysis are somewhat effective for long-term hair removal but are expensive 5

Topical Therapy

• Topical eflornithine is a useful adjuvant for hirsutism when used in conjunction with systemic medications or with laser/photoepilation 3

Temporary Hair Removal

• Hair removal methods such as shaving, waxing, and plucking may be effective, but their effects are temporary 5
• Since systemic therapy reduces hair growth in less than 50% of cases, hirsute women frequently require cosmetic measures 6

Initial Assessment Requirements

Laboratory evaluation to identify underlying causes and guide treatment should include measuring free and total testosterone, DHEA-S, androstenedione, LH, and FSH. 1

• Screen for metabolic abnormalities with fasting glucose and lipid profile 1
• Calculate BMI and waist-hip ratio 1
• Women with rapid onset of hirsutism over a few months or signs of virilization (clitoromegaly, truncal obesity, androgenic alopecia) are at high risk of having an androgen-secreting tumor and require urgent evaluation 5, 7

Special Population: Women Seeking Pregnancy

Clomiphene citrate is recommended as first-line for ovulation induction in women seeking pregnancy, not OCPs. 1

Treatment Timeline Expectations

Because of the length of the hair growth cycle, therapies should be tried for at least six months before switching treatments. 5

• Long-term use of COCs (>12 cycles) is necessary for optimal results 2
• Antiandrogens like flutamide are very effective within 6-12 months 2