What is the recommended treatment for hirsutism in a woman with polycystic ovary syndrome?

Treatment of Hirsutism in Women with PCOS

For women with PCOS and excessive hair growth, the most effective treatment is combination therapy with a combined oral contraceptive pill (OCP) plus spironolactone 50–100 mg daily, alongside lifestyle modification targeting 5–10% weight loss and concurrent mechanical hair removal methods. 1

Foundational Lifestyle Intervention

• Weight loss of just 5% of initial body weight significantly improves androgen levels and hirsutism in PCOS, making it the mandatory first step regardless of BMI. 1
• Target an energy deficit of 500–750 kcal/day through balanced dietary approaches, with total intake of 1,200–1,500 kcal/day adjusted for individual needs. 2
• Prescribe at least 150 minutes/week of moderate-intensity exercise or 75 minutes/week of vigorous activity, plus muscle-strengthening activities on 2 non-consecutive days/week, as exercise benefits PCOS even without weight loss. 2, 1

First-Line Medical Therapy: Combined Oral Contraceptives

• OCPs are the cornerstone of hirsutism treatment, suppressing ovarian androgen secretion and increasing sex hormone-binding globulin (SHBG), which reduces free testosterone levels. 3, 1
• Any combined OCP formulation is effective, though formulations containing 30–35 µg ethinyl estradiol with drospirenone, norgestimate, or levonorgestrel are specifically studied. 1
• OCPs provide additional benefits of menstrual regulation and endometrial protection against hyperplasia and cancer. 3, 1
• Allow 3–6 months of optimal-dose OCP therapy before considering additional antiandrogen treatment, as this is the minimum time needed to assess OCP efficacy. 2

Adding Spironolactone for Persistent Hirsutism

• Spironolactone 50–100 mg daily should be added when clinically significant hirsutism persists after 3–6 months of OCP therapy plus lifestyle modifications. 2, 1
• Spironolactone works through competitive antagonism of the androgen receptor, decreases testosterone production, and may inhibit 5α-reductase to prevent conversion of testosterone to the more potent dihydrotestosterone. 1, 4
• The combination of OCP plus spironolactone provides superior results compared to monotherapy, with synergistic reduction in androgenic activity. 2, 1
• Starting dose of 50 mg daily is effective for most patients with better tolerability; 100 mg daily may be required for severe hirsutism, though doses up to 200 mg have been studied with only marginal additional benefit. 2, 1

Critical Safety Considerations for Spironolactone

• Spironolactone is pregnancy category C and must be combined with reliable contraception in sexually active women due to risk of feminization of male fetuses. 1
• Baseline serum potassium should be measured before initiating spironolactone. 2
• Potassium monitoring is required only in patients who are older, have hypertension, diabetes, chronic kidney disease, or are taking ACE inhibitors, ARBs, or NSAIDs—it is not routinely required in young, healthy women without comorbidities. 2, 1
• Common side effects include menstrual irregularities (occurring in 40–68% of patients), breast tenderness, fatigue, headache, and dizziness, though these are less frequent when combined with an OCP. 2
• Studies demonstrate no clinically significant potassium elevation when spironolactone is combined with drospirenone-containing OCCs. 2

Adjunctive Topical Therapy

• Eflornithine hydrochloride cream is the only FDA-approved topical treatment specifically for hirsutism and should be used as adjunctive therapy, not as sole treatment. 1

Essential Role of Mechanical Hair Removal

• Medical management must be combined with hair removal techniques (laser, electrolysis, waxing, shaving) for optimal results, as drugs only partially affect terminalized hairs already present. 1
• Mechanical methods provide immediate cosmetic improvement while medical therapy works to prevent new terminal hair growth. 1

Alternative Pharmacologic Options

• Metformin (500–2000 mg daily) may be considered as second-line therapy, particularly when insulin resistance or glucose intolerance is documented, or when OCPs are contraindicated due to metabolic comorbidities. 2, 5
• Metformin reduces hyperinsulinemia and may effectively treat hirsutism through this mechanism, though it induces negligible direct change in androgen levels compared to OCPs. 5
• GLP-1 receptor agonists (liraglutide, semaglutide, exenatide) show promise for weight reduction and metabolic improvement when combined with lifestyle interventions. 2

Treatment Timeline and Expectations

• Hirsutism treatment is palliative rather than curative, and improvement takes 6–12 months due to hair growth cycles. 1, 6
• Clinical improvement in hirsutism, acne, and serum testosterone is typically observed by 6 months of combined OCP plus spironolactone therapy. 2
• Medical therapy must continue long-term to maintain androgen suppression; unless the underlying cause of PCOS is corrected, treatment will need to be continued indefinitely. 1, 7

Critical Pitfalls to Avoid

• Do not add spironolactone before 3 months of OCP therapy unless hyperandrogenic symptoms are severely impairing quality of life. 2
• Never prescribe spironolactone without confirmed effective contraception due to teratogenic risk. 2, 1
• Do not expect rapid results; set realistic expectations about the 6–12 month timeline for visible improvement to ensure treatment adherence. 1
• Do not discontinue the OCP when spironolactone is added; maintaining both agents yields superior efficacy and tolerability. 2
• Routine potassium monitoring is unnecessary in young, healthy PCOS women without comorbidities or interacting drugs. 2