How should hirsutism be managed in a reproductive‑age woman, including first‑line therapy and subsequent treatment options?

Hirsutism Management in Reproductive-Age Women

First-Line Treatment: Lifestyle Modification

Weight loss of as little as 5% of total body weight is the initial intervention for hirsutism, achieving significant reductions in testosterone levels and Ferriman-Gallwey scores (mean difference -1.19 points). 1 Target an energy deficit of 500-750 kcal/day combined with regular exercise, as obesity directly impairs treatment efficacy. 1

Pharmacological First-Line: Combined Oral Contraceptives

Combined oral contraceptives (OCCs) are the initial pharmacotherapy for hirsutism, suppressing ovarian androgen secretion and increasing sex hormone-binding globulin. 1, 2

Pre-Treatment Assessment

• Measure free and total testosterone, DHEA-S, androstenedione, LH, and FSH to identify underlying causes. 1
• Screen for metabolic abnormalities with fasting glucose and lipid profile. 1
• Calculate BMI and waist-hip ratio (>0.9 indicates truncal obesity). 2
• Check blood pressure and review contraindications. 2

Absolute Contraindications to OCCs

• Smoking ≥15 cigarettes/day in women ≥35 years 2
• Uncontrolled hypertension (≥160/100 mmHg) or hypertension with vascular disease 2
• History of venous thromboembolism or ischemic heart disease 2
• Active liver disease or tumors 2
• Breast cancer or unexplained abnormal uterine bleeding 2

OCC Selection

Avoid OCCs containing androgenic progestins (norethisterone derivatives, levonorgestrel) as they worsen hirsutism. 2 Prefer drospirenone-containing formulations or other non-androgenic progestins. 2

Expected Timeline

• Acne improvement: 3-6 months 2
• Hirsutism reduction: 6-12 months 2
• Menstrual regularity: 1-3 cycles 2

Second-Line: Add Antiandrogen Therapy

If response is inadequate after 6-9 months of OCC monotherapy, add spironolactone 100-150 mg daily to the OCC regimen. 1, 3

Spironolactone Efficacy and Dosing

• Achieves improvement in 85% of patients, with complete remission in 55%. 1
• Initiate at 50-100 mg daily; doses up to 200 mg daily are safe. 2
• Mechanism: reduces testosterone synthesis, blocks androgen receptors, inhibits 5α-reductase, increases SHBG. 2
• Co-administration with drospirenone-containing OCCs is safe without clinically significant hyperkalemia risk. 2

Alternative Antiandrogens (Second-Line)

• Finasteride: effective but second-line to spironolactone 4
• Cyproterone acetate: second-line option 4
• Flutamide: avoid as first-line due to hepatotoxicity risk; requires liver enzyme monitoring if used 4

Role of Insulin Sensitizers

Metformin monotherapy is recommended only when metabolic abnormalities (insulin resistance, prediabetes) coexist with hirsutism, not for hirsutism as the sole indication. 1, 4 Approximately 72% of patients with insulin resistance show significant acne improvement after 24 weeks at 500 mg 2-3 times daily. 2 Metformin improves metabolic parameters but has insufficient evidence for hirsutism alone. 1

Essential Adjunctive Therapy: Laser Hair Removal

Laser hair removal is an essential adjunct to systemic therapy and must be combined with medical management to address underlying androgen excess. 1 Multiple treatment sessions are required for optimal results. 1 Alexandrite and diode lasers show superior efficacy for permanent hair reduction. 4

Additional Cosmetic Options

• Topical eflornithine 13.9% cream: useful adjunct for facial hair, can be combined with laser therapy 5, 4
• Electrolysis: effective for permanent hair removal in localized areas 4
• Mechanical methods (shaving, waxing, plucking): temporary measures 5

Treatment Algorithm

1. Initiate weight loss (5% reduction target) with 500-750 kcal/day deficit plus exercise 1
2. Start OCC (non-androgenic progestin) after excluding contraindications 1, 2
3. Add topical therapy (eflornithine) and/or laser hair removal simultaneously 1, 4
4. Re-evaluate at 6-9 months: if inadequate response, add spironolactone 100-150 mg daily 1, 3
5. If metabolic abnormalities present: add metformin 500 mg 2-3 times daily 1, 2
6. Continue treatment until satisfactory response, then maintain long-term as hirsutism recurs with cessation 4

Special Population: Women Seeking Pregnancy

For women desiring pregnancy, use clomiphene citrate for ovulation induction, not OCCs. 1, 2 Refer to reproductive endocrinology for infertility evaluation and assisted reproduction consultation. 2

Red Flags Requiring Endocrinology Referral

• Total testosterone >200 ng/dL (suggests androgen-secreting tumor requiring immediate imaging) 2, 6
• Rapid onset over weeks to months 2
• Clitoromegaly 2
• Buffalo hump, moon facies, wide violaceous striae (Cushing's syndrome) 2
• Oligomenorrhea (<23 days) or amenorrhea (>6 months) 2

Common Pitfalls to Avoid

• Do not use OCCs with androgenic progestins (norethisterone, levonorgestrel) as they exacerbate hirsutism. 2
• Do not prescribe metformin for hirsutism alone without documented metabolic abnormalities. 1, 4
• Do not rely on medical therapy alone—laser hair removal is essential for optimal outcomes. 1
• Do not expect rapid results—counsel patients that visible improvement requires 6-12 months. 2, 4
• Do not discontinue treatment prematurely—lifelong therapy is often necessary for sustained benefit. 4