Pharmacotherapies for the treatment of hirsutism

Hirsutism is a condition that affects up to 20% of women and features excessive body hair in a male pattern distribution. It can cause significant psychological and sexual distress and is a common presentation in medical professionals such as endocrinologists, gynecologists, and dermatologists.

In this article, the authors discuss the definition, causes, and diagnosis of hirsutism and the available pharmacotherapy options with an evaluation of the evidence, consensus opinions, and guidelines to date. They also outline physical therapies that can be recommended along with medical treatments.

The authors recommend combined oral contraceptive pills (OCP) as the first-line therapy for hirsutism, with the addition of oral antiandrogens for severe cases. Antiandrogens and OCPs remain the most effective pharmacotherapy for hirsutism. However, insulin sensitizers such as metformin are the least effective. Further, it is crucial to combine medical treatments with physical therapies for optimal management and provide psychological support for patients with associated psychosocial morbidity.

Overall, the article provides expert opinions and insights into managing hirsutism, emphasizing the importance of a holistic approach in treating this condition.

KEY POINTS-

 The primary causes of hirsutism are idiopathic hirsutism and polycystic ovarian syndrome (PCOS).

 Additional dermatological signs of hyperandrogenism include acne/seborrhea and androgenetic alopecia.

 A full workup and expert review is mandated for pediatric/adolescent symptoms, rapid onset of hirsutism, and new onset virilization.

 In certain cases, a multidisciplinary approach involving dermatologists, endocrinologists, and gynecologists may be necessary.

 While robust evidence for the efficacy of pharmacological treatments of hirsutism is lacking, current guidelines recommend physical hair removal methods for mild disease. 

 It is crucial to consider the patient's perception of their hirsutism and the level of distress experienced to guide management.

 For moderate hirsutism, the recommended treatment is to start with an OCP and add an antiandrogen if no improvement is seen after six months. It is not recommended to start on antiandrogen monotherapy due to the risk of teratogenicity. Combination therapy of COCP and antiandrogen therapy may be more effective.

Asfour L, Kazmi A, Sinclair R. An evaluation of the available pharmacotherapy for the treatment of hirsutism. Expert Opinion on Pharmacotherapy. 2023. DOI: 10.1080/14656566.2023.2198088