Hirsutism Guideline Resources

1.1 We suggest testing for elevated androgen levels in all women with an abnormal hirsutism score (2 |ꚚꚚOO). In those cases where serum total testosterone levels are normal, if sexual hair growth is moderate/severe or sexual hair growth is mild but there is clinical evidence of a hyperandrogenic endocrine disorder (such as menstrual disturbance or progression in spite of therapy), we suggest measuring an early morning serum total and free testosterone by a reliable specialty assay. (2 |ꚚꚚOO)

1.2 We suggest screening hyperandrogenemic women for NCCAH due to 21-hydroxylase deficiency by measuring early morning 17-hydroxyprogesterone levels in the follicular phase or on a random day for those with amenorrhea or infrequent menses (2 |ꚚꚚOO). In hirsute patients with a high risk of congenital adrenal hyperplasia (positive family history, member of a high-risk ethnic group), we suggest this screening even if serum total and free testosterone are normal. (2 |ꚚꚚOO)

1.3 We suggest against testing for elevated androgen levels in eumenorrheic women with unwanted local hair growth (i.e., in the absence of an abnormal hirsutism score) because of the low likelihood of identifying a medical disorder that would change management or outcome. (2 |ꚚꚚOO)

2.1 For most women with patient-important hirsutism despite cosmetic measures, we suggest starting with pharmacological therapy (2 |ꚚOOO). For women who then desire additional cosmetic benefit, we suggest adding direct hair removal methods. However, for women with mild hirsutism and no evidence of an endocrine disorder, we suggest either approach. (2 |ꚚOOO)

2.2. For hirsute women with obesity, including those with polycystic ovary syndrome, we also recommend lifestyle changes. (1 |ꚚꚚOO)

3.1 For the majority of women with hirsutism who are not seeking fertility, we suggest oral contraceptives as initial therapy for treating patient-important hirsutism. (2 |ꚚꚚOO)

3.2 For most women with hirsutism, we suggest against antiandrogen monotherapy as initial therapy (because of the teratogenic potential of these medications) unless these women use adequate contraception (2 |ꚚOOO). However, for women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception, we suggest using either oral contraceptives or antiandrogens as initial therapy (2 |ꚚOOO). The choice between these options depends on patient preferences regarding efficacy, side effects, and cost.

3.3 For most women, we do not suggest one oral contraceptive over another as initial therapy, as all oral contraceptives appear to be equally effective for hirsutism, and the risk of side effects is low. (2 |ꚚꚚOO)

3.4 For women with hirsutism at higher risk for venous thromboembolism (e.g., those who are obese or over age 39 years), we suggest initial therapy with an oral contraceptive containing the lowest effective dose of ethinyl estradiol (usually 20 mcg) and a low-risk progestin (Table 2). (2 |ꚚOOO)

3.5 If patient-important hirsutism remains despite 6 months of monotherapy with an oral contraceptive, we suggest adding an antiandrogen. (2 |ꚚꚚOO)

3.6 We do not suggest one antiandrogen over another (2 |ꚚꚚOO). However, we recommend against the use of flutamide because of its potential hepatotoxicity. (1 |ꚚꚚOO)

3.7 For all pharmacologic therapies for hirsutism, we suggest a trial of at least 6 months before making changes in dose, switching to a new medication, or adding medication. (2 |ꚚOOO)

3.8 In patients with severe hirsutism causing emotional distress and/or in those women who have used oral contraceptives in the past and have not experienced sufficient improvement, we suggest initiating combination therapy with an oral contraceptive and antiandrogen (2 |ꚚꚚOO). However, we suggest against combination therapy as a standard first-line approach. (2 |ꚚꚚOO)

3.9 We suggest against using insulin-lowering drugs for the sole indication of treating hirsutism. (2 |ꚚꚚOO)

3.10 We suggest against using gonadotropin releasing hormone agonists except in women with severe forms of hyperandrogenemia (such as ovarian hyperthecosis) who have a suboptimal response to oral contraceptives and antiandrogens. (2 |ꚚOOO)

3.11 We suggest against the use of topical antiandrogen therapy for hirsutism. (2 |ꚚOOO)

4.1 For women who choose hair removal therapy, we suggest photoepilation for those whose unwanted hair is auburn, brown, or black, and we suggest electrolysis for those with white or blonde hair. (2 |ꚚꚚOO)

4.2 For women of color who choose photoepilation treatment, we suggest using a long-wavelength, long pulse-duration light source such as Nd:YAG or diode laser delivered with appropriate skin cooling (2 |ꚚOOO). Clinicians should warn Mediterranean and Middle Eastern women with facial hirsutism about the increased risk of developing paradoxical hypertrichosis (PH) with photoepilation therapy. We suggest topical treatment or electrolysis over photoepilation with these patients. (2 |ꚚꚚOO)

4.3 For women who desire more rapid response to photoepilation, we suggest adding eflornithine topical cream during treatment. (2 |ꚚꚚOO)

4.4 For women with known hyperandrogenemia who choose hair removal therapy, we suggest pharmacologic therapy to minimize hair regrowth. (2 |ꚚꚚOO)