Which specialist should I see for hirsutism?

Which Specialist Should Manage Hirsutism?

For hirsutism evaluation and treatment, start with a dermatologist or endocrinologist who has specific expertise in hyperandrogenic disorders, as these specialists are best equipped to diagnose the underlying cause (most commonly PCOS), initiate appropriate hormonal therapy, and coordinate cosmetic treatments. 1, 2

Primary Specialists for Hirsutism

Dermatology

• Dermatologists are ideal first-line specialists because they can comprehensively manage both the medical and cosmetic aspects of hirsutism, including prescribing combined oral contraceptives, antiandrogens (spironolactone), and coordinating laser hair removal. 1, 2
• The American Academy of Dermatology provides extensive evidence-based guidelines for hirsutism management, emphasizing that dermatologists routinely handle the full spectrum from diagnosis through long-term treatment. 1
• Dermatologists can perform the modified Ferriman-Gallwey scoring to objectively quantify hirsutism severity and monitor treatment response. 3

Endocrinology

• Endocrinologists should be consulted when there are signs of serious underlying endocrine pathology such as rapid-onset hirsutism (suggesting androgen-secreting tumor), Cushing's syndrome features, or when initial testosterone levels exceed 200 ng/dL. 1, 3
• They are essential for managing complex cases with metabolic comorbidities like insulin resistance, prediabetes, or when PCOS diagnosis requires sophisticated hormonal evaluation. 2
• The Endocrine Society recommends endocrinology referral for adolescents with PCOS and endocrine comorbidities who may benefit from early finasteride intervention. 1

When to Involve Gynecology/Obstetrics

• Gynecologists are appropriate when hirsutism presents alongside reproductive concerns such as infertility, severe menstrual irregularities, or when pregnancy is desired (requiring clomiphene citrate rather than oral contraceptives). 4, 2
• The American College of Obstetricians and Gynecologists provides guidelines specifically for PCOS-related hirsutism, including pelvic examination to assess for adnexal masses suggesting ovarian tumors. 4, 1
• OBGYN involvement is critical when managing the 70-80% of hirsutism cases caused by PCOS, particularly for coordinating fertility treatment. 1

Practical Approach Algorithm

Step 1: Initial Assessment (Primary Care or Specialist)

• Measure modified Ferriman-Gallwey score; scores ≥8 indicate abnormal hirsutism requiring workup. 3
• Obtain serum total testosterone; levels >200 ng/dL mandate urgent imaging for androgen-secreting tumors. 1, 3
• Assess for rapid onset (weeks to months), clitoromegaly, truncal obesity, severe acne, or androgenic alopecia—all red flags requiring endocrinology referral. 1

Step 2: Specialist Selection Based on Presentation

• Mild to moderate hirsutism with regular menses → Dermatology for combined oral contraceptives + topical therapy + laser hair removal coordination. 1, 2
• Hirsutism with oligomenorrhea, infertility, or metabolic syndrome → Endocrinology or Gynecology for comprehensive PCOS management including metformin and ovulation induction if needed. 1, 2
• Severe, rapid-onset, or tumor-suspected cases → Endocrinology urgently for imaging (CT/MRI) and potential surgical referral. 1, 3

Step 3: Multidisciplinary Coordination

• Dermatology manages long-term hormonal suppression (OCPs, spironolactone) and coordinates laser treatments, which require 6-12 months for hirsutism improvement. 1, 2
• Endocrinology optimizes metabolic parameters with weight loss (5% reduction significantly improves hirsutism) and metformin when insulin resistance is present. 2
• Gynecology handles fertility planning, switching from OCPs to clomiphene when pregnancy is desired. 2

Common Pitfalls to Avoid

• Do not delay specialist referral for mild hirsutism without other hyperandrogenic signs, as the American Academy of Dermatology states routine endocrine testing is unnecessary in these cases—dermatology can initiate treatment empirically. 1
• Avoid sending patients to multiple specialists simultaneously without a clear lead coordinator, as hirsutism treatment requires 6-12 months to show improvement and needs consistent medication adjustments. 1
• Do not refer to general surgery or plastic surgery as primary specialists; these are only involved for rare cases of androgen-secreting tumor resection after endocrinology workup. 1
• Recognize that family medicine or internal medicine can initiate treatment with combined oral contraceptives for straightforward PCOS-related hirsutism, reserving specialist referral for inadequate response after 6-9 months or concerning features. 1, 2