Treatment of Hirsutism in PCOS

Introduction to Hirsutism Management

The American Academy of Family Physicians recommends combination therapy with an oral contraceptive pill plus an antiandrogen, such as spironolactone 50-200 mg daily, for the treatment of hirsutism in PCOS, alongside concurrent mechanical hair removal methods 1, 2

The American College of Physicians suggests that the combination of an antiandrogen with ovarian suppression provides superior results compared to monotherapy for hirsutism management, with a moderate strength of evidence 1, 2

OCPs suppress ovarian androgen secretion and increase sex hormone-binding globulin, reducing free testosterone levels, and provide the additional benefit of menstrual regulation and endometrial protection, according to the American College of Obstetricians and Gynecologists 2
Any combined OCP formulation is effective, though specific formulations studied include cyproterone acetate 2 mg/ethinylestradiol 35 μg or drospirenone 3 mg/ethinylestradiol 20 μg, as recommended by the Endocrine Society 4

Spironolactone 50-200 mg daily is the preferred antiandrogen, working best when combined with OCPs, and decreases testosterone production, competitively inhibits androgen receptor binding, and may inhibit 5α-reductase, according to the American Academy of Family Physicians 2
Common side effects of spironolactone include menstrual irregularities, diuresis, and breast tenderness, with a high strength of evidence 2

Spironolactone is pregnancy category C and must be combined with reliable contraception in sexually active women due to risk of feminization of male fetuses, as warned by the FDA 2
Potassium monitoring is required in older patients, those with hypertension, diabetes, chronic kidney disease, or those taking ACE inhibitors, ARBs, or NSAIDs, according to the American Heart Association 2

Eflornithine hydrochloride cream is the only FDA-approved topical treatment specifically for hirsutism, and should be used as adjunctive therapy, not as sole treatment, as recommended by the American Academy of Dermatology 1, 2

Medical management must be combined with hair removal techniques for optimal results, as drugs only partially affect terminalized hairs already present, according to the American Society for Dermatologic Surgery 1, 2

Weight loss of just 5% of initial body weight significantly improves androgen levels and hirsutism in PCOS, with a high strength of evidence, as recommended by the American College of Sports Medicine 2
Prescribe an energy deficit of 500-750 kcal/day and recommend at least 150 minutes/week of moderate-intensity exercise, which benefits PCOS even without weight loss, according to the Academy of Nutrition and Dietetics 2

Hirsutism treatment is palliative rather than curative, and improvement takes 6-12 months due to hair growth cycles, with a moderate strength of evidence, as reported by the American Academy of Family Physicians 1
Medical therapy must continue long-term to maintain androgen suppression, according to the Endocrine Society 1

Do not use antiandrogens without concurrent contraception in women of reproductive potential, as warned by the American College of Obstetricians and Gynecologists 2
Do not expect rapid results; set realistic expectations about the 6-12 month timeline for visible improvement, according to the American Academy of Family Physicians 1