Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Hirsutism Treatment & Management

  • Author: George T Griffing, MD; Chief Editor: Michel E Rivlin, MD  more...
 
Updated: Jul 14, 2016
 

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) or light-based (laser or pulsed-light) hair removal.

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.[9] 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 (withdrawn from US market October 8, 2010[10] ): 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. In many patients, hirsutism can be controlled just with laser, without using any drugs.
 
 
Contributor Information and Disclosures
Author

George T Griffing, MD Professor Emeritus 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, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from www.DrScore.com for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

Michel E Rivlin, MD Former Professor, 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, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

References
  1. Ekback M, Wijma K, Benzein E. "It is always on my mind": women's experiences of their bodies when living with hirsutism. Health Care Women Int. 2009 May. 30(5):358-72. [Medline].

  2. Shah D, Patel S. Hirsutism. Gynecol Endocrinol. 2009 Mar. 25(3):140-8. [Medline].

  3. Hawryluk EB, English JC 3rd. Female adolescent hair disorders. J Pediatr Adolesc Gynecol. 2009 Aug. 22(4):271-81. [Medline].

  4. Comim FV, Marchesan LQ, Copes RM, et al. Increased risk of humerus and lower leg fractures in postmenopausal women with self-reported premenopausal hirsutism and/or oligomenorrhea. Eur J Obstet Gynecol Reprod Biol. 2016 Jun 10. 203:162-166. [Medline].

  5. Yildiz BO, Bolour S, Woods K, Moore A, Azziz R. Visually scoring hirsutism. Hum Reprod Update. 2009 Jun 30. [Medline]. [Full Text].

  6. Costello MF, Shrestha B, Eden J, Johnson NP, Sjoblom P. Metformin versus oral contraceptive pill in polycystic ovary syndrome: a Cochrane review. Hum Reprod. 2007 May. 22(5):1200-9. Epub 2007 Jan 29. [Medline].

  7. Villarroel C, Lopez P, Merino PM, Iniguez G, Sir-Petermann T, Codner E. Hirsutism and oligomenorrhea are appropriate screening criteria for polycystic ovary syndrome in adolescents. Gynecol Endocrinol. 2015. 31 (8):625-9. [Medline].

  8. Mueller A, Cupisti S, Binder H, Hoffmann I, Kiesewetter F, Beckmann MW, et al. Endocrinological markers for assessment of hyperandrogenemia in hirsute women. Horm Res. 2007. 67(1):35-41. [Medline].

  9. Unluhizarci K, Ozel D, Tanriverdi F, Karaca Z, Kelestimur F. A comparison between finasteride, flutamide, and finasteride plus flutamide combination in the treatment of hirsutism. J Endocrinol Invest. 2009 Jan. 32(1):37-40. [Medline].

  10. FDA News Release. Abbott Laboratories agrees to withdraw its obesity drug Meridia. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm228812.htm. Accessed: October 8, 2010.

  11. Ajossa S, Guerriero S, Paoletti AM, Orrù M, Melis GB. The treatment of polycystic ovary syndrome. Minerva Ginecol. 2004 Feb. 56(1):15-26. [Medline].

  12. Ali I, Dawber R. Hirsutism: diagnosis and management. Hosp Med. 2004 May. 65(5):293-7. [Medline].

  13. Amato MC, Galluzzo A, Merlino S, Mattina A, Richiusa P, Criscimanna A, et al. Lower insulin sensitivity differentiates hirsute from non-hirsute Sicilian women with polycystic ovary syndrome. Eur J Endocrinol. 2006 Dec. 155(6):859-65. [Medline].

  14. Archer JS, Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2004 Oct. 18(5):737-54. [Medline].

  15. Barbieri RL, Gargiulo AR. Metformin for the treatment of the polycystic ovary syndrome. Minerva Ginecol. 2004 Feb. 56(1):63-79. [Medline].

  16. Beigi A, Sobhi A, Zarrinkoub F. Finasteride versus cyproterone acetate-estrogen regimens in the treatment of hirsutism. Int J Gynaecol Obstet. 2004 Oct. 87(1):29-33. [Medline].

  17. Boronat M, Carrillo A, Ojeda A, et al. Clinical manifestations and hormonal profile of two women with Cushing's disease and mild deficiency of 21-hydroxylase. J Endocrinol Invest. 2004 Jun. 27 (6):583-90. [Medline].

  18. Carmina E. Mild androgen phenotypes. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):207-20. [Medline].

  19. Carmina E, Rosato F, Jannì A, Rizzo M, Longo RA. Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab. 2006 Jan. 91(1):2-6. [Medline].

  20. Cheewadhanaraks S, Peeyananjarassri K, Choksuchat C. Clinical diagnosis of hirsutism in Thai women. J Med Assoc Thai. 2004 May. 87(5):459-63. [Medline].

  21. Christy NA, Franks AS, Cross LB. Spironolactone for hirsutism in polycystic ovary syndrome. Ann Pharmacother. 2005 Sep. 39(9):1517-21. [Medline].

  22. Clayton WJ, Lipton M, Elford J, Rustin M, Sherr L. A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome. Br J Dermatol. 2005 May. 152 (5):986-92. [Medline].

  23. Curran DR, Moore C, Huber T. Clinical inquiries. What is the best approach to the evaluation of hirsutism?. J Fam Pract. 2005 May. 54(5):465-7. [Medline].

  24. Dawber RP. Guidance for the management of hirsutism. Curr Med Res Opin. 2005 Aug. 21(8):1227-34. [Medline].

  25. Dereli D, Dereli T, Bayraktar F, Ozgen AG, Yilmaz C. Endocrine and metabolic effects of rosiglitazone in non-obese women with polycystic ovary disease. Endocr J. 2005 Jun. 52(3):299-308. [Medline].

  26. DeUgarte CM, Woods KS, Bartolucci AA, Azziz R. Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. J Clin Endocrinol Metab. 2006 Apr. 91(4):1345-50. [Medline].

  27. Eberting CL, Javor E, Gorden P, Turner ML, Cowen EW. Insulin resistance, acanthosis nigricans, and hypertriglyceridemia. J Am Acad Dermatol. 2005 Feb. 52(2):341-4. [Medline].

  28. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med. 2005 Mar 24. 352(12):1223-36. [Medline].

  29. Glintborg D, Andersen M, Hagen C, Hermann AP. Higher bone mineral density in Caucasian, hirsute patients of reproductive age. Positive correlation of testosterone levels with bone mineral density in hirsutism. Clin Endocrinol (Oxf). 2005 Jun. 62(6):683-91. [Medline].

  30. Glintborg D, Henriksen JE, Andersen M, Hagen C, Hangaard J, Rasmussen PE, et al. Prevalence of endocrine diseases and abnormal glucose tolerance tests in 340 Caucasian premenopausal women with hirsutism as the referral diagnosis. Fertil Steril. 2004 Dec. 82(6):1570-9. [Medline].

  31. Glintborg D, Henriksen JE, Andersen M, Hagen C, Hangaard J, Rasmussen PE, et al. Prevalence of endocrine diseases and abnormal glucose tolerance tests in 340 Caucasian premenopausal women with hirsutism as the referral diagnosis. Fertil Steril. 2004 Dec. 82(6):1570-9. [Medline].

  32. Glintborg D, Hermann AP, Brusgaard K, Hangaard J, Hagen C, Andersen M. Significantly higher adrenocorticotropin-stimulated cortisol and 17-hydroxyprogesterone levels in 337 consecutive, premenopausal, Caucasian, hirsute patients compared with healthy controls. J Clin Endocrinol Metab. 2005 Mar. 90(3):1347-53. [Medline].

  33. Goodarzi MO, Shah NA, Antoine HJ, Pall M, Guo X, Azziz R. Variants in the 5alpha-reductase type 1 and type 2 genes are associated with polycystic ovary syndrome and the severity of hirsutism in affected women. J Clin Endocrinol Metab. 2006 Oct. 91(10):4085-91. [Medline].

  34. Guzelmeric K, Seker N, Unal O, Turan C. High serum prostate-specific antigen concentrations in hirsute women do not decrease with treatment by the combination of spironolactone and the contraceptive pill. Gynecol Endocrinol. 2004 Oct. 19(4):190-5. [Medline].

  35. Hahn S, Fingerhut A, Khomtsiv U, Khomtsiv L, Tan S, Quadbeck B, et al. The peroxisome proliferator activated receptor gamma Pro12Ala polymorphism is associated with a lower hirsutism score and increased insulin sensitivity in women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2005 May. 62(5):573-9. [Medline].

  36. Harper JC. Antiandrogen therapy for skin and hair disease. Dermatol Clin. 2006 Apr. 24(2):137-43, v. [Medline].

  37. Hart R, Hickey M, Franks S. Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2004 Oct. 18(5):671-83. [Medline].

  38. Hassa H, Tanir HM, Yildirim A, Senses T, Eskalen M, Mutlu FS. The hirsutism scoring system should be population specific. Fertil Steril. 2005 Sep. 84(3):778-80. [Medline].

  39. Hassa H, Tanir HM, Yildiz Z. Comparison of clinical and laboratory characteristics of cases with polycystic ovarian syndrome based on Rotterdam's criteria and women whose only clinical signs are oligo/anovulation or hirsutism. Arch Gynecol Obstet. 2006 Jul. 274(4):227-32. [Medline].

  40. Hoyt KL, Schmidt MC. Polycystic ovary (Stein-Leventhal) syndrome: etiology, complications, and treatment. Clin Lab Sci. 2004. 17(3):155-63. [Medline].

  41. Kazerooni T, Dehghan-Kooshkghazi M. Effects of metformin therapy on hyperandrogenism in women with polycystic ovarian syndrome. Gynecol Endocrinol. 2003 Feb. 17(1):51-6. [Medline].

  42. Kelestimur F, Everest H, Unluhizarci K, Bayram F, Sahin Y. A comparison between spironolactone and spironolactone plus finasteride in the treatment of hirsutism. Eur J Endocrinol. 2004 Mar. 150(3):351-4. [Medline].

  43. Keller J, Subramanyam L, Simha V, Gustofson R, Minjarez D, Garg A. Lipodystrophy: an unusual diagnosis in a case of oligomenorrhea and hirsutism. Obstet Gynecol. 2009 Aug. 114(2 Pt 2):427-31. [Medline]. [Full Text].

  44. Lipton MG, Sherr L, Elford J, Rustin MH, Clayton WJ. Women living with facial hair: the psychological and behavioral burden. J Psychosom Res. 2006 Aug. 61(2):161-8. [Medline].

  45. Mermejo LM, Elias LL, Marui S, Moreira AC, Mendonca BB, de Castro M. Refining hormonal diagnosis of type II 3beta-hydroxysteroid dehydrogenase deficiency in patients with premature pubarche and hirsutism based on HSD3B2 genotyping. J Clin Endocrinol Metab. 2005 Mar. 90(3):1287-93. [Medline].

  46. Moghetti P, Toscano V. Treatment of hirsutism and acne in hyperandrogenism. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):221-34. [Medline].

  47. Raja A, Hashmi SN, Sultana N, Rashid H. Presentation of polycystic ovary syndrome and its management with clomiphene alone and in combination with metformin. J Ayub Med Coll Abbottabad. 2005 Apr-Jun. 17(2):50-3. [Medline].

  48. Randall VA, Lanigan S, Hamzavi I, et al. New dimensions in Hirsutism. Lasers Med Sci. 2006 Sep. 21(3):126-33. [Medline].

  49. Sagsoz N, Kamaci M, Orbak Z. Body hair scores and total hair diameters in healthy women in the Kirikkale Region of Turkey. Yonsei Med J. 2004 Jun 30. 45(3):483-91. [Medline].

  50. Sahin Y, Kelestimur F. Medical treatment regimens of hirsutism. Reprod Biomed Online. 2004 May. 8(5):538-46. [Medline].

  51. Scheinfeld N. Impact of phenytoin therapy on the skin and skin disease. Expert Opin Drug Saf. 2004 Nov. 3(6):655-65. [Medline].

  52. Souter I, Sanchez LA, Perez M, Bartolucci AA, Azziz R. The prevalence of androgen excess among patients with minimal unwanted hair growth. Am J Obstet Gynecol. 2004 Dec. 191(6):1914-20. [Medline].

  53. Souter I, Sanchez LA, Perez M, Bartolucci AA, Azziz R. The prevalence of androgen excess among patients with minimal unwanted hair growth. Am J Obstet Gynecol. 2004 Dec. 191(6):1914-20. [Medline].

  54. Stanczyk FZ. Diagnosis of hyperandrogenism: biochemical criteria. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):177-91. [Medline].

  55. Taponen S, Ahonkallio S, Martikainen H, Koivunen R, Ruokonen A, Sovio U, et al. Prevalence of polycystic ovaries in women with self-reported symptoms of oligomenorrhoea and/or hirsutism: Northern Finland Birth Cohort 1966 Study. Hum Reprod. 2004 May. 19(5):1083-8. [Medline].

  56. Tekin O, Avci Z, Isik B, Ozkara A, Uraldi C, Catal F, et al. Hirsutism: common clinical problem or index of serious disease?. MedGenMed. 2004 Oct 15. 6(4):56. [Medline].

  57. Tok EC, Ertunc D, Evruke C, Dilek S. The androgenic profile of women with non-insulin-dependent diabetes mellitus. J Reprod Med. 2004 Sep. 49(9):746-52. [Medline].

  58. Townsend KA, Marlowe KF. Relative safety and efficacy of finasteride for treatment of hirsutism. Ann Pharmacother. 2004 Jun. 38(6):1070-3. [Medline].

  59. Vergoulas G, Eleftheriadis T, Avdelidou A, Ioannou K, Miserlis G, Solonaki F, et al. Body dysmorphic disorder due to hirsutism in a patient treated with cyclosporin. Nephrol Dial Transplant. 2005 Feb. 20(2):473. [Medline].

  60. Watts J. Understanding the causes and management of hirsutism. Nurs Times. 2006 Feb 21-27. 102(8):26-8. [Medline].

  61. Wild RA, Vesely S, Beebe L, Whitsett T, Owen W. Ferriman Gallwey self-scoring I: performance assessment in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2005 Jul. 90(7):4112-4. [Medline].

  62. Yildiz BO. Diagnosis of hyperandrogenism: clinical criteria. Best Pract Res Clin Endocrinol Metab. 2006 Jun. 20(2):167-76. [Medline].

  63. Zawar V, Sankalecha C. Facial hirsutism following danazol therapy. Cutis. 2004 Nov. 74(5):301-3. [Medline].

Previous
Next
 
Idiopathic hirsutism in an elderly woman.
The photograph depicts hirsutism in a young woman with polycystic ovary syndrome. Note the acne lesions and excessive hair on her face and neck.
The photograph depicts familial hirsutism in a Pakistani woman.
Etiologic diagnosis of hirsutism.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.