What treatment options are available for a post-menopausal woman with mild hirsutism?

Management of Mild Hirsutism in Postmenopausal Women

For a postmenopausal woman with mild hirsutism, topical eflornithine 13.9% cream applied twice daily is the most appropriate first-line treatment, combined with mechanical hair removal methods such as laser therapy or electrolysis. 1

Initial Diagnostic Evaluation

Before initiating treatment, exclude serious underlying causes:

• Measure total testosterone levels – values >200 ng/dL suggest an androgen-secreting tumor requiring immediate imaging 2
• Check DHEA-S to evaluate for adrenal sources of androgen excess 3
• Perform pelvic examination to assess for adnexal masses that might indicate ovarian tumors 2
• Consider pelvic ultrasound or MRI if testosterone is elevated or physical exam is abnormal, as benign ovarian tumors like cystadenofibroma can cause hirsutism in postmenopausal women 4

Critical caveat: Approximately 1% of hirsutism cases in postmenopausal women are caused by ovarian tumors, and new-onset hirsutism after menopause warrants thorough evaluation even when mild 4

First-Line Treatment: Topical Eflornithine

Topical eflornithine 13.9% cream (Vaniqa) should be applied twice daily to affected facial areas. 1

• Mechanism: Retards hair growth rather than removing existing hair 1
• Efficacy: 32% of patients showed marked improvement or greater after 24 weeks, compared to 8% with vehicle 1
• Onset of benefit: Improvement seen as early as 4-8 weeks, with consistent marked improvement by 8 weeks 1
• Postmenopausal efficacy: Significant improvement was demonstrated specifically in postmenopausal women (38% vs 0% vehicle, p≤0.001) 1
• Reversibility: Hair growth returns to pretreatment levels within 8 weeks of discontinuation 1

Patients must continue mechanical hair removal methods (shaving, plucking) in conjunction with eflornithine, as it is not a depilatory. 1

Adjunctive Mechanical Hair Removal

Laser hair removal is an essential adjunct to topical therapy and should be recommended for optimal results. 3, 5

• Multiple treatment sessions are required for sustained benefit 3
• Electrolysis is an alternative permanent hair removal option 6
• These methods address existing hair while eflornithine prevents new growth 5

Why Systemic Hormonal Therapy Is NOT Recommended

Hormone replacement therapy (HRT) should NOT be initiated solely for hirsutism management in postmenopausal women. 7

• The U.S. Preventive Services Task Force recommends against routine use of estrogen and progestin for prevention of chronic conditions in postmenopausal women (Grade D recommendation) 8, 7
• For every 10,000 women taking combined estrogen-progestin for 1 year, there are 8 additional invasive breast cancers, 8 additional strokes, and 8 additional pulmonary emboli 8, 7
• HRT is indicated only for management of vasomotor symptoms (hot flashes) or genitourinary symptoms, not for hirsutism 7

Oral contraceptives and antiandrogens (spironolactone, cyproterone acetate) are contraindicated in postmenopausal women as these are appropriate only for premenopausal women with ovarian androgen production 2, 3, 6

When to Consider Systemic Antiandrogens

If hirsutism is severe or associated with significantly elevated androgens despite topical therapy:

• Spironolactone 100-150 mg daily can be considered, though this is primarily studied in premenopausal women 3, 9
• Achieves improvement in 85% of patients, with complete remission in 55% 3
• Must exclude contraindications: renal insufficiency, hyperkalemia, and cardiovascular disease 9

Monitoring and Follow-Up

• Reassess at 8 weeks for initial response to eflornithine 1
• If skin irritation develops, reduce application frequency to once daily temporarily 1
• If irritation persists, discontinue eflornithine and rely on mechanical methods alone 1
• Continue treatment for at least 24 weeks to achieve maximal benefit 1

Common Pitfalls to Avoid

• Do not assume mild hirsutism is benign in postmenopausal women – always measure testosterone to exclude androgen-secreting tumors 2, 4
• Do not prescribe HRT for hirsutism alone – the risks outweigh benefits in asymptomatic postmenopausal women 8, 7
• Do not use metformin – it is ineffective for hirsutism without concurrent insulin resistance or metabolic abnormalities 3, 9
• Do not expect immediate results – eflornithine requires 4-8 weeks minimum for visible improvement 1