What is the best treatment approach for a patient presenting with hirsutism, potentially due to Polycystic Ovary Syndrome (PCOS) or hormonal imbalance?

Treatment of Hirsutism

Combined oral contraceptives (COCs) are the first-line medical therapy for hirsutism, particularly in women with PCOS, and should be combined with spironolactone if improvement is insufficient after 6-9 months. 1, 2

Initial Diagnostic Evaluation

Before initiating treatment, establish the underlying cause through targeted assessment:

• Measure total or free testosterone levels - values >200 ng/dL suggest an androgen-secreting tumor requiring immediate imaging 1
• Assess for PCOS (accounts for 70-80% of hirsutism cases) - requires only 2 of 3 criteria: hyperandrogenism, ovulatory dysfunction, or polycystic ovaries on ultrasound 1
• Check DHEAS and androstenedione - markedly elevated DHEAS suggests adrenal source 3
• Obtain 17-hydroxyprogesterone if clinical suspicion for non-classical congenital adrenal hyperplasia 1
• Evaluate for rapid onset (weeks to months) or virilization signs (clitoromegaly, voice deepening) - these indicate high risk for androgen-secreting tumor 1, 4

Note: Mild hirsutism without oligomenorrhea, infertility, or other hyperandrogenic signs does not require routine endocrine testing 1

First-Line Pharmacologic Treatment

Combined Oral Contraceptives

Start with COCs as monotherapy - they suppress ovarian androgen production, increase sex hormone-binding globulin, reduce 5-alpha-reductase activity, and block androgen receptors 1

Critical contraindications to verify before prescribing:

• Smoking ≥15 cigarettes/day at age ≥35 years 1
• Hypertension with systolic ≥160 or diastolic ≥100 mmHg 1
• History of deep vein thrombosis, pulmonary embolism, or ischemic heart disease 1

Avoid androgenic progestins (norethisterone derivatives, levonorgestrel) as they worsen hirsutism 1

Expected timeline: Hirsutism reduction begins at 6-12 months; acne improves in 3-6 months 1

Second-Line: Add Anti-Androgen Therapy

If hirsutism persists after 6-9 months of COC monotherapy, add spironolactone 100-150 mg daily 3, 2

• In one series, spironolactone achieved improvement in 85% of patients, with complete remission in 55% 3
• Combination of anti-androgen with ovarian suppression (COC) is more effective than either alone 5, 2
• Alternative anti-androgens include finasteride (1.25-5 mg daily) or cyproterone acetate (where available) 3, 1

For women who cannot use COCs (due to contraindications): Use spironolactone or finasteride with reliable non-hormonal contraception, as these agents are teratogenic 6, 4

Adjunctive Metabolic Management

For PCOS with Insulin Resistance

Metformin 500 mg 2-3 times daily showed significant improvement in 72% of PCOS patients with features of insulin resistance in a 24-week study 3

Weight loss of just 5% of initial body weight improves metabolic and reproductive abnormalities in obese PCOS patients, potentially reducing hirsutism severity 1, 5

For Women with Epilepsy

Women with epilepsy have 10-25% prevalence of PCOS even without anti-epileptic drugs, and certain medications (particularly valproate) may worsen hirsutism 3, 1

Cosmetic and Physical Treatments

Topical eflornithine hydrochloride cream can be used as adjunctive therapy alongside systemic medications 1, 2

Laser hair removal or electrolysis are effective but require multiple treatments and work best when combined with medical therapy to reduce androgen levels 5

• Laser treatment addresses the symptom but not the underlying hormonal cause 5
• Concomitant medical management is necessary for optimal outcomes 5

Temporary methods (shaving, waxing, plucking) are safe and can be used while awaiting pharmacologic effects 1, 4

Treatment Timeline and Monitoring

Minimum trial duration: 6-12 months before switching therapies, as the hair growth cycle is prolonged 1, 2, 4

Monitor clinical response:

• Hirsutism reduction: 6-12 months 1
• Menstrual regularity: 1-3 cycles 1
• Metabolic parameters: reassess at 3-6 months 1

Lifelong therapy is typically required to prevent recurrence once treatment is discontinued 7

Critical Pitfalls to Avoid

• Do not prescribe COCs with androgenic progestins - they exacerbate hirsutism 1
• Do not expect rapid improvement - warn patients that visible reduction takes 6-12 months minimum 1, 7
• Do not miss androgen-secreting tumors - testosterone >200 ng/dL or rapid onset mandates imaging 1
• Do not use anti-androgens without contraception in women of reproductive potential - these agents are teratogenic 6
• Ensure adequate uterine surveillance in women with chronic anovulation due to unopposed estrogen exposure risk 1