What is the appropriate evaluation and management for facial hirsutism in a 25‑year‑old woman?

Evaluation and Management of Facial Hirsutism in a 25-Year-Old Woman

Begin with combined oral contraceptives (COCs) containing a non-androgenic progestin as first-line therapy while simultaneously initiating topical treatments and evaluating for polycystic ovary syndrome (PCOS), which accounts for 70-80% of hirsutism cases in young women. 1

Initial Clinical Assessment

Assess the following specific features during your examination:

• Menstrual pattern: Document cycle length over the past 6 months; cycles <23 days (polymenorrhea), >35 days (oligomenorrhea), or absent bleeding >6 months (amenorrhea) suggest underlying endocrine dysfunction 2
• Distribution of hair growth: Use the modified Ferriman-Gallwey score to quantify hirsutism severity; a score ≥8 is abnormal and warrants hormonal evaluation 3
• Signs of hyperandrogenism: Look for acne, androgenic alopecia (temporal recession), clitoromegaly, and deepening voice 1
• Metabolic indicators: Calculate BMI and waist-hip ratio (WHR >0.9 indicates truncal obesity); examine for acanthosis nigricans (darkened, velvety skin in neck/axillae suggesting insulin resistance) 2, 4
• Rapidity of onset: Sudden or rapidly progressive hirsutism over weeks to months raises concern for androgen-secreting tumors 1

Laboratory Evaluation Algorithm

First-Line Tests (Obtain in ALL patients with moderate-severe hirsutism or menstrual irregularity):

• Total testosterone and free testosterone by LC-MS/MS (not immunoassay): Total testosterone >200 ng/dL suggests androgen-secreting tumor 1, 4
• Thyroid-stimulating hormone (TSH): Exclude thyroid disease as cause of menstrual irregularity 4
• Prolactin (morning, resting sample): Levels >20 µg/L are abnormal and suggest hyperprolactinemia 4
• Fasting glucose and insulin: Calculate glucose/insulin ratio; ratio >4 suggests reduced insulin sensitivity 4
• Fasting lipid panel: Assess cardiovascular risk, particularly in obese patients 4

Second-Line Tests (If first-line tests normal but clinical suspicion remains high):

• DHEAS: Age-adjusted thresholds (≥3800 ng/mL for ages 20-29) suggest non-classical congenital adrenal hyperplasia 4
• Androstenedione: Levels >10 nmol/L raise suspicion for adrenal/ovarian tumor 4
• 17-hydroxyprogesterone: Consider if DHEAS elevated to screen for 21-hydroxylase deficiency 1

Imaging:

• Pelvic ultrasound (transvaginal preferred): Obtain if hormonal tests suggest PCOS or to exclude ovarian masses; ≥20 follicles per ovary and/or ovarian volume ≥10 mL confirms polycystic ovarian morphology 1, 4

Treatment Algorithm

Step 1: Initiate First-Line Therapy Immediately

Combined oral contraceptives are the cornerstone of treatment:

• Mechanism: Suppress ovarian androgen production, increase sex hormone-binding globulin, reduce 5α-reductase activity, and block androgen receptors 1
• Formulation: Choose COCs containing non-androgenic progestins (drospirenone, norgestimate, desogestrel); avoid androgenic progestins (norethisterone, levonorgestrel) as they worsen hirsutism 1
• Pre-treatment screening: Check blood pressure; exclude smoking ≥15 cigarettes/day if age ≥35, uncontrolled hypertension (≥160/100 mmHg), history of venous thromboembolism, ischemic heart disease, or active liver disease 1
• Expected timeline: Visible improvement begins at 3-6 months; hirsutism reduction requires 6-12 months 1

Simultaneously add topical therapy:

• Eflornithine hydrochloride 13.9% cream: Apply twice daily to facial areas; slows hair growth and is effective as adjunct therapy 5, 6
• Mechanical hair removal: Shaving, waxing, or plucking for immediate cosmetic improvement 1

Step 2: Re-evaluate at 6 Months

If hirsutism improvement is insufficient after 6-9 months of COC monotherapy:

Add spironolactone 50-100 mg daily:

• Efficacy: 66-85% of women achieve clear skin or marked improvement 1
• Mechanism: Reduces testosterone synthesis, competitively blocks androgen receptors, inhibits 5α-reductase 1
• Safety: Can be safely combined with COCs (including drospirenone-containing formulations) without clinically significant hyperkalemia risk 1
• Monitoring: Routine potassium monitoring is not required unless patient has renal disease or takes other potassium-sparing agents 1

Step 3: Address Metabolic Abnormalities (If Present)

If patient has obesity (BMI >25), acanthosis nigricans, or documented insulin resistance:

Add metformin 500 mg three times daily:

• Efficacy: ~72% show significant improvement after 24 weeks, with normalization of ovarian and adrenal androgen excess 1
• Best responders: Those with menstrual-related symptom flares or classic PCOS phenotype 1
• Lifestyle modification: Recommend 5% weight reduction, which improves metabolic and reproductive abnormalities in obese women with PCOS 1

Step 4: Consider Permanent Hair Removal

Laser therapy (alexandrite or diode lasers):

• Provides permanent hair reduction and can be used as adjunct to pharmacotherapy 6
• Most effective when combined with systemic androgen suppression 6

Electrolysis:

• Provides permanent hair removal in localized areas 6

Common Pitfalls to Avoid

• Do not delay treatment while awaiting complete laboratory workup; begin COCs and topical therapy immediately if no contraindications exist 1
• Do not use AMH levels as a standalone diagnostic test for PCOS; it lacks standardization and validated cut-offs 4
• Do not prescribe insulin sensitizers (metformin) as monotherapy for hirsutism alone; they are ineffective without metabolic abnormalities 6
• Do not use ultrasound for PCOS diagnosis if patient already has both irregular cycles AND clinical/biochemical hyperandrogenism; two Rotterdam criteria are sufficient 4
• Do not expect rapid results: Counsel patients that visible improvement requires 6-12 months of consistent therapy 1
• Do not use flutamide as first-line antiandrogen due to hepatotoxicity risk; spironolactone is preferred 6

When to Refer

Endocrinology referral is indicated for:

• Total testosterone >200 ng/dL (concern for androgen-secreting tumor) 1
• Rapid onset or progression of virilization (clitoromegaly, voice deepening) 1
• Suspected Cushing's syndrome (buffalo hump, moon facies, wide violaceous striae) 2
• Confirmed non-classical congenital adrenal hyperplasia 1

Gynecology referral is indicated for:

• Infertility concerns or desire for pregnancy (clomiphene citrate preferred over COCs) 1
• Palpable adnexal mass on examination 1