Treatment
➤ For most women with patient-important hirsutism despite cosmetic measures,
ES suggests starting with pharmacological therapy (2|⊕
).
• For women who then desire additional cosmetic benefit, ES suggests adding direct
hair removal methods. However, for women with mild hirsutism and no evidence of
an endocrine disorder, ES suggests either approach. (2|⊕
)
➤ For hirsute women with obesity, including those with polycystic ovary
syndrome, ES also recommends lifestyle changes. (1|⊕⊕
)
Pharmacological Treatments
Initial Therapies
➤ For the majority of women with hirsutism who are not seeking fertility, ES
suggests OCs as initial therapy for treating patient-important hirsutism.
(2|⊕⊕
)
➤ For most women with hirsutism, ES suggests against antiandrogen
monotherapy as initial therapy (because of the teratogenic potential of these
medications) unless these women use adequate contraception (2|⊕
).
• However, for women who are not sexually active, have undergone permanent
sterilization, or who are using long-acting reversible contraception, ES suggests using
either OCs or antiandrogens as initial therapy (2|⊕
).
Note: The choice between these options depends on patient preferences regarding efficacy,
side effects, and cost.
➤ For most women, ES does not suggest one oral contraceptive over another as
initial therapy, as all OCs appear to be equally effective for hirsutism, and the
risk of side effects is low. (2|⊕⊕
)
➤ For women with hirsutism at higher risk for venous thromboembolism (e.g.,
those who are obese or over age 39 years), ES suggests initial therapy with
an OC containing the lowest effective dose of ethinyl estradiol (EE) (usually
20 mcg) and a low-risk progestin (Table 2). (2|⊕
)
➤ If patient-important hirsutism remains despite 6 months of monotherapy with
an OC, ES suggests adding an antiandrogen. (2|⊕⊕
)
➤ ES does not suggest one antiandrogen over another (2|⊕⊕
). However,
we recommend against the use of flutamide because of its potential
hepatotoxicity. (1|⊕⊕
)
➤ For all pharmacologic therapies for hirsutism, ES suggests a trial of at least
6 months before making changes in dose, switching to a new medication, or
adding medication. (2|⊕
)
