An evaluation of the available pharmacotherapy for the treatment of hirsutism

ABSTRACT

Introduction

Hirsutism is the presence of excessive body hair in a male pattern distribution in a woman, and can affect up to 20% of women. It can be associated with high levels of psychosocial and psychosexual morbidity. It is a common cause for presentation to medical staff, particularly endocrinologists, gynecologists, and dermatologists.

Areas covered

The authors discuss the definition, causes, and diagnosis of hirsutism. Current and evolving pharmacotherapy is available for hirsutism with an evaluation of the available evidence, consensus opinions, and guidelines to date. Physical therapies that can be recommended in combination with medical pharmacotherapies are also outlined.

Expert opinion

Combined oral contraceptive pills (OCP) are recommended as first-line therapy. The addition of oral antiandrogens can be combined for severe cases. Antiandrogens and OCPs have been demonstrated to be the most effective pharmacotherapy available in improving hirsutism. Greater insight is being achieved in the use of antiandrogens and their role in managing hyperandrogenism states such as hirsutism. Insulin sensitizers such as metformin are found to be the least effective. Medical treatments for hirsutism often need to be combined with physical therapies for optimal management. Psychological support should be considered in patients with associated psychosocial morbidity.

KEYWORDS:

• Hirsutism
• hypertrichosis
• hyperandrogenism
• antiandrogens
• hair disorders
• pharmacotherapy

Article highlights

• Hirsutism is the presence of excessive body hair in a male pattern distribution in a woman, and can affect up to 20% of women. Idiopathic hirsutism and polycystic ovarian syndrome (PCOS) account for 95% of hirsutism. Other dermatological signs of hyperandrogenism include acne/seborrhea and androgenetic alopecia.

• Pediatric/adolescent symptoms, rapid onset of hirsutism, and the presence of a new onset of virilization will always mandate a full work-up and expert review. A multidisciplinary approach involving dermatologists, endocrinologists, and gynecologists may be indicated in certain cases.

• Robust evidence for the efficacy of pharmacological treatments of hirsutism is lacking. There are several challenges in hirsutism research with current studies demonstrating several limitations including: small sample size, short duration, and lack of blinding during study.

• Current guidelines recommend physical methods of hair removal for mild disease. It is important to appreciate the patient’s perception of their hirsutism and level of distress experienced to help guide management.

• For moderate hirsutism, it is recommended to start an OCP and, if no improvement has arisen after six months to add in an antiandrogen. A combination therapy of COCP and anti-androgen therapy may be more efficacious. It is not advocated to start on anti-androgen monotherapy in view of the risk of teratogenicity.

Declaration of interest

R Sinclair reports being Director and Founder of Samson Clinical Pty Ltd, participating on the pharmaceutical advisory board for Eli Lilly, Pfizer Inc, Leo Pharmaceutical; is on the speakers bureau for Abbvie and Novartis; and is principal investigator in clinical trials for Amgen, Novartis, Arcutis Biotherapeutics, Aerotech, Merck and Co, Celgene, Coherus BioSciences, Jannsen, Regeneron, MedImmune, Glaxo Smith Kline, Samson Clinical, Boehringer Ingelheim, Oncobiologics, Roche, Ascend, Dermira, AstraZeneca, Akesobio, Reistone Biopharma, UCB, Sanofi, Connect, Arena, Sun Pharma, Bristol Myer Squibb, and Galderma.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.