Approach to Hirsutism
Begin with lifestyle modification (5% weight loss if overweight) and combined oral contraceptive pills (OCPs) as first-line pharmacological therapy, adding an antiandrogen (spironolactone) after 6 months if response is inadequate, while simultaneously offering mechanical hair removal methods (laser/photoepilation preferred over electrolysis) for immediate cosmetic benefit. 1, 2, 3
Initial Evaluation
Clinical Assessment
Assess hirsutism severity using the modified Ferriman-Gallwey (mFG) score at nine body sites (upper lip, chin, chest, upper/lower back, upper/lower abdomen, upper arms, thighs). An mFG score >4-6 (varies by ethnicity) defines hirsutism and warrants hormonal evaluation 4. Document menstrual history, rapidity of onset, and signs of virilization (clitoromegaly, voice deepening, male-pattern baldness) which suggest androgen-secreting tumors requiring urgent investigation 5, 6.
Laboratory Workup
For women with abnormal mFG scores, obtain 5, 2:
- Random total testosterone (day 3-6 of cycle): >2.5 nmol/L is abnormal
- Early morning 17-hydroxyprogesterone if testosterone elevated or high-risk ethnicity (screens for non-classic congenital adrenal hyperplasia)
- DHEAS to rule out adrenal tumors if markedly elevated
- LH/FSH ratio (average of three measurements 20 minutes apart, day 3-6): ratio >2 suggests PCOS
- Prolactin (morning, resting, NOT postictal): >20 μg/L warrants thyroid/pituitary evaluation
- Fasting glucose and insulin to assess insulin resistance
- Pelvic ultrasound (transvaginal, day 3-9): >10 peripheral cysts 2-8mm diameter suggests PCOS
Do NOT test androgen levels in eumenorrheic women with normal mFG scores and only localized unwanted hair growth 2, 3.
Treatment Algorithm
Step 1: Lifestyle Modification (All Patients with Excess Weight)
Weight loss of as little as 5% improves metabolic, reproductive, and psychological outcomes in PCOS-related hirsutism 1, 7. This should be the foundation before or concurrent with pharmacotherapy. Exercise programs provide benefit even without weight loss 1.
Step 2: First-Line Pharmacological Therapy
For women not seeking pregnancy: Start combined OCPs 1, 2, 3. OCPs suppress ovarian androgen production and increase sex hormone-binding globulin, reducing free testosterone. Low-dose or antiandrogenic OCPs (containing drospirenone or cyproterone acetate) may be slightly more effective than standard formulations 8.
For women with mild hirsutism and no endocrine disorder: Either pharmacological therapy OR direct hair removal methods are acceptable 2.
Step 3: Add Antiandrogen After 6 Months if Inadequate Response
If patient-important hirsutism persists after 6 months of OCP monotherapy, add spironolactone (typically 50-200 mg daily) 1, 2, 3. Spironolactone is the first-line antiandrogen; finasteride and cyproterone acetate are second-line options 8.
Critical caveat: NEVER use antiandrogen monotherapy without adequate contraception due to teratogenicity risk 1, 2. For women using long-acting reversible contraception, permanent sterilization, or who are not sexually active, either OCPs or antiandrogens are acceptable initial therapies 3.
Flutamide carries hepatotoxicity risk and is NOT first-line; if used, employ lowest effective dose with liver enzyme monitoring 8.
Step 4: Mechanical Hair Removal
Laser/photoepilation is preferred over electrolysis for long-term hair reduction 2, 6. Alexandrite and diode lasers demonstrate the best efficacy 8, 9. Multiple treatments are required, and concomitant medical management is usually necessary to prevent new hair growth 1.
Electrolysis provides permanent hair removal but is impractical for large areas 1. Temporary methods (shaving, waxing, plucking) are acceptable adjuncts 1, 6.
Topical eflornithine hydrochloride cream is the only FDA-approved topical agent for hirsutism; use as monotherapy for mild cases or as adjunct to other treatments 1, 8.
What NOT to Do
Do NOT use insulin-sensitizing agents (metformin, thiazolidinediones) as monotherapy for hirsutism 2, 8. While they improve metabolic parameters in PCOS, they do not significantly improve hirsutism and are not recommended when hirsutism is the sole indication 8.
Do NOT use ovarian surgery, statins, or vitamin D supplementation for hirsutism—insufficient evidence of efficacy 8.
Timeline Expectations
All pharmacological therapies require minimum 6 months to show benefit due to the hair growth cycle 2, 6, 8. Lifelong treatment is often necessary for sustained benefit 8. Set realistic expectations with patients to prevent premature treatment discontinuation.
Special Considerations
Rapid onset hirsutism (over few months) or virilization signs indicate high risk of androgen-secreting tumor—requires urgent imaging and endocrine evaluation 6, 4.
PCOS accounts for 80-90% of hirsutism cases, idiopathic hirsutism 5-10%, and non-classic congenital adrenal hyperplasia 1-10% (ethnicity-dependent) 4. The combination approach of pharmacotherapy plus mechanical hair removal is most effective 1.