New guidelines released for the treatment of hirsutism

A task force developed by the Endocrine Society has issued new clinical practice guidelines for the diagnosis and treatment of hirsutism in premenopausal women. The guidelines were published in the Journal of Clinical Endocrinology and Metabolism.

“Hirsutism is a very common problem and all endocrinologists treat it, but we are often unsure about the evidence that drives our decision-making. These guidelines provide practical, evidence-based recommendations for both drug therapy and direct hair removal methods,” Kathryn Martin, MD, chair of the Society’s task force, told Endocrine Today.

The task force developed diagnostic and treatment recommendations using data from systematic reviews and the Grading of Recommendations, Assessment, Development and Evaluation criteria.

Making a diagnosis

When diagnosing hirsutism, the task force recommended testing for elevated androgen levels in women with moderate or severe hirsutism. They also suggested testing women with any degree of hirsutism when onset is sudden, it is rapidly progressive or associated with any of the following:

• menstrual irregularity or infertility;
• central obesity;
• acanthosis nigricans;
• rapid progression; or
• clitoromegaly.

The task force did not recommend that women with isolated mild hirsutism be tested for elevated androgen levels because identifying a medical disorder that would change management or outcome is unlikely, as stated in the study.

As a first test, the task force recommended obtaining an early morning plasma total testosterone level. In cases where total testosterone is normal but risk factors for hyperandrogenism are present or hirsutism progresses, the task force suggested an early morning plasma total and free testosterone test.

Suggested treatment options

Martin and her colleagues suggested pharmacological therapy or direct hair removal to treat patient-important hirsutism in premenopausal women. Physicians should choose between these two options based on: patient preferences; the amenability of direct hair removal in the area of hirsutism; and access to and affordability of the two choices, they wrote in the study.

“For pharmacologic therapy we suggest oral contraceptives for the majority of women, adding an anti-androgen after six months if the response is suboptimal,” Martin said. “We suggest against using insulin-lowering drugs. For women who choose hair removal therapy, we suggest laser/photoepilation.”

The task force did not support the use of antiandrogens if a contraceptive is not used concurrently due to the potential risk antiandrogens pose on the sexual development of male fetuses. Martin and colleagues also suggested against using flutamide and topical antiandrogen therapy. They suggested against the routine use of glucocorticoids except in women with nonclassic congenital adrenal hyperplasia who have not responded to other medical therapies or who are undergoing ovulation induction. They also suggested against GnRH agonists except in some or severe forms of hyperandrogenemia.

Regardless of the type of monotherapy chosen, the Society recommended a six-month trial before changing dosage or medication or adding medication.

For women who choose direct hair removal methods, the task force suggested the use of laser/photoepilation methods over electrolysis. Although photoepilation is more expensive per treatment session, it is more efficient and less painful, Martin said. – by Stacey L. Adams

Hirsutism is a common problem for many women, and frequently results in referral to endocrinologists. The clinician must judge the patient’s level of concern, the rapidity of development, progression and severity when deciding whether to evaluate and how to treat. This systematic review of the diagnosis and management of hirsutism in premenopausal women by a panel of seven experts, two technical experts and a medical writer is thorough and practical. In addition to providing evidence-based recommendations regarding systemic treatments, it also provides recommendations for direct hair removal therapy.

– Glenn R. Cunningham, MD

Endocrine Today Editorial Board member

For more information:

• Martin KA, Chang RJ, Ehrmann DA, et al. Evaluation and treatment of hirsutism in premenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93:1105-1120.