Updated Guidelines on Hirsutism in Premenopausal Women

An updated clinical guideline from the Endocrine Society recommends all women with hirsutism who are premenopausal should be tested for polycystic ovary syndrome (PCOS) and other underlying health issues.

The guidance was published online March 7 in the Journal of Clinical Endocrinology & Metabolism and is cosponsored by the Androgen Excess and PCOS Society and European Society of Endocrinology. It updates the 2008 guideline.

"Excess facial or body hair is not only distressing to women, it is often a symptom of an underlying medical problem," lead author Kathryn A Martin, MD, from Massachusetts General Hospital in Boston, and chair of the task force that authored the guideline, said in a Endocrine Society news release. "It is important to see your health care provider to find out what is causing the excess hair growth and treat it."

"Hirsutism affects 5% to 10% of women," say Martin and colleagues, and "as it is common, often associated with an underlying endocrine disorder, and associated with significant personal distress, treatment is appropriate for most women who present with this problem."

"In this current version, we have attempted to address several issues, as well as incorporate insights from relevant studies published since the 2008 guideline," they explain.

Diagnosis of Hirsutism

The authors have broadened the previous recommendation for measuring serum total testosterone concentration to include all women with hirsutism. The guideline had previously recommended testing only for women with moderate to severe hirsutism.

They also broadened the recommendation for measuring the serum-free testosterone concentration to include women with normal serum total testosterone in whom moderate to severe hirsutism or other clinical evidence of hyperandrogenemia, such as progressive growth of hair in androgen-dependent areas, is also present.

Other changes include an advisory to screen women with hyperandrogenemia for nonclassic congenital adrenal hyperplasia (NCCAH) resulting from 21-hydroxylase deficiency by measuring early morning 17-hydroxyprogesterone levels during the follicular phase, or on a random day for women with amenorrhea or infrequent menses.

And hirsute women with a high risk for NCCAH, such as having a positive family history or belonging to a high-risk ethnic group, should still undergo screening for NCCAH, even if their serum total and free testosterone levels are normal.

The authors do not recommend testing eumenorrheic women with unwanted local hair growth (that is, in the absence of an abnormal hirsutism score) for elevated androgen levels, as the probability of finding a medical disorder that would change the patient's management or outcome "is low," they say.

Updated Treatment Recommendations

Mildly hirsute women without evidence of an endocrine disorder should be treated with pharmacologic therapy (first choice, an oral contraceptive) initially or direct hair removal methods.

Women with patient-important hirsutism should initially receive pharmacological therapy, with direct hair removal methods such as laser removal or photoepilation added if necessary.

It is also reasonable to use combined pharmacological therapy (oral contraceptives and antiandrogens) initially for certain women with severe, distressing hirsutism.

The authors added a recommendation for lower estrogen dose oral contraceptives with low-risk progestins in women with higher venous thromboembolism risk, such as those who are obese or older than 39 years.

For other women, the approach is unchanged from the original guideline, and the guideline does not favor one oral contraceptive formulation over another.

The recommendation against using flutamide for hirsutism is stronger than the 2008 recommendation.

The authors suggest using electrolysis rather than photoepilation for women with blond or white hair who desire direct hair removal methods and they include guidance for, and potential complications of, photoepilation in women of color.

The authors also cite a meta-analysis of four studies that included 132 participants with obesity and PCOS which found that patients who implemented lifestyle changes including diet, exercise, behavioral, or combination therapy, experienced weight loss, and decreased serum testosterone and fasting insulin concentrations, and slightly improved hirsutism, compared with women who received minimal or no treatment.

Therefore, they have added a recommend for similar lifestyle changes for women with obesity and hirsutism.

"However, lifestyle changes should not be considered a primary therapy for hirsutism, as their impact is not clinically significant, particularly when compared with oral contraceptives. Our approach is consistent with the Endocrine Society clinical guidelines on the diagnosis and treatment of PCOS," they explain.

Stepwise Therapy

The guideline recommends oral combined estrogen-progestin contraceptives for most women, with the addition of an antiandrogen after 6 months in patients with suboptimal response.

"For all pharmacologic therapies for hirsutism, we suggest a trial of at least 6 months before making changes in dose, switching to a new medication, or adding a medication," they advise.

And antiandrogen monotherapy is not recommended unless the woman uses adequate contraception as these medications are potentially teratogenic.

"However, for women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception, we suggest using either oral contraceptives or antiandrogens as initial therapy. The choice between these options depends on patient preferences regarding efficacy, side effects, and cost," they explain.

And they recommend against using insulin-lowering drugs for the sole indication of treating hirsutism. They also advise against using gonadotropin-releasing hormone agonists except in women with severe forms of hyperandrogenemia (such as ovarian hyperthecosis) who have a suboptimal response to oral contraceptives and antiandrogens. And they advise against the use of topical antiandrogen therapy for hirsutism.

One task force member reports receiving speaker fees from Pfizer. The other task force members have reported no relevant financial relationships.

JCEM. Published online March 7, 2018. Full text

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