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Management of Hirsutism in a PCOS Patient

Author: Camille A. Clare, MD, MPH

Mentor: Lisa M. Keder, MD, MPH
Editor: Elizabeth Ferries-Rowe, MD

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Hirsutism is often a primary complaint in women with PCOS. The most effective treatment includes a long-term approach that reduces androgen receptor activity, thus decreasing new terminal hair development, and the removal of existing terminal hairs. Treatment should be based on the amount of distress that hirsutism causes the patient.  The degree of hirsutism and effectiveness of therapy may be guided by the modified Ferriman-Gallwey score. This index is a clinical method of evaluating and quantifying body hair growth in women. A score of 1 to 4 is given for nine areas of the body. A total score of less than 8 is considered normal in white or black women, less than 9 for Mediterranean, Hispanic, and Middle Eastern women, and less than 2 for Asian women. A score of 0 indicates the absence of terminal hair.

Medical interventions to decrease hair growth include the suppression of androgen excess by using combined oral contraceptives (COCs). This medication reduces androgen production by the suppression of circulating luteinizing hormone and follicle stimulating hormone and decrease free testosterone by stimulating sex hormone binding globulin production. Moderate and severe hirsutism may require the addition of systemic anti-androgens to COCs.

Spironolactone is the most commonly used androgen blocker.  It competes with dihydrotestosterone (DHT) by binding to the androgen receptor and inhibits enzymes involved in androgen production. Finasteride inhibits the conversion of testosterone to DHT. Flutamide is a nonsteroidal androgen receptor antagonist that has been used for hirsutism but is not recommended due to potential hepatotoxicity. When used without COCs, other effective methods of contraception are needed secondary to teratogenicity. Insulin-sensitizing agents, such as metformin, have not been shown to have clinically significant effects on hirsutism. Long-acting gonadotropin-releasing hormone analogs are reserved for patients who do not respond to or who cannot tolerate other therapy.

Eflornithine is a topical facial cream that inhibits the enzyme ornithine decarboxylase to treat hair that is already present. Improvement in hirsutism has been shown in 60% of patients after 6 months of use. Eflornithine plus laser treatment is superior to laser alone. Hair removal (shaving, plucking, waxing, depilatory creams, electrolysis, and laser vaporization) is often needed in addition to medical therapy. Patients should be advised to avoid the plucking of hairs to prevent scarring, pigmentation, and folliculitis. Laser treatment and intense pulsed light are methods of photoepilation, which generally require multiple sessions to achieve adequate results.  Limited studies have found laser treatment to be more effective than electrolysis. Women with dark hair and light skin are better candidates for laser therapy, especially during the anagen phase of hair growth. Electrolysis is intended to result in permanent hair removal by the destruction of the follicle, but is painful and technically difficult, and best suited to treatment of small areas.  

Further Reading:

ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin No. 108: Polycystic ovary syndrome. Obstet Gynecol. 2018 June;114(4):936-49. doi: 10.1097/AOG.0b013e3181bd12cb.

Goodman NF, Cobin RH, Futterweit W, et al., American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society: Disease state clinical review – Guide to the best practices in the evaluation and treatment of polycystic ovary syndrome.  Part 1. Endocr Pract. 2015 Nov;21(11):1291-300. doi: 10.4158/EP15748.DSC.

Initial approval March 2018 Reaffirmed January 2020; Reaffirmed September 2021. Minor Revision July 2023


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