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.
Insulin sensitizers
Metformin (Glucophage) and other insulin sensitizers are less effective than antiandrogens at reducing hirsutism.20,38 However, metformin is effective at inducing ovulation in patients with polycystic ovary syndrome.38 Gastrointestinal upset is a common side effect; lactic acidosis is a serious but rare adverse effect.1
Gonadotropin-releasing hormone analogues
GnRH analogues are an option only if oral contraceptives and antiandrogen drugs are unsuccessful in patients with severe hyperandrogenism. 20 They suppress secretion of luteinizing hormone and the synthesis of ovarian androgen.1,20 These drugs are given as monthly intramuscular injections, usually with some form of estrogen-progestin replacement, since GnRH analogues cause estrogen levels to fall to menopausal levels.1
Side effects include signs and symptoms of menopause including hot flushes, atrophic vaginitis, and osteoporosis.1,15 These drugs completely inhibit ovulation, and some endocrinologists and gynecologists do not suggest further contraception in women of childbearing years for this reason. However, GnRH analogues are not approved as a contraceptive and are pregnancy category X.
Other drugs
Other drugs with antiandrogen activity include cimetidine and ketoconazole.12 Cimetidine (Tagamet) is not effective for the treatment of hirsutism, and ketoconazole (Nizoral) is associated with significant risk for adrenocortical suppression12 and hepatotoxicity in addition to multiple drug interactions, given its effect on the hepatic P450 enzyme system.
Acknowledgment: Many thanks to Rebecca Tung, MD, dermatologic surgeon, Cleveland Clinic, for her advice on lasers.
