What is the approach and treatment for a post-menopausal woman presenting with hirsutism, characterized by beard hair growth?

Postmenopausal Hirsutism: Diagnostic Approach and Treatment

For postmenopausal women presenting with new-onset beard hair growth, immediately measure total testosterone (>200 ng/dL suggests tumor), DHEAS, and TSH, then initiate spironolactone 50-200 mg daily combined with topical eflornithine and cosmetic hair removal while excluding ovarian/adrenal tumors. 1, 2, 3

Diagnostic Evaluation

Initial Laboratory Assessment

The diagnostic workup must prioritize excluding androgen-secreting tumors, which are rare but critical to identify:

• Measure total testosterone or free testosterone - levels >200 ng/dL strongly suggest an androgen-secreting ovarian or adrenal tumor requiring immediate imaging 1
• Check DHEAS to evaluate adrenal androgen production 1
• Obtain TSH and free T4 to exclude thyroid disorders that can contribute to hirsutism 2
• Consider 17-hydroxyprogesterone if clinical suspicion exists for non-classical congenital adrenal hyperplasia 1

Clinical Red Flags Requiring Urgent Evaluation

Look specifically for these concerning features that indicate possible malignancy:

• Rapid onset over weeks to months (versus gradual progression) 1
• Virilization signs: clitoromegaly, voice deepening, increased muscle mass 1, 4
• Very elevated testosterone (>200 ng/dL) 1
• Palpable adnexal mass on pelvic examination 1

Imaging Studies

• Transvaginal ultrasound to evaluate for ovarian masses, even if initial exam is unremarkable, as benign tumors like cystadenofibroma can cause androgen excess 4
• Repeat imaging if symptoms persist despite normal initial studies 4
• Consider pelvic MRI for better characterization of suspicious ovarian lesions 4

Common Etiologies in Postmenopausal Women

Iatrogenic Causes (Check First)

• Aromatase inhibitor therapy for breast cancer commonly causes hirsutism by reducing estrogen and increasing relative androgen effects - monitor patients on these medications 2
• Androgenic medications: certain antiepileptics, exogenous androgens 1

Ovarian Sources

• Androgen-secreting tumors (rare but serious): Sertoli-Leydig cell tumors, hilus cell tumors, granulosa cell tumors 4
• Benign ovarian tumors: even cystadenofibroma can produce androgens 4
• Associated endometrial pathology: chronic unopposed estrogen from anovulation increases endometrial cancer risk - ensure adequate surveillance 1, 4

Other Endocrine Causes

• Cushing's syndrome (rare) 1
• Thyroid disorders 2

Treatment Algorithm

First-Line Pharmacologic Therapy

Spironolactone is the cornerstone of treatment for postmenopausal hirsutism:

• Start spironolactone 50-100 mg daily, titrate up to 200 mg daily based on response 3, 5, 6
• Mechanism: competitively blocks testosterone and DHT binding to androgen receptors, inhibits 5-alpha-reductase, increases SHBG 3
• Reduces total and free testosterone within the first weeks of treatment 3
• Monitor potassium levels in patients with compromised liver, adrenal, or renal function 3
• Clinical improvement expected in 6-12 months for hirsutism 1

Important contraindication: Spironolactone is pregnancy category C (causes feminization of male fetus) - ensure adequate contraception if any pregnancy risk exists 3

Alternative Antiandrogens (Second-Line)

If spironolactone is contraindicated or ineffective:

• Finasteride 5 mg daily: inhibits 5-alpha-reductase 5, 6, 7
• Flutamide 250-500 mg daily: potent androgen receptor blocker, but monitor liver function due to hepatotoxicity risk 8, 5
• Cyproterone acetate (not available in US): effective antiandrogen 5, 6, 7

Topical Therapy

• Eflornithine hydrochloride 13.9% cream applied twice daily to affected facial areas - inhibits ornithine decarboxylase, slowing hair growth 5, 6
• Use as adjuvant with systemic therapy for enhanced results 6

Cosmetic/Mechanical Hair Removal

Pharmacologic therapy alone reduces hair growth in <50% of cases, so cosmetic measures are usually necessary:

• Laser hair removal or photoepilation: most effective for permanent reduction 6
• Electrolysis: permanent hair destruction 5
• Temporary methods: shaving, waxing, plucking, depilatory creams 1

Treatment Timeline and Monitoring

• Hirsutism improvement: expect 6-12 months for noticeable reduction 1
• Testosterone normalization: monitor levels at 3-6 months 1
• Continue treatment chronically - hirsutism recurs if therapy is discontinued 9
• Combination therapy (systemic + topical + cosmetic) achieves satisfactory results in most cases 7

Critical Pitfalls to Avoid

1. Do not delay imaging if testosterone >200 ng/dL or rapid symptom onset - tumor must be excluded urgently 1, 4
2. Do not use oral contraceptives in postmenopausal women - they are inappropriate for this age group and increase thrombotic risk 1
3. Do not prescribe antiandrogens without contraception in women with any pregnancy potential due to teratogenic effects 3
4. Do not stop evaluation after normal initial ultrasound if symptoms persist - repeat imaging may reveal previously undetected lesions 4
5. Do not forget endometrial surveillance - chronic androgen excess and anovulation increase endometrial cancer risk 1, 4