Hirsutism Treatment & Management

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. ^[18] 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 ^[19] ): 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. A study by Shrimal et al reported that idiopathic facial hirsutism can be more effectively treated with a long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (1064 nm) than with intense pulsed light (IPL)–755 nm. After six sessions, 14 of the 15 women who underwent laser therapy (93.3%) experienced hair reduction of more than 75%, compared with three of the 18 patients treated with IPL (16.7%). Moreover, erythema, perifollicular edema, and hyperpigmentation occurred in 26.7%, 13.3%, and 13.3% of the laser group, respectively, compared with 50.0%, 16.7%, and 38.9% of the IPL patients, respectively. ^[20]