Update on the management of hirsutism
ABSTRACTHirsutism is a source of significant anxiety in women. While polycystic ovary syndrome or other endocrine conditions are responsible for excess androgen in many patients, other patients have normal menses and normal androgen levels (“idiopathic” hirsutism). The goal of the evaluation is to rule out any underlying pathology. The goals of therapy are to treat any underlying condition and to remove the excess hair. Current options for hair removal are discussed. Educating patients so they have reasonable treatment expectations is essential, as significant improvement may take weeks or months, and treatment may need to be repeated on an ongoing basis.
KEY POINTS
- The finding of polycystic ovaries is not required for the diagnosis of polycystic ovary syndrome, nor does their presence prove the diagnosis. Gonadotropin-dependent functional ovarian hyperandrogenism is believed to cause this syndrome; however, mild adrenocorticotropic-dependent functional adrenal hyperandrogenism also is a feature in many cases.
- Even women with mild hirsutism with subtle symptoms and signs of hyperandrogenism can have elevated androgen levels, and thus, they deserve a laboratory evaluation.
- Laser treatment does not result in complete, permanent hair reduction, but it is more effective than shaving, waxing, and electrolysis, producing partial hair reduction for up to 6 months.
Clinic-based methods
Electrolysis often results in a permanent reduction in hair growth.1,32 A fine needle is placed into the hair follicle and an electrical current is applied. Each follicle is treated individually. 1,32 Best results are seen on darker hairs in patients with lighter skin, but it can be used on all skin types and hair colors.1,32
Electrolysis is operator-dependent, and there are US Food and Drug Administration (FDA) regulations regarding electrolysis techniques. It requires multiple treatments, and it is painful and can cause erythema, folliculitis, pseudofolliculitis, infection, scarring, and postinflammatory dyspigmentation.1,32 Some reports suggest that prior waxing and plucking of hairs damages the hair by twisting the hair shaft, making electrolysis more difficult.32
Laser treatment uses light of certain wavelengths to damage the hair follicles. While laser hair removal does not result in complete or persistent hair removal, it is more effective than shaving, waxing, and electrolysis, producing partial hair reduction for up to 6 months; the effect is enhanced with multiple treatments.33,34 The number of treatments required depends on the laser type and on the nature of the patient’s hair follicles.35
Laser systems for hair removal are of various wavelengths and also include intense pulsed light systems. The choice of system depends on the patient’s skin type and hair color. Women with fair skin and dark hair are ideal candidates; longer-wavelength lasers are preferred for darker or tanned skin types.
Adverse effects of laser hair removal include pain, erythema, burns, dyspigmentation, and scarring. Laser cooling devices can prevent or minimize some of these effects. Laser treatment has also been known to cause a paradoxical increase in hair growth.1,33,34
DRUG THERAPIES FOR HIRSUTISM
The drugs most commonly used for hirsutism are oral contraceptives (off-label use) and antiandrogenic drugs (off-label use). Topical eflornithine cream (Vaniqa) is FDA-approved for hirsutism but is less commonly used. Insulin sensitizers, GnRH analogues, and other drugs are occasionally used (off-label) to treat hirsutism.
Topical eflornithine cream
Topical eflornithine cream treats facial hirsutism by slowing the rate of hair growth; it does this by irreversibly inhibiting ornithine decarboxylase, an enzyme essential for hair growth.39,40 Studies showed that twice-daily application reduced unwanted facial hair in women after 24 weeks of treatment.39,40 Treatment must be continuous, since hair growth rapidly returns to the pretreatment rate by 8 weeks after discontinuing eflornithine.39,40 White women have been shown to respond better than black women.39 Adverse effects include a mild burning sensation, acne, pseudofolliculitis barbae, irritation, and allergic contact dermatitis.39,40 Improved outcomes have been suggested when eflornithine cream is combined with laser hair removal.41
Oral contraceptives
Oral contraceptives are commonly used off-label for the management of hirsutism.20 Oral contraceptives suppress the secretion of luteinizing hormone and, hence, the synthesis of ovarian androgen, thereby increasing levels of sex hormone-binding globulin and decreasing free plasma testosterone.1,20 Adrenal androgen production is also slightly reduced.20
Oral contraceptives usually combine a synthetic estrogen and a progestin. Certain progestins are more androgenic and should be avoided.1
For treating hirsutism, oral contraceptives should be used that contain low-androgenic progestins such as cyproterone acetate (not available in the United States), drosperinone (eg, in Yasmin), norgestimate (eg, in Ortho Tri-Cyclen), or desogestrel (eg, in Mircette).1,20
Side effects of oral contraceptives include breast tenderness, gastrointestinal upset, headache, loss of libido, hypertension, and the potential risk of venous thromboembolism.1,15,32,36
Antiandrogenic drugs
Several antiandrogenic drugs are used off-label to treat hirsutism.
Spironolactone (Aldactone), a competitive inhibitor of the androgen receptor and 5-alpha reductase activity,20 can be effective in the treatment of hirsutism. Monotherapy with spironolactone, without an oral contraceptive or other reliable form of contraception, is not recommended because of the teratogenic potential of all antiandrogens to feminize a developing male fetus.20 Thus, reliable contraception should be used in females of childbearing age when starting antiandrogen therapy.
The dosage of spironolactone for hirsutism is usually 100 mg to 200 mg daily.1,20 Hyperkalemia, polyuria, postural hypotension, irregular menses, and liver abnormalities are among the possible adverse effects (Table 3). Spironolactone was found to be tumorigenic in animal studies, although this has unknown relevance in humans.36
Cyproterone, an antiandrogen not available in the United States,42 competitively inhibits the androgen receptor and 5-alpha-reductase activity.1,20,36 It can be used for only the first 10 days of the menstrual cycle (50-mg or 100-mg dose) with an oral contraceptive pill, or in a low dose in a combined oral contraceptive pill (Diane-35 in Canada and the United Kingdom).1
Side effects are similar to those of oral contraceptives and include fatigue, mood change, risk of venous thromboembolism, and decreased libido.1,15,36 Importantly, in woman of childbearing age, there is the potential risk of feminization of a male fetus, so reliable contraception must be used.15,36
Flutamide, an investigational antiandrogen, has shown promise in the treatment of hirsutism.20 Flutamide is a nonsteroidal competitive inhibitor of androgen receptor binding. It carries a significant risk of hepatotoxicity. 1,15
Finasteride (Propecia) 1 mg is only occasionally used in the treatment of hirsutism (off-label usage). It inhibits type II 5-alphareductase to suppress dihydrotestosterone levels. 32 It carries a risk of gastrointestinal disturbance, decreased libido, hepatotoxicity, and feminization of a male fetus (pregnancy category X), so reliable contraception is required in all females of childbearing age, as with all antiandrogens1 (Table 3).
Dutasteride (Avodart), a type I and II 5-alpha-reductase inhibitor, has not been studied for the treatment of hirsutism (pregnancy category X).
