What is the approach to evaluating and treating hirsutism?

Hirsutism Evaluation and Treatment

For women presenting with hirsutism, begin by documenting the modified Ferriman-Gallwey (mFG) score and assessing menstrual regularity, as cycle disturbances combined with hirsutism warrant investigation for underlying endocrine disorders. 1

Initial Clinical Assessment

Key clinical features to evaluate:

• Distribution and severity of hair growth using mFG scoring 1, 2
• Menstrual history (oligomenorrhea, amenorrhea) 3, 2
• Associated hyperandrogenic signs: acne, androgenetic alopecia, clitoromegaly, truncal obesity 4, 3, 2
• Onset and progression: rapid onset over weeks to months suggests neoplasm versus gradual peripubertal onset suggesting functional disorder 2, 5
• Signs of insulin resistance: obesity, acanthosis nigricans 2
• Family history of similar conditions 2

Common pitfall: Mild hirsutism without other hyperandrogenic signs does not require routine endocrine testing. 4, 2 However, the presence of oligomenorrhea, infertility, clitoromegaly, or truncal obesity mandates full endocrine evaluation. 4, 2

Laboratory Testing Algorithm

For mild hirsutism alone (no other signs):

• No endocrine testing required 4, 2

For hirsutism with any hyperandrogenic signs or menstrual irregularity:

Essential first-tier tests:

• Total testosterone or free/bioavailable testosterone: levels >2.5 nmol/L suggest PCOS or other pathology; levels >200 ng/dL suggest androgen-secreting tumor 1, 2
• DHEAS: age-specific cutoffs (>3800 ng/mL for ages 20-29, >2700 ng/mL for ages 30-39) to rule out non-classical congenital adrenal hyperplasia 1
• Androstenedione: values >10.0 nmol/L warrant evaluation for adrenal or ovarian tumor 1
• LH and FSH on cycle days 3-6: LH/FSH ratio >2 suggests PCOS 1

Additional testing based on clinical suspicion:

• 17-hydroxyprogesterone for non-classical congenital adrenal hyperplasia 4, 3
• Prolactin to exclude hyperprolactinemia 3
• TSH for thyroid disease 3
• Fasting glucose/insulin, lipid panel for metabolic screening in PCOS 1, 2

Red flags requiring urgent imaging:

• Total testosterone >200 ng/dL 2
• Rapid onset with virilization (deepening voice, clitoromegaly) 3, 5
• Palpable adnexal mass on pelvic examination 2

Diagnostic Criteria for Common Causes

PCOS (accounts for 70-80% of hirsutism cases):

• Requires 2 of 3 Rotterdam criteria: hyperandrogenism, ovulatory dysfunction, or polycystic ovary morphology 3, 2
• In adolescents: requires hyperandrogenism plus persistent oligomenorrhea 3

Non-classical congenital adrenal hyperplasia:

• Elevated 17-hydroxyprogesterone 4, 3
• In prepubertal children: early-onset body odor, axillary/pubic hair, accelerated growth, advanced bone age 3

Functional Hypothalamic Amenorrhea with polycystic ovarian morphology:

• Distinguished from PCOS by history of weight loss, vigorous exercise, or stress 3
• Lower estradiol, androgens, LH, and AMH compared to PCOS 3
• Higher SHBG, low insulin levels, normal insulin sensitivity 3

Neoplastic causes:

• Suspect if tumor >3 cm, irregular morphology, lipid-poor, doesn't wash out on contrast CT, or secretes multiple hormones 3

Treatment Approach

First-line therapy for PCOS-related hirsutism:

• Combined oral contraceptives (COCs) to suppress ovarian androgen production 2
• Avoid androgenic progestins (norethisterone derivatives, levonorgestrel) as they worsen hirsutism 2
• Maintain treatment for minimum 6-12 months, as hair growth cycles require prolonged therapy 1

For insufficient response after 6-9 months of COC monotherapy:

• Combine COCs with antiandrogens (spironolactone, cyproterone acetate, or finasteride) for synergistic effect 1, 6, 7
• Spironolactone is first-line antiandrogen; finasteride and cyproterone acetate are second-line 7
• Flutamide carries hepatotoxicity risk and is not first-line 7

For PCOS with metabolic comorbidities (obesity, insulin resistance):

• Lifestyle interventions reducing weight by ≥5% improve hirsutism (mean mFG score reduction -1.19), testosterone levels, and metabolic parameters 1
• Metformin may improve ovulation and reduce androgens but is not recommended for hirsutism alone 2, 7

Adjunctive cosmetic/physical treatments:

• Topical eflornithine hydrochloride cream for mild hirsutism or as adjunct 2, 6, 7
• Electrolysis for permanent hair removal in localized areas 7
• Alexandrite and diode lasers for permanent hair reduction 7

Special consideration: Screen all women with PCOS and hirsutism for cardiovascular risk factors (blood pressure, lipids, HbA1c). 1