Approach to Hirsutism Management

Initial Assessment and Diagnosis

The American College of Obstetricians and Gynecologists recommends laboratory evaluation to identify underlying causes and guide treatment, including measuring free and total testosterone, DHEA-S, androstenedione, LH, and FSH 2
Screening for metabolic abnormalities, such as fasting glucose and lipid profile, is essential for guiding treatment 3
Calculating BMI and waist-hip ratio is crucial, as obesity negatively impacts treatment efficacy 3

The Endocrine Society recommends a weight loss of as little as 5% of total body weight to significantly improve hirsutism through reduction in testosterone levels and improvement in metabolic parameters 1
Targeting an energy deficit of 500-750 kcal/day and combining diet with regular exercise is recommended 3, 1
This approach reduces Ferriman-Gallwey scores by a mean difference of -1.19 points 1

The American College of Obstetricians and Gynecologists recommends combined oral contraceptives as the initial pharmacotherapy, which suppress ovarian androgen secretion and increase sex hormone binding globulin 3
Adding antiandrogen therapy, such as spironolactone 100-150 mg daily, to the OCP regimen is recommended for inadequate response after 6-9 months 2, 4
Spironolactone achieves improvement in 85% of patients, with complete remission in 55% 4

The American Diabetes Association recommends metformin monotherapy only when metabolic abnormalities, such as insulin resistance or prediabetes, coexist with hirsutism 4, 3
Metformin improves metabolic parameters but has insufficient evidence for hirsutism as the sole indication 3

The American Academy of Dermatology recommends laser hair removal as an essential adjunct to systemic therapy, with multiple treatments required for optimal results 2
Laser hair removal must be combined with medical management to address underlying androgen excess 2

The American College of Obstetricians and Gynecologists recommends clomiphene citrate as first-line for ovulation induction in women seeking pregnancy, not OCPs 3
Bariatric surgery may be considered in severe obesity with inadequate response to lifestyle modification, with over 90% achieving moderate resolution of hirsutism by 1 year post-surgery 5