According to a new treatment guideline from the Endocrine Society, endocrinologists should base treatment of hirsutism on the distress and perceptions of the patient, not their opinion of its severity.
A newly released Endocrine Society guideline on treatment of hirsutism does not make major changes from the 2008 version, but it does make a host of tweaks and updates regarding both treatment and diagnosis based on the latest knowledge.
“To maintain the quality of the guideline, we did an updated literature review and meta-analysis to see if there was a compelling reason to change any of our treatment recommendations,” says Kathryn A. Martin, MD, a faculty member in the Reproductive Endocrine Unit at Massachusetts General Hospital in Boston who chaired the task force that drew up the guideline.
“We hope that women who present with any degree of hirsutism will be offered an endocrine evaluation followed by appropriate therapy as outlined in the guideline. Treatment options include pharmacologic treatment, direct hair removal methods, or both.” – Kathryn A. Martin, MD, task force chair; faculty member, Reproductive Endocrine Unit, Massachusetts General Hospital, Boston
“Hirsutism is common, occurring in 5% to 10% of all women. It is usually a sign of an underlying endocrine disorder, most commonly polycystic ovary syndrome (PCOS),” Martin says. “The Endocrine Society has a separate guideline on the diagnosis and treatment of PCOS. Our task was to focus on the evaluation and management of hirsutism and not other aspects of PCOS. We hope that women who present with any degree of hirsutism will be offered an endocrine evaluation followed by appropriate therapy as outlined in the guideline. Treatment options include pharmacologic treatment, direct hair removal methods, or both.”
- Hirsutism is distressing to many patients. Because it is associated with anxiety and depression, treatment should be guided by the patient’s perceptions, not the clinician’s opinion of its severity.
- Hirsutism is most often caused by an endocrine disorder such as polycystic ovary syndrome, so clinicians should focus on the underlying problem, if present, in addition to the hirsutism. If the patient has PCOS, this could include treating irregular menstrual cycles as well as metabolic problems such as obesity and an increased risk of type 2 diabetes. Women with hirsutism and PCOS are typically started on estrogen-progestin contraceptives; an antiandrogen is added after six months if the patient feels there has not been enough improvement.
- Photoepilation has proven to be an effective treatment for hirsutism, particularly for patients with light skin and dark hair, but should be avoided among patients with dark skin.
Many clinicians have treated hirsutism based on their judgment of the severity of the hair growth. But the new guideline reinforces the notion put forth in the previous version that the need for treatment should be the patient’s call, not the physician’s. “Treatment should be based on the level of distress the woman is experiencing,” Martin says. “Some women are distressed by a little bit of hair growth, while others with very severe hair growth may not be as distressed.”
Martin adds that one important message to clinicians is that they should not ignore the patient’s cosmetic concerns “just because you think their hirsutism is minimal or mild,” she says. “We now know how distressing any degree of hirsutism can be. It is associated with anxiety and depression, so we do want clinicians to take it seriously.”
More Evidence Confirming Practices
Two other areas where additional evidence reinforced their previous recommendations were the choice of oral contraceptive and hair removal through photoepilation.
The previous guideline found that all formulations of oral contraceptives are equally effective for treatment of hirsutism. Even so, one school of thought has maintained that because hirsutism is associated with high levels of androgens, birth control pills containing progestins, which are considered “anti-androgens,” must be more effective. But a meta-analysis of an increasing number of studies in the literature suggested that “all available birth control pills seem to be equally effective for hirsutism, so it really doesn’t matter which one you use,” Martin says.
“To maintain the quality of the guideline, we did an updated literature review and meta-analysis to see if there was a compelling reason to change any of our treatment recommendations.” – Kathryn A. Martin, MD, task force chair; faculty member, Reproductive Endocrine Unit, Massachusetts General Hospital, Boston
“This version has more detail on the uses, efficacy, and safety of photoepilation — hair removal using laser and intense pulsed light,” Martin says. “In 2008, we were less enthusiastic about recommending it for patients, but this time there were more clinical trials that had been published. We were very comfortable saying it is effective therapy for women with light skin and dark hair. But it is less effective and sometimes associated with complications in women with darker skin, especially those with Middle Eastern and Mediterranean ancestry. Some women with dark skin get unusual complications. One is called paradoxical hypertrichosis, which is a type of hair growth that is not hirsutism. Instead of having a reduction in their facial hair, patients end up with a lot more facial hair. And it is not just in the areas where they laser, it is all over their face, and no one knows why.”
While the new version of the guideline does not differ greatly from the 2008 edition, there have been several modifications:
- For women with mild hirsutism and no evidence of an endocrine disorder, the new guideline suggests that initial therapy can be either pharmacologic therapy that targets androgen production and action or direct hair removal methods, consistent with the approach of offering treatment options based on the patient’s preferences. “For other women with patient-important hirsutism, we suggest starting with pharmacological therapy and adding direct hair removal methods if needed,” the statement says.
- Although the statement recommends against combination therapy as a standard first-line approach, the committee added a recommendation that in treating women with severe hirsutism who are experiencing a high level of distress, it is reasonable to start with combined pharmacological therapy of both oral contraceptives and anti-androgens.
- The previous guideline advised against the use of the anti-androgen flutamide, and the revised version strengthens this recommendation. “Clinicians prescribing flutamide started using it at lower and lower doses, saying it was safe. We found plenty of evidence that even at lower doses it is not safe, so we made a definitive recommendation that you should avoid it under any circumstances,” Martin says. “It causes liver toxicity, and we couldn’t justify giving it to an otherwise healthy young woman when there are other drugs that are very effective.”
- Hirsutism is most often caused by polycystic ovary syndrome, so the guideline writers added a recommendation that first-line treatment should include the lifestyle changes of diet and exercise, especially for patients with obesity.
Broadened Diagnostic Testing
The guideline broadens the suggestions for biochemical testing. “We now suggest testing the serum total testosterone level of all women with hirsutism,” Martin says, in contrast to the previous guideline’s suggestion that only those with moderate-to-severe hirsutism be tested.
The guideline also recommends broadening testing when:
- Patients who have a normal serum total testosterone concentration in the presence of moderate-to-severe hirsutism or other clinical evidence of hyperandrogenemia should have their serum free testosterone concentrations measured.
- Hyperandrogenemic women should be screened for non-classic congenital adrenal hyperplasia (NCCAH) due to 21-hydroxylase deficiency by measuring early morning 17-hydroxyprogesterone levels in the follicular phase. Patients with amenorrhea or infrequent menses should be tested on a random day.
- Women with hirsutism whose family history or ethnicity puts them at high risk for NCCAH should have their 17-hydroxyprogesterone levels measured even if their serum total and free testosterone concentrations are normal.
In addition to the Endocrine Society, “Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Guideline” was cosponsored by the Androgen Excess and Polycystic Ovary Syndrome Society and the European Society of Endocrinology. It will be published in the April issue of The Journal of Clinical Endocrinology & Metabolism, and is available online.
Seaborg is a freelance writer based in Charlottesville, Va. He wrote about a new scientific statement on treating patients with diabetic microvascular disease in the February issue.
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