eMedicine Specialties > Endocrinology > Gonads

Hirsutism: Treatment & Medication

Author: George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
Contributor Information and Disclosures

Updated: Aug 14, 2009

Treatment

Medical Care

The treatment of hirsutism begins with a careful explanation about the cause of the problem and reassurance that the patient is not losing her femininity. Then, direct intervention, if possible, is instituted for the underlying disorder. If hirsutism persists (or the patient has idiopathic hirsutism), other cosmetic or systemic treatment may be necessary. In some cases, cosmetic measures may be sufficient. In others, the slow progress of systemic therapy may necessitate more immediate cosmetic treatment. The most effective strategy is to combine systemic therapy, which has a slow onset of effectiveness, with mechanical depilation (shaving, plucking, waxing, depilatory creams).

Hirsutism requires a careful and systematic clinical evaluation coupled with a rational approach to treatment. Throughout this process, the patient must understand that, although diagnostic testing can be time consuming (and even inconclusive), it is sometimes essential for determining an effective intervention. In other cases, counseling and education may be all that is needed. For the patient who desires treatment, a wide variety of pharmacologic strategies are available. Informing the patient that current systemic therapy is imperfect is important. Furthermore, none of the drugs used to treat hirsutism have US Food and Drug Administration (FDA) approval for such use. Initiate therapy only in patients who give informed consent after a complete explanation of the potential benefits and risks of a particular treatment and alternative approaches.

  • Systemic therapies directed at hirsutism can be divided into those that decrease ovarian or adrenal androgen production and those that inhibit androgen action in the skin. The systemic therapies include glucocorticoids, oral contraceptives (OCs), spironolactone, flutamide, finasteride, cyproterone acetate (not available in the United States), and insulin sensitizers (metformin and rosiglitazone).
    • Glucocorticoids: Glucocorticoids (dexamethasone or prednisone), which suppress adrenocorticotropin hormone (ACTH)–dependent adrenal androgen synthesis, have been used with variable success in women with adrenal hirsutism, as in congenital adrenal hyperplasia (CAH) or idiopathic adrenal hyperandrogenism. Usually, 0.5-1 mg of dexamethasone at bedtime is sufficient to suppress ACTH and adrenal androgen production. Unfortunately, some patients gain weight and develop cushingoid features, even with this small of a dose. Further investigations may establish that lower doses (perhaps 0.25 mg) can be effective without adverse effects.
    • OCs: The drugs most widely used to suppress ovarian androgen production are OCs. They are probably the first choice for young women with hirsutism who do not want to become pregnant.
      • OCs are inexpensive and promote regular uterine bleeding. In addition, OCs can be used in combination with one of the antiandrogens or other forms of therapy. On the other hand, do not use OCs in women with a history of migraines, known or possible thrombotic disease, or breast or uterine cancer.
      • Moreover, for several reasons, OCs have a significant failure rate in patients with hirsutism. Low-dose OCs and progestin-only minipills fail to suppress ovulation in as many as 50% of women. Ovarian function continues at a variable rate, and ovarian androgens continue to be produced. Second, the progestins in OCs are attenuated derivatives of testosterone and have variable degrees of androgenic activity in women. The degree depends on the type of progestin and, more importantly, on individual susceptibility.
    • Spironolactone: Spironolactone, in daily doses of 50-200 mg, blocks androgen receptors. Spironolactone also decreases testosterone production, making it additionally effective for hirsutism. Spironolactone is especially useful in a patient with hypertension or edema because the drug is a mild diuretic.
      • Sexually active women taking spironolactone should ensure that contraceptive measures are adequate. In some cases, spironolactone can be combined with an OC for added effect on the hirsutism.
      • With current systemic therapies for hirsutism, 6 months to a year of therapy is usually required before results are noticeable. Even then, only approximately one half to three quarters of patients show improvement. The problem may lie partially in the nature of the hair follicle, which persists for 6 months to a year even after androgen levels have been normalized. Ineffectiveness may also be due to the inability of treatment to completely normalize elevated tissue dihydrotestosterone levels. Newer therapies directed at inhibition of 5-alpha-reductase or blockade of the androgen receptor may improve the ability to treat patients.
    • Finasteride: Finasteride is a 5-alpha-reductase inhibitor approved for the treatment of benign prostatic hyperplasia. No adverse effects have been reported in women, and the efficacy is similar to that of spironolactone. In at least one study, finasteride was added to spironolactone, demonstrating an additive reduction in hirsutism scores. The main concern with finasteride, however, is the risk of ambiguous genitalia in male fetuses exposed to the enzyme inhibitor during the first trimester. Therefore, use this drug only in women who are postmenopausal with no chance of becoming pregnant.
    • Flutamide: Flutamide, an example of the newer therapies, is a potent nonsteroidal selective antiandrogen without progestational, estrogenic, corticoid, or antigonadotropin activity. Preliminary data indicate that it is effective as therapy for hirsutism (and also acne); however, flutamide is expensive and has caused fatal hepatitis.
      • Unluhizarci et al investigated the effectiveness of combining finasteride with flutamide for the treatment of hirsutism.7 Of the 44 women in the study, 14 patients received finasteride (5 mg/d), 16 women received flutamide (125 mg/d), and 14 women received a combination of finasteride and flutamide (5 mg/d and 125 mg/d, respectively).
      • The authors found that after 12 months of treatment, the hirsutism score for patients receiving combination therapy had been reduced by 49%, compared with 45% for the group receiving flutamide alone, and 32% for patients receiving only finasteride. They therefore concluded that a combination of finasteride and flutamide is approximately as effective as flutamide alone in the treatment of hirsutism and that both of these alternatives are more effective than the administration of finasteride by itself.
    • Cyproterone acetate has been effective in the treatment of hirsutism. When added to ethinyl estradiol, it is as effective as flutamide in the treatment of hirsutism. Cyproterone is not available in the United States.
    • Insulin sensitizers: Both metformin and rosiglitazone improve insulin resistance and have been shown to be effective in lowering androgen levels and in treating hirsutism.
    • Sibutramine: Weight loss with this anorectic agent improves hirsutism scores, androgen levels, and cardiovascular risk factors in women with polycystic ovary syndrome (PCOS).
  • Cosmetic measures for hirsutism and their disadvantages are as follows:
    • Hydrogen peroxide bleaching is not suitable for severe hirsutism.
    • Plucking can cause skin irritation, folliculitis, and scarring.
    • Waxing can cause skin irritation, folliculitis, and scarring. The wax used has a low melting point.
    • Shaving may be psychologically unacceptable.
    • Chemical depilatories can cause skin irritation.
    • Electrolysis can be painful, and short-wave diathermy can cause scarring.
    • Laser therapy has been shown not only to reduce unwanted hair but also to improve depression and anxiety in women with hirsutism.

Medication

The most effective strategy for treating hirsutism is to combine systemic therapy, which has a slow onset of effectiveness, with mechanical depilation (shaving, plucking, waxing, depilatory creams).

Systemic therapies directed at hirsutism can be divided into those that decrease ovarian or adrenal androgen production and those that inhibit androgen action in the skin.

Oral contraceptives

OCs inhibit ovarian androgen production and are probably the first choice for young women with hirsutism who do not want to become pregnant. OCs are inexpensive, and they promote regular uterine bleeding. OCs can be used in combination with antiandrogens or other agents. They have a significant failure rate in hirsutism for several reasons. Low-dose OCs and progestin-only minipills fail to suppress ovulation in as many as 50% of women. Ovarian function continues at a variable rate, and ovarian androgens continue to be produced. Second, the progestins in OCs are attenuated derivatives of testosterone and have variable degrees of androgenic activity in women. The degree depends on the type of progestin and, more importantly, on individual susceptibility.


Estrogen-progestin combinations (Ortho-Novum, Ortho Tri-Cyclen, Triphasil)

Reduces secretion of LH and FSH from the pituitary gland by decreasing amount of gonadotropin-releasing hormones.

Adult

1 tab PO qd

Pediatric

Not established

May reduce hypoprothrombinemic effects of anticoagulants; estrogen levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; corticosteroid levels may increase when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and decreased contraception; increase in fluid retention caused by estrogen intake may reduce seizure control

Documented hypersensitivity; thrombophlebitis; undiagnosed vaginal bleeding; cerebral apoplexy

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in patients with hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, thromboembolic disease, asthma, depression, and renal or cardiac dysfunction

Glucocorticoids

Glucocorticoids are used to inhibit adrenal androgens. These agents have antiinflammatory properties and cause profound and varied metabolic effects. Glucocorticoids suppress ACTH-dependent adrenal androgen synthesis. These agents are used with variable success in women with adrenal hirsutism, CAH, and idiopathic adrenal hyperandrogenism.


Prednisone (Deltasone, Orasone, Meticorten)

May inhibit ACTH-dependent androgen synthesis through negative feedback.

Adult

5 mg PO qhs

Pediatric

Not established

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may develop with glucocorticoid use


Dexamethasone (Decadron, AK-Dex, Alba-Dex)

May inhibit ACTH-dependent androgen synthesis through negative feedback.
Lower doses (eg, 0.25 mg) may prove to be effective with fewer adverse effects.

Adult

0.5-1 mg/d PO qhs

Pediatric

Not established

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization

Documented hypersensitivity; active bacterial or fungal infection

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, weight gain, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, and growth suppression may develop

Antiandrogens

Antiandrogens are used to block androgen action.


Spironolactone (Aldactone)

Decreases testosterone production. Can be combined with OCs for added effects.

Adult

50-200 mg PO qd

Pediatric

Not established

May decrease effect of anticoagulants; potassium and potassium-sparing diuretics may increase toxicity

Documented hypersensitivity; anuria; renal failure; hyperkalemia

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal and hepatic impairment; contraception is imperative in sexually active women

5 alpha-reductase inhibitors

These agents are indicated for treatment of benign prostatic hyperplasia and male pattern baldness. An unlabeled use is for the treatment of female hirsutism.


Finasteride (Proscar, Propecia)

Specific inhibitor of the intracellular enzyme that converts testosterone into the androgen 5-a -dihydrotestosterone. Efficacy in hirsutism is similar to that of spironolactone. To be used only in postmenopausal women with no chance of becoming pregnant.

Adult

5 mg PO qd

Pediatric

Do not administer

Documented hypersensitivity; not to be used in children, pregnancy, or women who may become pregnant

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in hepatic impairment; may cause ambiguous genitalia development in male fetus during first trimester of pregnancy

More on Hirsutism

Overview: Hirsutism
Differential Diagnoses & Workup: Hirsutism
Treatment & Medication: Hirsutism
Follow-up: Hirsutism
Multimedia: Hirsutism
References
Further Reading
[ CLOSE WINDOW ]

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Keywords

hirsutism, hirsute women, androgen excess, PCOS, ovarian polycystic syndrome, polycystic ovary syndrome, polycystic ovarian disease, PCOD, virilization, masculinization, excessive hairiness, excess body hair, endocrine disorders, androgen levels, congenital adrenal hyperplasia, CAH, androgen-secreting tumor, hyperandrogenism, Cushing syndrome, Cushing’s syndrome, Ferriman and Gallwey scale, idiopathic hirsutism

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Contributor Information and Disclosures

Author

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

Medical Editor

Stanley Wallach, MD, Executive Director, American College of Nutrition; Clinical Professor, Department of Medicine, New York University School of Medicine
Stanley Wallach, MD is a member of the following medical societies: American Society for Bone and Mineral Research, American Society for Clinical Investigation, American Society for Clinical Nutrition, American Society for Nutritional Sciences, Association of American Physicians, and Endocrine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Don S Schalch, MD, Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics
Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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