Last updated December 18, 2021

Hirsutism in Premenopausal Women

Recommendations

Diagnosis of hirsutism

We suggest testing for elevated androgen levels in all women with an abnormal hirsutism score (2 |⊕⊕OO). In those cases where serum total testosterone levels are normal, if sexual hair growth is moderate/severe or sexual hair growth is mild but there is clinical evidence of a hyperandrogenic endocrine disorder (such as menstrual disturbance or progression in spite of therapy), we suggest measuring an early morning serum total and free testosterone by a reliable specialty assay. (2-L)
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We suggest screening hyperandrogenemic women for NCCAH due to 21-hydroxylase deficiency by measuring early morning 17-hydroxyprogesterone levels in the follicular phase or on a random day for those with amenorrhea or infrequent menses (2 |⊕⊕OO). In hirsute patients with a high risk of congenital adrenal hyperplasia (positive family history, member of a high-risk ethnic group), we suggest this screening even if serum total and free testosterone are normal. (2-L)
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We suggest against testing for elevated androgen levels in eumenorrheic women with unwanted local hair growth (i.e., in the absence of an abnormal hirsutism score) because of the low likelihood of identifying a medical disorder that would change management or outcome. (2-L)
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Treatment of hirsutism in premenopausal women

For most women with patient-important hirsutism despite cosmetic measures, we suggest starting with pharmacological therapy. (2-VL)
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For hirsute women with obesity, including those with polycystic ovary syndrome, we also recommend lifestyle changes. (1-L)
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Pharmacological treatments

Initial therapies

For the majority of women with hirsutism who are not seeking fertility, we suggest oral contraceptives as initial therapy for treating patient-important hirsutism. (2-L)
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For most women with hirsutism, we suggest against antiandrogen monotherapy as initial therapy (because of the teratogenic potential of these medications) unless these women use adequate contraception (2 |⊕OOO). 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. (2-VL)
The choice between these options depends on patient preferences regarding efficacy, side effects, and cost.
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For most women, we do not suggest one oral contraceptive over another as initial therapy, as all oral contraceptives appear to be equally effective for hirsutism, and the risk of side effects is low. (2-L)
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For women with hirsutism at higher risk for venous thromboembolism (e.g., those who are obese or over age 39 years), we suggest initial therapy with an oral contraceptive containing the lowest effective dose of ethinyl estradiol (usually 20 mcg) and a low-risk progestin. (2-VL)
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 If patient-important hirsutism remains despite 6 months of monotherapy with an oral contraceptive, we suggest adding an antiandrogen. (2-L)
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We do not suggest one antiandrogen over another. (2-L)
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However, we recommend against the use of flutamide because of its potential hepatotoxicity. (1-L)
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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 medication. (2-VL)
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In patients with severe hirsutism causing emotional distress and/or in those women who have used oral contraceptives in the past and have not experienced sufficient improvement, we suggest initiating combination therapy with an oral contraceptive and antiandrogen. (2-L)
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However, we suggest against combination therapy as a standard first-line approach. (2-L)
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Other drug therapies

We suggest against using insulin-lowering drugs for the sole indication of treating hirsutism. (2-L)
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We suggest 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. (2-VL)
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We suggest against the use of topical antiandrogen therapy for hirsutism. (2-VL)
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Direct hair removal methods

For women who choose hair removal therapy, we suggest photoepilation for those whose unwanted hair is auburn, brown, or black, and we suggest electrolysis for those with white or blonde hair. (2-L)
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For women of color who choose photoepilation treatment, we suggest using a long-wavelength, long pulse-duration light source such as Nd:YAG or diode laser delivered with appropriate skin cooling. (2-VL)
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Clinicians should warn Mediterranean and Middle Eastern women with facial hirsutism about the increased risk of developing paradoxical hypertrichosis (PH) with photoepilation therapy. We suggest topical treatment or electrolysis over photoepilation with these patients. (2-L)
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For women who desire more rapid response to photoepilation, we suggest adding eflornithine topical cream during treatment. (2-L)
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For women with known hyperandrogenemia who choose hair removal therapy, we suggest pharmacologic therapy to minimize hair regrowth. (2-L)
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Recommendation Grading

Overview

Title

Evaluation and Treatment of Hirsutism in Premenopausal Women

Authoring Organization

Publication Month/Year

March 7, 2018

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory

Scope

Assessment and screening, Diagnosis, Treatment

Diseases/Conditions (MeSH)

D000728 - Androgens, D006628 - Hirsutism

Keywords

androgen, hirsutism, hair

Source Citation

Kathryn A Martin, R Rox Anderson, R Jeffrey Chang, David A Ehrmann, Rogerio A Lobo, M Hassan Murad, Michel M Pugeat, Robert L Rosenfield, Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 103, Issue 4, April 2018, Pages 1233–1257, https://doi.org/10.1210/jc.2018-00241