Last updated March 31, 2022

Hirsutism in Premenopausal Women

Diagnosis

Endocrine Society (ES) suggests testing for elevated androgen levels in all women with an abnormal hirsutism score. (2-L)
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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), ES suggests measuring an early morning serum total and free testosterone by a reliable specialty assay. (2-L)
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ES suggests screening hyperandrogenemic women for nonclassical congenital adrenal hyperplasia (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-L)
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In hirsute patients with a high risk of congenital adrenal hyperplasia (positive family history, member of a high-risk ethnic group), ES suggests this screening even if serum total and free testosterone are normal. (2-L)
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ES suggests 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

For most women with patient-important hirsutism despite cosmetic measures, ES suggests starting with pharmacological therapy. (2-VL)
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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-VL)
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For hirsute women with obesity, including those with polycystic ovary syndrome, ES also recommends lifestyle changes. (1-L)
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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-L)
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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-VL )
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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-VL)
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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-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), 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-VL)
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If patient-important hirsutism remains despite 6 months of monotherapy with an OC, ES suggests adding an antiandrogen. (2-L)
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ES does 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, ES suggests 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 OCs in the past and have not experienced sufficient improvement, ES suggests initiating combination therapy with an oral contraceptive and antiandrogen. (2-L)
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However, ES suggests against combination therapy as a standard first-line approach. (2-L)
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Other Drug Therapies

ES suggests against using insulin-lowering drugs for the sole indication of treating hirsutism. ( 2-L )
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ES suggests against using gonadotropin-releasing hormone (GnRH) agonists except in women with severe forms of hyperandrogenemia (such as ovarian hyperthecosis) who have a suboptimal response to OCs and antiandrogens. ( 2-VL )
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ES suggests against the use of topical antiandrogen therapy for hirsutism. ( 2-VL )
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Direct Hair Removal Method

For women who choose hair removal therapy, ES suggests photoepilation for those whose unwanted hair is auburn, brown, or black, and ES suggests electrolysis for those with white or blonde hair. (2-L)
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For women of color who choose photoepilation treatment, ES suggests 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. ES suggests topical treatment or electrolysis over photoepilation with these patients. (2-L)
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For women who desire more rapid response to photoepilation, ES suggests adding eflornithine topical cream during treatment. ( 2-L )
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For women with known hyperandrogenemia who choose hair removal therapy, ES suggests 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

Intended Users

Nurse, nurse practitioner, physician, physician assistant

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