What is the best course of treatment for a 36-year-old female with hirsutism (excessive hair growth), presenting with hair growth on her chin?

Hirsutism in a 36-Year-Old Female: Diagnostic and Treatment Approach

Start combined oral contraceptives (COCs) as first-line therapy after ruling out serious causes, and add spironolactone if insufficient improvement after 6-9 months. 1

Initial Diagnostic Evaluation

The most critical first step is determining whether this represents benign hyperandrogenism (most commonly PCOS) versus a dangerous androgen-secreting tumor or other serious endocrine disorder.

Key Clinical Features to Assess

• Onset and progression: Rapid onset over weeks to months suggests tumor; gradual onset suggests PCOS or idiopathic hirsutism 1
• Menstrual history: Oligomenorrhea or amenorrhea points toward PCOS (70-80% of hirsutism cases) 1, 2
• Associated signs of virilization: Clitoromegaly, severe acne, androgenic alopecia, voice deepening, or increased muscle mass suggest severe hyperandrogenism 1
• Metabolic features: Obesity, acanthosis nigricans (insulin resistance), truncal obesity 1
• Family history: Strong genetic component in PCOS and hirsutism 2

Laboratory Testing Strategy

For mild hirsutism without other hyperandrogenic signs: No routine endocrine testing is needed 1

For hirsutism with oligomenorrhea, infertility, clitoromegaly, or truncal obesity, obtain comprehensive testing 1:

• Total testosterone or free testosterone: Levels >200 ng/dL suggest androgen-secreting tumor requiring urgent imaging 1
• DHEAS: Elevated in adrenal sources
• 17-hydroxyprogesterone: Screen for non-classical congenital adrenal hyperplasia if clinically suspected 1
• TSH and prolactin: Exclude thyroid dysfunction and hyperprolactinemia 1
• Fasting glucose/insulin: Assess for insulin resistance in PCOS 1

Pelvic ultrasound: Look for polycystic ovaries (>10 peripheral cysts, 2-8 mm diameter) if PCOS suspected 1

First-Line Treatment: Combined Oral Contraceptives

COCs are the recommended first-line therapy for PCOS-related hirsutism, addressing the underlying hormonal imbalance by suppressing ovarian androgen production, increasing sex hormone-binding globulin, reducing 5-alpha-reductase activity, and blocking androgen receptors 1

Critical COC Selection

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

Screen for absolute contraindications before prescribing 1:

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

Expected Timeline for Response

• Menstrual regularity: 1-3 cycles 1
• Acne improvement: 3-6 months 1
• Hirsutism reduction: 6-12 months 1

The delay in hirsutism improvement reflects the hair growth cycle; existing terminal hairs must complete their growth phase before reduction becomes apparent.

Second-Line: Add Antiandrogen Therapy

If insufficient improvement after 6-9 months of COC monotherapy, add an antiandrogen 3. The combination of an antiandrogen with ovarian suppression (COC) is highly effective 1, 4.

Antiandrogen Options (in order of preference based on efficacy and safety)

1. Spironolactone 100-200 mg/day: Blocks androgen receptors; most commonly used in the US 4

   • Must be combined with COC for contraception (teratogenic to male fetus) 4
   • Monitor for hyperkalemia, especially at higher doses

2. Flutamide 250-500 mg/day: Pure antiandrogen, very effective within 6-12 months 4

   • Warning: Hepatotoxicity possible; requires liver function monitoring 5, 4
   • Dry skin is common 4
   • Must use contraception (teratogenic) 5, 4

3. Finasteride 5 mg/day: 5-alpha-reductase inhibitor, least effective but well-tolerated 4

   • Fewer side effects than other antiandrogens 4
   • Must use contraception (teratogenic) 4

Adjunctive Therapies

Lifestyle Modification (Essential for PCOS)

Weight loss of just 5% improves metabolic and reproductive abnormalities in PCOS, potentially reducing hirsutism severity 1, 6

• Target 500-750 kcal/day deficit (1,200-1,500 kcal/day total) 6
• ≥250 minutes/week moderate-intensity exercise 6

Cosmetic/Mechanical Hair Removal

Laser hair removal is highly effective but requires multiple treatments and works best with concurrent medical therapy to address ongoing androgen stimulation 7

Other options include 2:

• Electrolysis (permanent)
• Shaving, waxing, plucking (temporary)
• Topical eflornithine 13.9% cream: Slows facial hair growth, useful adjunct 2, 3

Insulin Sensitizers

Metformin may help in PCOS patients with insulin resistance, improving ovulation and reducing androgen levels, but evidence for hirsutism improvement alone is limited 1, 3

Ongoing Monitoring

• Clinical response assessment: Every 3-6 months initially 1
• Metabolic screening: Annual fasting glucose, lipids, BMI in all PCOS patients regardless of weight 6
• Psychological support: PCOS patients have higher rates of depression and anxiety; address emotional impact 6

Common Pitfalls to Avoid

• Don't miss androgen-secreting tumors: Always check testosterone levels if rapid onset or severe virilization 1
• Don't use androgenic progestins: They worsen hirsutism 1
• Don't expect rapid results: Hirsutism takes 6-12 months to improve due to hair growth cycles 1
• Don't neglect metabolic screening: Even normal-weight PCOS patients have metabolic risk 6
• Don't forget contraception with antiandrogens: All are teratogenic to male fetuses 4