How should I evaluate and treat an adult woman with new progressive coarse hair growth on the face, chest, abdomen, and back (hirsutism)?

Evaluation and Treatment of Hirsutism in Adult Women

Initial Clinical Assessment

Begin with a focused history targeting menstrual patterns (oligomenorrhea, amenorrhea), infertility, rapid onset of symptoms (weeks to months suggests tumor), family history of similar conditions, medication use (antiepileptics, exogenous androgens), and associated features including acne, androgenetic alopecia, clitoromegaly, truncal obesity, and acanthosis nigricans. 1

Physical Examination Priorities

• Quantify hirsutism severity using the modified Ferriman-Gallwey score across nine body sites (upper lip, chin, chest, upper/lower back, upper/lower abdomen, upper arms, thighs); scores >4-6 define hirsutism depending on ethnicity 2
• Perform pelvic examination to detect adnexal masses that may indicate androgen-secreting ovarian tumors 1
• Assess for hyperandrogenic signs: acne, androgenetic alopecia (crown thinning with frontal/bitemporal recession), clitoromegaly, truncal obesity, and acanthosis nigricans (insulin resistance marker) 1
• Check blood pressure and document smoking history before initiating hormonal therapy 1

Laboratory Testing Algorithm

Mild Hirsutism Without Other Signs

• No routine endocrine testing is required for mild hirsutism in women with regular menses and no other hyperandrogenic features 1, 3

Moderate-to-Severe Hirsutism or Associated Features

Order a comprehensive hormonal panel when hirsutism occurs with oligomenorrhea, amenorrhea, infertility, clitoromegaly, truncal obesity, or rapid progression: 1

• Total and free/bioavailable testosterone: Levels >200 ng/dL strongly suggest androgen-secreting tumor and mandate imaging 1
• DHEA-S: Elevated levels suggest adrenal source 1
• Androstenedione 1
• 17-hydroxyprogesterone (morning, follicular phase): Consider for non-classical congenital adrenal hyperplasia (21-hydroxylase deficiency) based on clinical suspicion 1
• LH and FSH: Elevated LH:FSH ratio supports PCOS 3
• Prolactin: Exclude hyperprolactinemia 1
• TSH and free T4: Rule out thyroid dysfunction 4, 1
• Fasting glucose/insulin or HbA1c: Assess for insulin resistance 1

Imaging Studies

• Pelvic ultrasound: Obtain when PCOS is suspected to identify polycystic ovaries (>10 peripheral cysts 2-8 mm diameter with thickened stroma) 1
• Adrenal/ovarian CT or MRI: Indicated when testosterone >200 ng/dL to localize androgen-secreting tumors 1

Differential Diagnosis

PCOS accounts for 70-80% of hirsutism cases and requires only 2 of 3 Rotterdam criteria: clinical/biochemical hyperandrogenism, ovulatory dysfunction, or polycystic ovaries on ultrasound. 1 In adolescents, diagnosis requires both hyperandrogenism and persistent oligomenorrhea 1

Other causes in descending frequency:

• Idiopathic hirsutism (5-10%): Normal ovulation and androgen levels 5, 2
• Non-classical congenital adrenal hyperplasia (1-10% depending on ethnicity): Elevated 17-hydroxyprogesterone 1, 2
• Androgen-secreting tumors (rare): Testosterone >200 ng/dL, rapid onset 1
• Medication-induced: Antiepileptics, exogenous androgens 1
• Cushing's syndrome, acromegaly, hyperprolactinemia (rare) 4, 2

Treatment Algorithm

First-Line Therapy: Combined Oral Contraceptives (COCs)

Initiate a COC containing a non-androgenic progestin (avoid norethisterone derivatives and levonorgestrel) as first-line therapy for PCOS-related hirsutism, combined with topical retinoid and benzoyl peroxide from day 1. 1, 3

COC Mechanism and Selection

• COCs suppress ovarian androgen production, increase sex hormone-binding globulin, reduce 5α-reductase activity, and block androgen receptors 1
• Drospirenone-containing COCs are preferred due to additional anti-androgenic properties 1
• Avoid androgenic progestins (norethisterone, levonorgestrel) as they worsen hirsutism 1

Pre-Treatment Screening

Verify absolute contraindications before prescribing COCs: 1

• Smoking ≥15 cigarettes/day at age ≥35 years
• Uncontrolled hypertension (≥160/100 mmHg) or hypertension with vascular disease
• History of venous thromboembolism, pulmonary embolism, or ischemic heart disease
• Active liver disease or hepatic tumors
• Breast cancer
• Unexplained abnormal uterine bleeding

Expected Timeline

• Hirsutism reduction requires 6-12 months of continuous COC therapy 1, 3
• Acne improvement occurs by 3-6 months 1
• Menstrual regularity returns within 1-3 cycles 1

Second-Line: Add Spironolactone

If inadequate response after 3-6 months of COC therapy, add spironolactone 50-100 mg daily (up to 200 mg daily studied safely). 1

• Spironolactone achieves 66-85% clear skin or marked improvement when used as monotherapy or adjunctive therapy 1
• Mechanism: Reduces testosterone synthesis, competitively blocks androgen receptors, inhibits 5α-reductase, increases SHBG 1
• Combination with drospirenone-containing COCs is safe without clinically significant hyperkalemia risk 1
• Always combine with COCs in women of childbearing potential due to teratogenic risk and need for contraception 1, 6

Alternative Anti-Androgens

Finasteride 5 mg daily can be considered when spironolactone is contraindicated or not tolerated, but must be combined with COCs in women of childbearing age due to severe teratogenic risk to male fetuses 6

• Contraindicated in pregnancy: Women must not donate blood until 6 months after last dose 6
• Postmenopausal women may use finasteride off-label with careful consideration of limited efficacy data 6

Metabolic Management: Metformin

Add metformin 500 mg 2-3 times daily in PCOS patients with insulin resistance features (obesity, acanthosis nigricans, documented metabolic abnormalities). 1

• 72% of treated patients show significant acne improvement after 24 weeks with normalization of ovarian and adrenal androgen excess 1
• Weight loss of 5% body weight improves metabolic and reproductive abnormalities in obese PCOS patients 1, 3
• Best responders: Women with menstrual-related symptom flares or classic PCOS phenotype 1

Adjunctive Cosmetic/Mechanical Treatments

Combine medical therapy with mechanical hair removal methods for optimal results: 3, 5

• Laser hair removal: Multiple treatments needed; most effective when combined with androgen suppression 3
• Topical eflornithine hydrochloride 13.9% cream: Slows facial hair growth 5
• Electrolysis, shaving, waxing, plucking: Immediate cosmetic improvement 5

Special Populations and Referral Indications

Reproductive Concerns

Refer to gynecology when hirsutism coexists with infertility, marked menstrual irregularities, or desire for pregnancy; clomiphene citrate is preferred over COCs in these situations. 1

Severe or Refractory Cases

• Isotretinoin 0.5-1 mg/kg/day reserved for severe nodulocystic acne failing optimized hormonal therapy; can be safely combined with COCs and spironolactone but requires strict pregnancy prevention (iPLEDGE) 1

Monitoring and Patient Counseling

• Re-evaluate at 3-6 months for clinical response; adjust therapy if inadequate improvement 1
• Reassess metabolic parameters (glucose, lipids) at 3-6 months in PCOS patients 1
• Warn patients not to expect improvement for at least 3-6 months after initiating therapy 7
• Lifelong therapy may be needed to prevent recurrence unless underlying condition is corrected 7
• Do not underestimate patient distress: Evaluate all women complaining of excess hair growth regardless of observable severity 2

Common Pitfalls to Avoid

• Never use topical antibiotics alone: Always combine with benzoyl peroxide to prevent bacterial resistance 1
• Do not prescribe anti-androgens as monotherapy in women of childbearing potential: Always combine with effective contraception 6
• Avoid routine Pap smear and pelvic exam before initiating COCs; these are no longer mandatory 1
• Do not overlook adnexal masses on pelvic examination that may indicate ovarian tumors 1
• Recognize that treatment is palliative, not curative: Medical therapy addresses symptoms but not underlying PCOS pathophysiology 3