How should hirsutism be managed in a 23-year-old woman with excessive facial hair and regular menstrual cycles?

Management of Hirsutism in a 23-Year-Old Woman with Regular Menstrual Cycles

Start with combined oral contraceptives (OCCs) as first-line pharmacotherapy, and if inadequate response after 6-9 months, add spironolactone 100-150 mg daily while continuing the OCP. 1

Initial Diagnostic Workup

Before initiating treatment, obtain laboratory evaluation to identify underlying causes:

• Measure free and total testosterone, DHEA-S, androstenedione, LH, and FSH to assess androgen excess and distinguish between ovarian versus adrenal sources 1
• Screen for metabolic abnormalities including fasting glucose and lipid profile, as these guide treatment decisions 1
• Calculate BMI and waist-hip ratio, since obesity significantly impairs treatment efficacy and weight loss alone can reduce hirsutism 1

The regular menstrual cycles suggest either idiopathic hirsutism (5-15% of cases with normal androgen levels) or mild polycystic ovary syndrome without ovulatory dysfunction 2. Laboratory results will clarify this distinction.

First-Line Treatment Strategy

Weight Management (If Applicable)

If BMI is elevated, prioritize weight loss as the initial intervention:

• Target 5% reduction in total body weight, which significantly improves hirsutism by reducing testosterone levels and improving metabolic parameters 1
• Create an energy deficit of 500-750 kcal/day combined with regular exercise 1
• This approach reduces Ferriman-Gallwey scores by a mean of -1.19 points 1

Pharmacological First-Line: Combined Oral Contraceptives

Initiate OCPs as the primary medical therapy:

• OCPs suppress ovarian androgen secretion and increase sex hormone-binding globulin (SHBG), reducing free testosterone levels 1, 3
• Third-generation OCPs containing new progestogens or cyproterone are preferred, as long-term use (>12 cycles) cures mild-to-moderate hirsutism and improves severe cases 4
• Improvement requires at least 6-9 months of continuous therapy before assessing response 3, 5
• OCPs are effective as monotherapy for mild-to-moderate hirsutism 1, 6

Second-Line: Adding Antiandrogen Therapy

If hirsutism remains inadequately controlled after 6-9 months of OCP monotherapy, add spironolactone:

• Spironolactone 100-150 mg daily achieves improvement in 85% of patients, with complete remission in 55% 1
• Continue the OCP when adding spironolactone to provide menstrual cycle control and contraception (critical due to teratogenic risk) 4, 5
• Spironolactone blocks androgen receptors peripherally and is highly effective at these doses 7, 4

Alternative Antiandrogens

If spironolactone is contraindicated or not tolerated:

• Finasteride 5 mg daily can be used as an alternative, but must always be combined with OCPs for contraception due to severe teratogenic risk to male fetuses 8
• Finasteride is less effective than spironolactone but has fewer side effects 4
• Women must not donate blood until 6 months after the last finasteride dose 8

Role of Insulin Sensitizers

Metformin should only be added if metabolic abnormalities coexist:

• Reserve metformin 500 mg 2-3 times daily for patients with documented insulin resistance, prediabetes, or polycystic ovary syndrome features 1
• Metformin improves metabolic parameters but has insufficient evidence for hirsutism as the sole indication 1
• In PCOS patients with insulin resistance, metformin combined with lifestyle changes may be considered if OCPs are contraindicated 5

Essential Adjunctive Cosmetic Treatment

Laser hair removal must be combined with systemic medical therapy:

• Laser hair removal is an essential adjunct, not a standalone treatment, as it does not address underlying androgen excess 1
• Multiple treatment sessions are required for optimal results 1
• Medical management prevents new terminal hair development while laser removes existing hair 6

Treatment Timeline and Expectations

• Pharmacological therapy requires 6-12 months minimum before significant improvement is visible 3, 5
• Terminal hairs already present will not reverse with medication alone, necessitating mechanical removal 6
• Treatment must continue indefinitely unless the underlying endocrine abnormality resolves 8

Critical Contraception Considerations

Any woman of childbearing age receiving antiandrogen therapy must use reliable contraception:

• Spironolactone and finasteride carry significant teratogenic risks to male fetuses 8, 4
• OCPs serve dual purposes: treating hirsutism and providing contraception 5
• Pregnancy must be avoided during all antiandrogen therapy 4