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Hirsutism: An Evidence-Based Treatment Update

  • Evidence-Based Review
  • Published:
American Journal of Clinical Dermatology Aims and scope Submit manuscript

Abstract

Background

Hirsutism has a relatively high prevalence among women. Depending upon societal and ethnic norms, it can cause significant psychosocial distress. Importantly, hirsutism may be associated with underlying disorders and co-morbidities. Hirsutism should not simply be looked upon as an issue of cosmesis. Patients require appropriate evaluation so that underlying etiologies and associated sequelae are recognized and managed. Treatment of hirsutism often requires a multidisciplinary approach, and a variety of physical or pharmacologic modalities can be employed. Efficacy of these therapies is varied and depends, among other things, upon patient factors including the underlying etiology, hormonal drive, and local tissue sensitivity to androgens.

Objective

The objective of this paper is to review and summarize current evidence evaluating the efficacy of various treatment modalities for hirsutism in premenopausal women.

Methods

Online databases were searched to identify all relevant prior systematic reviews and meta-analyses as well as recently published (2012–present) randomized controlled trials (RCTs) on hirsutism treatment.

Results

Four recently published RCTs met criteria for inclusion in our review. In addition, one meta-analysis and one systematic review/treatment guideline were identified in the recent literature. Physical modalities and oral contraceptive pills (OCPs) remain first-line treatments. Evidence supports the use of electrolysis for permanent hair removal in localized areas and lasers (particularly alexandrite and diode lasers) for permanent hair reduction. Topical eflornithine can be used as monotherapy for mild hirsutism and as an adjunct therapy with lasers or pharmacotherapy in more severe cases. Combined OCPs as a class are superior to placebo; however, antiandrogenic and low-dose neutral OCPs may be slightly more efficacious in improving hirsutism compared with other types of OCPs. Antiandrogens are indicated for moderate to severe hirsutism, with spironolactone being the first-line antiandrogen and finasteride and cyproterone acetate being second-line antiandrogens. Due to its risk for hepatotoxicity, flutamide is not considered a first-line therapy. If used, the lowest effective dose should be administered with careful monitoring of liver enzymes. Monotherapy with an insulin sensitizer does not significantly improve hirsutism. While insulin sensitizers improve important metabolic and endocrine aberrations in polycystic ovary syndrome, they are not recommended when hirsutism is the sole indication for use. Lifestyle modification counseling is recommended. Gonadotropin-releasing hormone analogs and glucocorticoids are only recommended in specific circumstances. Additional therapies without sufficient supportive evidence of efficacy are ovarian surgery, statins (HMG-CoA reductase inhibitors), and vitamin D supplementation.

Limitations

In general, most therapies garner recommendations that are weak (where the estimates of benefits versus risks of therapy are either closely balanced or uncertain) and are based on low- to moderate-quality evidence.

Conclusions

Risks and benefits of treatment must be carefully considered and discussed with the patient. Expectations for efficacy should be appropriately set. A minimum of 6 months is required to see benefit from pharmacotherapy and lifelong treatment is often necessary for sustained benefit.

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References

  1. Azziz R. The evaluation and management of hirsutism. Obstet Gynecol. 2003;101(5 Pt 1):995–1007.

    PubMed  Google Scholar 

  2. Reingold SB, Rosenfield RL. The relationship of mild hirsutism or acne in women to androgens. Arch Dermatol. 1987;123(2):209–12.

    CAS  PubMed  Google Scholar 

  3. Pfeifer M, Prezelj J, Kocijancic A. The correlation between clinical and hormonal parameters in androgenisation. Acta Eur Fertil. 1989;20(1):31–3.

    CAS  PubMed  Google Scholar 

  4. Carmina E, Lobo RA. Polycystic ovaries in hirsute women with normal menses. Am J Med. 2001;111(8):602–6.

    CAS  PubMed  Google Scholar 

  5. Legro RS, Schlaff WD, Diamond MP, Coutifaris C, Casson PR, et al. Total testosterone assays in women with polycystic ovary syndrome: precision and correlation with hirsutism. J Clin Endocrinol Metab. 2010;95(12):5305–13.

    CAS  PubMed Central  PubMed  Google Scholar 

  6. Souter I, Sanchez LA, Perez M, Bartolucci AA, Azziz R. The prevalence of androgen excess among patients with minimal unwanted hair growth. Am J Obstet Gynecol. 2004;191(6):1914–20.

    CAS  PubMed  Google Scholar 

  7. Di Fede G, Mansueto P, Pepe I, Rini GB, Carmina E. High prevalence of polycystic ovary syndrome in women with mild hirsutism and no other significant clinical symptoms. Fertil Steril. 2010;94(1):194–7.

    PubMed  Google Scholar 

  8. Escobar-Morreale HF, Carmina E, Dewailly D, Gambineri A, Kelestimur F, et al. Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update. 2012;18(2):146–70.

    CAS  PubMed  Google Scholar 

  9. Blume-Peytavi U, Atkin S, Shapiro J, Lavery S, Grimalt R, et al. European consensus on the evaluation of women presenting with excessive hair growth. Eur J Dermatol. 2009;19(6):597–602.

    PubMed  Google Scholar 

  10. Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008;93(4):1105–20.

    CAS  PubMed  Google Scholar 

  11. Ekbäck MP, Lindberg M, Benzein E, Årestedt K. Health-related quality of life, depression and anxiety correlate with the degree of hirsutism. Dermatology. 2013; 227:278–284.

  12. Kligman AM, Peters L. Histologic changes of human hair follicles after electrolysis: a comparison of two methods. Cutis. 1984;34(2):169–76.

    CAS  PubMed  Google Scholar 

  13. Richards RN, Meharg GE. Electrolysis: observations from 13 years and 140,000 hours of experience. J Am Acad Dermatol. 1995;33(4):662–6.

    CAS  PubMed  Google Scholar 

  14. Lolis MS, Marmur ES. Paradoxical effects of hair removal systems: a review. J Cosmet Dermatol. 2006;5(4):274–6.

    PubMed  Google Scholar 

  15. Alajlan A, Shapiro J, Rivers JK, MacDonald N, Wiggin J, et al. Paradoxical hypertrichosis after laser epilation. J Am Acad Dermatol. 2005;53(1):85–8.

    PubMed  Google Scholar 

  16. Haedersdal M, Wulf HC. Evidence-based review of hair removal using lasers and light sources. J Eur Acad Dermatol Venereol. 2006;20(1):9–20.

    CAS  PubMed  Google Scholar 

  17. Haedersdal M, Gotzsche PC. Laser and photoepilation for unwanted hair growth. Cochrane Database Syst Rev. 2006;(4):CD004684.

  18. Sadighha A, Mohaghegh Zahed G. Meta-analysis of hair removal laser trials. Lasers Med Sci. 2009;24(1):21–5.

    PubMed  Google Scholar 

  19. Haak CS, Nymann P, Pedersen AT, Clausen HV, Feldt Rasmussen U, et al. Hair removal in hirsute women with normal testosterone levels: a randomized controlled trial of long-pulsed diode laser vs. intense pulsed light. Br J Dermatol. 2010;163(5):1007–13.

    CAS  PubMed  Google Scholar 

  20. Eremia S, Li C, Newman N. Laser hair removal with alexandrite versus diode laser using four treatment sessions: 1-year results. Dermatol Surg. 2001;27(11):925–9 (discussion 929–30).

  21. Thaysen-Petersen D, Bjerring P, Dierickx C, Nash JF, Town G, et al. A systematic review of light-based home-use devices for hair removal and considerations on human safety. J Eur Acad Dermatol Venereol. 2012;26(5):545–53.

    CAS  PubMed  Google Scholar 

  22. Dawber RP. Guidance for the management of hirsutism. Curr Med Res Opin. 2005;21(8):1227–34.

    CAS  PubMed  Google Scholar 

  23. Wolf JE Jr, Shander D, Huber F, Jackson J, Lin CS, et al. Randomized, double-blind clinical evaluation of the efficacy and safety of topical eflornithine HCl 13.9% cream in the treatment of women with facial hair. Int J Dermatol. 2007;46(1):94–8.

    CAS  PubMed  Google Scholar 

  24. Balfour JA, McClellan K. Topical eflornithine. Am J Clin Dermatol. 2001;2(3):197–201 (discussion 202).

  25. Jackson J, Caro JJ, Caro G, Garfield F, Huber F, et al. The effect of eflornithine 13.9% cream on the bother and discomfort due to hirsutism. Int J Dermatol. 2007;46(9):976–81.

    CAS  PubMed  Google Scholar 

  26. Lapidoth M, Dierickx C, Lanigan S, Paasch U, Campo-Voegeli A, et al. Best practice options for hair removal in patients with unwanted facial hair using combination therapy with laser: guidelines drawn up by an expert working group. Dermatology. 2010;221(1):34–42.

    CAS  PubMed  Google Scholar 

  27. Smith SR, Piacquadio DJ, Beger B, Littler C. Eflornithine cream combined with laser therapy in the management of unwanted facial hair growth in women: a randomized trial. Dermatol Surg. 2006;32(10):1237–43.

    CAS  PubMed  Google Scholar 

  28. Hamzavi I, Tan E, Shapiro J, Lui H. A randomized bilateral vehicle-controlled study of eflornithine cream combined with laser treatment versus laser treatment alone for facial hirsutism in women. J Am Acad Dermatol. 2007;57(1):54–9.

    PubMed  Google Scholar 

  29. Escobar-Morreale HF. Topical eflornithine. Am J Clin Dermatol. 2001;2(3):202.

    Google Scholar 

  30. Malhotra B, Noveck R, Behr D, Palmisano M. Percutaneous absorption and pharmacokinetics of eflornithine HCl 13.9% cream in women with unwanted facial hair. J Clin Pharmacol. 2001;41(9):972–8.

    CAS  PubMed  Google Scholar 

  31. Hickman JG, Huber F, Palmisano M. Human dermal safety studies with eflornithine HCl 13.9% cream (Vaniqa), a novel treatment for excessive facial hair. Curr Med Res Opin. 2001;16(4):235–44.

    CAS  PubMed  Google Scholar 

  32. Lucas KJ. Finasteride cream in hirsutism. Endocr Pract. 2001;7(1):5–10.

    CAS  PubMed  Google Scholar 

  33. Farshi S, Mansouri P, Rafie F. A randomized double blind, vehicle controlled bilateral comparison study of the efficacy and safety of finasteride 0.5% solution in combination with intense pulsed light in the treatment of facial hirsutism. J Cosmet Laser Ther. 2012;14(4):193–9.

    PubMed  Google Scholar 

  34. Raj SG, Raj MH, Talbert LM, Sloan CS, Hicks B. Normalization of testosterone levels using a low estrogen-containing oral contraceptive in women with polycystic ovary syndrome. Obstet Gynecol. 1982;60(1):15–9.

    CAS  PubMed  Google Scholar 

  35. Dewis P, Petsos P, Newman M, Anderson DC. The treatment of hirsutism with a combination of desogestrel and ethinyl oestradiol. Clin Endocrinol (Oxf). 1985;22(1):29–36.

    CAS  Google Scholar 

  36. Guido M, Romualdi D, Giuliani M, Suriano R, Selvaggi L, et al. Drospirenone for the treatment of hirsute women with polycystic ovary syndrome: a clinical, endocrinological, metabolic pilot study. J Clin Endocrinol Metab. 2004;89(6):2817–23.

    CAS  PubMed  Google Scholar 

  37. Casey JH, Burger HG, Kent JR, Kellie AE, Moxham A, et al. Treatment of hirsutism by adrenal and ovarian suppression. J Clin Endocrinol Metab. 1966;26(12):1370–4.

    CAS  PubMed  Google Scholar 

  38. Cullberg G, Hamberger L, Mattsson LA, Mobacken H, Samsioe G. Effects of a low-dose desogestrel-ethinylestradiol combination on hirsutism, androgens and sex hormone binding globulin in women with a polycystic ovary syndrome. Acta Obstet Gynecol Scand. 1985;64(3):195–202.

    CAS  PubMed  Google Scholar 

  39. Venturoli S, Marescalchi O, Colombo FM, Macrelli S, Ravaioli B, et al. A prospective randomized trial comparing low dose flutamide, finasteride, ketoconazole, and cyproterone acetate-estrogen regimens in the treatment of hirsutism. J Clin Endocrinol Metab. 1999;84(4):1304–10.

    CAS  PubMed  Google Scholar 

  40. Batukan C, Muderris II. Efficacy of a new oral contraceptive containing drospirenone and ethinyl estradiol in the long-term treatment of hirsutism. Fertil Steril. 2006;85(2):436–40.

    CAS  PubMed  Google Scholar 

  41. Porcile A, Gallardo E. Long-term treatment of hirsutism: desogestrel compared with cyproterone acetate in oral contraceptives. Fertil Steril. 1991;55(5):877–81.

    CAS  PubMed  Google Scholar 

  42. Saeed R, Akram J, Changezi HU, Saeed M. Treatment of hirsutism in polycystic ovarian syndrome with Diane, 50 mcg ethinyl estradiol and 2 mg cyproterone acetate. Specialist Pak J Med Sci. 1993;9:109–12.

    Google Scholar 

  43. Van der Spuy ZM, le Roux PA. Cyproterone acetate for hirsutism. Cochrane Database Syst Rev. 2003;(4):CD001125.

  44. Bhattacharya SM, Jha A. Comparative study of the therapeutic effects of oral contraceptive pills containing desogestrel, cyproterone acetate, and drospirenone in patients with polycystic ovary syndrome. Fertil Steril. 2012;98(4):1053–9.

    CAS  PubMed  Google Scholar 

  45. Colonna L, Pacifico V, Lello S, Sorge R, Raskovic D, et al. Skin improvement with two different oestroprogestins in patients affected by acne and polycystic ovary syndrome: clinical and instrumental evaluation. J Eur Acad Dermatol Venereol. 2012;26(11):1364–71.

    CAS  PubMed  Google Scholar 

  46. Sanam M, Ziba O. Desogestrel+ethinylestradiol versus levonorgestrel+ethinylestradiol. Which one has better affect on acne, hirsutism, and weight change. Saudi Med J. 2011;32(1):23–6.

    PubMed  Google Scholar 

  47. Vermeulen A, Rubens R. Effects of cyproterone acetate plus ethinylestradiol low dose on plasma androgens and lipids in mildly hirsute or acneic young women. Contraception. 1988;38(4):419–28.

    CAS  PubMed  Google Scholar 

  48. Luque-Ramirez M, Mendieta-Azcona C, del Rey Sanchez JM, Maties M, Escobar-Morreale HF. Effects of an antiandrogenic oral contraceptive pill compared with metformin on blood coagulation tests and endothelial function in women with the polycystic ovary syndrome: influence of obesity and smoking. Eur J Endocrinol. 2009;160(3):469–80.

    CAS  PubMed  Google Scholar 

  49. Plu-Bureau G, Maitrot-Mantelet L, Hugon-Rodin J, Canonico M. Hormonal contraceptives and venous thromboembolism: an epidemiological update. Best Pract Res Clin Endocrinol Metab. 2013;27(1):25–34.

    CAS  PubMed  Google Scholar 

  50. van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, Doggen CJ, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case–control study. BMJ. 2009;339:2921.

    Google Scholar 

  51. Jick SS, Hernandez RK. Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case–control study using United States claims data. BMJ. 2011;342:d2151.

    PubMed Central  PubMed  Google Scholar 

  52. Parkin L, Sharples K, Hernandez RK, Jick SS. Risk of venous thromboembolism in users of oral contraceptives containing drospirenone or levonorgestrel: nested case–control study based on UK General Practice Research Database. BMJ. 2011;342:d2139.

    PubMed Central  PubMed  Google Scholar 

  53. Lidegaard O, Lokkegaard E, Svendsen AL, Agger C. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ. 2009;339:b2890.

    PubMed Central  PubMed  Google Scholar 

  54. Lidegaard O, Nielsen LH, Skovlund CW, Skjeldestad FE, Lokkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001-9. BMJ. 2011;343:d6423.

    PubMed Central  PubMed  Google Scholar 

  55. Lidegaard O, Milsom I, Geirsson RT, Skjeldestad FE. Hormonal contraception and venous thromboembolism. Acta Obstet Gynecol Scand. 2012;91(7):769–78.

    PubMed  Google Scholar 

  56. Martinez F, Ramirez I, Perez-Campos E, Latorre K, Lete I. Venous and pulmonary thromboembolism and combined hormonal contraceptives. Systematic review and meta-analysis. Eur J Contracept Reprod Health Care. 2012;17(1):7–29.

    CAS  PubMed  Google Scholar 

  57. Folger SG, Curtis KM, Tepper NK, Gaffield ME, Marchbanks PA. Guidance on medical eligibility criteria for contraceptive use: identification of research gaps. Contraception. 2010;82(1):113–8.

    PubMed  Google Scholar 

  58. Swiglo BA, Cosma M, Flynn DN, Kurtz DM, Labella ML, et al. Clinical review: antiandrogens for the treatment of hirsutism: a systematic review and metaanalyses of randomized controlled trials. J Clin Endocrinol Metab. 2008;93(4):1153–60.

    PubMed  Google Scholar 

  59. Moghetti P, Tosi F, Tosti A, Negri C, Misciali C, et al. Comparison of spironolactone, flutamide, and finasteride efficacy in the treatment of hirsutism: a randomized, double blind, placebo-controlled trial. J Clin Endocrinol Metab. 2000;85(1):89–94.

    CAS  PubMed  Google Scholar 

  60. Brown J, Farquhar C, Lee O, Toomath R, Jepson RG. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev. 2009;(2):CD000194.

  61. McLellan AR, Rentoul J, MacKie R, McInnes GT. Lack of effect of spironolactone on hair shaft diameter in hirsute females. Postgrad Med J. 1989;65(765):459–62.

    CAS  PubMed Central  PubMed  Google Scholar 

  62. Ciotta L, Cianci A, Calogero AE, Palumbo MA, Marletta E, et al. Clinical and endocrine effects of finasteride, a 5 alpha-reductase inhibitor, in women with idiopathic hirsutism. Fertil Steril. 1995;64(2):299–306.

    CAS  PubMed  Google Scholar 

  63. Lakryc EM, Motta EL, Soares JM Jr, Haidar MA, de Lima GR, et al. The benefits of finasteride for hirsute women with polycystic ovary syndrome or idiopathic hirsutism. Gynecol Endocrinol. 2003;17(1):57–63.

    CAS  PubMed  Google Scholar 

  64. Gambineri A, Pelusi C, Genghini S, Morselli-Labate AM, Cacciari M, et al. Effect of flutamide and metformin administered alone or in combination in dieting obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2004;60(2):241–9.

    CAS  Google Scholar 

  65. Sahin Y, Bayram F, Kelestimur F, Muderris I. Comparison of cyproterone acetate plus ethinyl estradiol and finasteride in the treatment of hirsutism. J Endocrinol Invest. 1998;21(6):348–52.

    CAS  PubMed  Google Scholar 

  66. Calaf J, Lopez E, Millet A, Alcaniz J, Fortuny A, et al. Long-term efficacy and tolerability of flutamide combined with oral contraception in moderate to severe hirsutism: a 12-month, double-blind, parallel clinical trial. J Clin Endocrinol Metab. 2007;92(9):3446–52.

    CAS  PubMed  Google Scholar 

  67. Kelestimur F, Sahin Y. Comparison of Diane 35 and Diane 35 plus spironolactone in the treatment of hirsutism. Fertil Steril. 1998;69(1):66–9.

    CAS  PubMed  Google Scholar 

  68. Tartagni M, Schonauer LM, De Salvia MA, Cicinelli E, De Pergola G, et al. Comparison of Diane 35 and Diane 35 plus finasteride in the treatment of hirsutism. Fertil Steril. 2000;73(4):718–23.

    CAS  PubMed  Google Scholar 

  69. Sahin Y, Dilber S, Kelestimur F. Comparison of Diane 35 and Diane 35 plus finasteride in the treatment of hirsutism. Fertil Steril. 2001;75(3):496–500.

    CAS  PubMed  Google Scholar 

  70. Gregoriou O, Bakas P, Konidaris S, Papadias K, Mathiopoulos D, et al. The effect of combined oral contraception with or without spironolactone on bone mineral density of hyperandrogenic women. Gynecol Endocrinol. 2000;14(5):369–73.

    CAS  PubMed  Google Scholar 

  71. Gokmen O, Senoz S, Gulekli B, Isik AZ. Comparison of four different treatment regimes in hirsutism related to polycystic ovary syndrome. Gynecol Endocrinol. 1996;10(4):249–55.

    CAS  PubMed  Google Scholar 

  72. Barth JH, Cherry CA, Wojnarowska F, Dawber RP. Cyproterone acetate for severe hirsutism: results of a double-blind dose-ranging study. Clin Endocrinol (Oxf). 1991;35(1):5–10.

    CAS  Google Scholar 

  73. Belisle S, Love EJ. Clinical efficacy and safety of cyproterone acetate in severe hirsutism: results of a multicentered Canadian study. Fertil Steril. 1986;46(6):1015–20.

    CAS  PubMed  Google Scholar 

  74. Kelekci KH, Kelekci S, Yengel I, Gul S, Yilmaz B. Cyproterone acetate or drospirenone containing combined oral contraceptives plus spironolactone or cyproterone acetate for hirsutism: randomized comparison of three regimens. J Dermatolog Treat. 2012;23(3):177–83.

    CAS  PubMed  Google Scholar 

  75. Fruzzetti F, Bersi C, Parrini D, Ricci C, Genazzani AR. Treatment of hirsutism: comparisons between different antiandrogens with central and peripheral effects. Fertil Steril. 1999;71(3):445–51.

    CAS  PubMed  Google Scholar 

  76. Spritzer PM, Lisboa KO, Mattiello S, Lhullier F. Spironolactone as a single agent for long-term therapy of hirsute patients. Clin Endocrinol (Oxf). 2000;52(5):587–94.

    CAS  Google Scholar 

  77. Beigi A, Sobhi A, Zarrinkoub F. Finasteride versus cyproterone acetate-estrogen regimens in the treatment of hirsutism. Int J Gynaecol Obstet. 2004;87(1):29–33.

    CAS  PubMed  Google Scholar 

  78. Grigoriou O, Papadias C, Konidaris S, Antoniou G, Karakitsos P, et al. Comparison of flutamide and cyproterone acetate in the treatment of hirsutism: a randomized controlled trial. Gynecol Endocrinol. 1996;10(2):119–23.

    CAS  PubMed  Google Scholar 

  79. Falsetti L, De Fusco D, Eleftheriou G, Rosina B. Treatment of hirsutism by finasteride and flutamide in women with polycystic ovary syndrome. Gynecol Endocrinol. 1997;11(4):251–7.

    CAS  PubMed  Google Scholar 

  80. Wong IL, Morris RS, Chang L, Spahn MA, Stanczyk FZ, et al. A prospective randomized trial comparing finasteride to spironolactone in the treatment of hirsute women. J Clin Endocrinol Metab. 1995;80(1):233–8.

    CAS  PubMed  Google Scholar 

  81. Cusan L, Dupont A, Gomez JL, Tremblay RR, Labrie F. Comparison of flutamide and spironolactone in the treatment of hirsutism: a randomized controlled trial. Fertil Steril. 1994;61(2):281–7.

    CAS  PubMed  Google Scholar 

  82. Erenus M, Yucelten D, Durmusoglu F, Gurbuz O. Comparison of finasteride versus spironolactone in the treatment of idiopathic hirsutism. Fertil Steril. 1997;68(6):1000–3.

    CAS  PubMed  Google Scholar 

  83. Falsetti L, Gambera A, Legrenzi L, Iacobello C, Bugari G. Comparison of finasteride versus flutamide in the treatment of hirsutism. Eur J Endocrinol. 1999;141(4):361–7.

    CAS  PubMed  Google Scholar 

  84. Pazos F, Escobar-Morreale HF, Balsa J, Sancho JM, Varela C. Prospective randomized study comparing the long-acting gonadotropin-releasing hormone agonist triptorelin, flutamide, and cyproterone acetate, used in combination with an oral contraceptive, in the treatment of hirsutism. Fertil Steril. 1999;71(1):122–8.

    CAS  PubMed  Google Scholar 

  85. Unluhizarci KK, Everest H, Bayram F, Kelestimur F. Comparison of spironolactone and spironolactone plus finasteride in the treatment of hirsutism. Fertil Steril. 2002;78(6):1331–3.

    Google Scholar 

  86. Kelestimur F, Everest H, Unluhizarci K, Bayram F, Sahin Y. A comparison between spironolactone and spironolactone plus finasteride in the treatment of hirsutism. Eur J Endocrinol. 2004;150(3):351–4.

    CAS  PubMed  Google Scholar 

  87. Brahm J, Brahm M, Segovia R, Latorre R, Zapata R, et al. Acute and fulminant hepatitis induced by flutamide: case series report and review of the literature. Ann Hepatol. 2011;10(1):93–8.

    PubMed  Google Scholar 

  88. Paradisi R, Venturoli S. Retrospective observational study on the effects and tolerability of flutamide in a large population of patients with various kinds of hirsutism over a 15-year period. Eur J Endocrinol. 2010;163(1):139–47.

    CAS  PubMed  Google Scholar 

  89. Dikensoy E, Balat O, Pence S, Akcali C, Cicek H. The risk of hepatotoxicity during long-term and low-dose flutamide treatment in hirsutism. Arch Gynecol Obstet. 2009;279(3):321–7.

    CAS  PubMed  Google Scholar 

  90. Castelo-Branco C, Del Pino M. Hepatotoxicity during low-dose flutamide treatment for hirsutism. Gynecol Endocrinol. 2009;25(7):419–22.

    CAS  PubMed  Google Scholar 

  91. Bruni V, Peruzzi E, Dei M, Nannini S, Seravalli V, et al. Hepatotoxicity with low- and ultralow-dose flutamide: a surveillance study on 203 hyperandrogenic young females. Fertil Steril. 2012;98(4):1047–52.

    CAS  PubMed  Google Scholar 

  92. Ibanez L, Lopez-Bermejo A, Diaz M, Enriquez G, Del Rio L, et al. Low-dose pioglitazone, flutamide, metformin plus an estro-progestogen for non-obese young women with polycystic ovary syndrome: increasing efficacy and persistent safety over 30 months. Gynecol Endocrinol. 2010;26(12):869–73.

    CAS  PubMed  Google Scholar 

  93. Gafny M, Silbergeld A, Klinger B, Wasserman M, Laron Z. Comparative effects of GH, IGF-I and insulin on serum sex hormone binding globulin. Clin Endocrinol (Oxf). 1994;41(2):169–75.

    CAS  Google Scholar 

  94. Cosma M, Swiglo BA, Flynn DN, Kurtz DM, Labella ML, et al. Clinical review: Insulin sensitizers for the treatment of hirsutism: a systematic review and metaanalyses of randomized controlled trials. J Clin Endocrinol Metab. 2008;93(4):1135–42.

    CAS  PubMed  Google Scholar 

  95. Azziz R, Ehrmann D, Legro RS, Whitcomb RW, Hanley R, et al. Troglitazone improves ovulation and hirsutism in the polycystic ovary syndrome: a multicenter, double blind, placebo-controlled trial. J Clin Endocrinol Metab. 2001;86(4):1626–32.

    CAS  PubMed  Google Scholar 

  96. Hoeger KM, Kochman L, Wixom N, Craig K, Miller RK, et al. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study. Fertil Steril. 2004;82(2):421–9.

    CAS  PubMed  Google Scholar 

  97. Kelly CJ, Gordon D. The effect of metformin on hirsutism in polycystic ovary syndrome. Eur J Endocrinol. 2002;147(2):217–21.

    CAS  PubMed  Google Scholar 

  98. Maciel GA, Soares Junior JM, Alves da Motta EL, Abi Haidar M, de Lima GR, et al. Nonobese women with polycystic ovary syndrome respond better than obese women to treatment with metformin. Fertil Steril. 2004;81((2):355–60.

    CAS  PubMed  Google Scholar 

  99. Onalan G, Goktolga U, Ceyhan T, Bagis T, Onalan R, et al. Predictive value of glucose-insulin ratio in PCOS and profile of women who will benefit from metformin therapy: obese, lean, hyper or normoinsulinemic? Eur J Obstet Gynecol Reprod Biol. 2005;123(2):204–11.

    PubMed  Google Scholar 

  100. Pasquali R, Gambineri A, Biscotti D, Vicennati V, Gagliardi L, et al. Effect of long-term treatment with metformin added to hypocaloric diet on body composition, fat distribution, and androgen and insulin levels in abdominally obese women with and without the polycystic ovary syndrome. J Clin Endocrinol Metab. 2000;85(8):2767–74.

    CAS  PubMed  Google Scholar 

  101. Moghetti P, Castello R, Negri C, Tosi F, Perrone F, et al. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin Endocrinol Metab. 2000;85(1):139–46.

    CAS  PubMed  Google Scholar 

  102. Aroda VR, Ciaraldi TP, Burke P, Mudaliar S, Clopton P, et al. Metabolic and hormonal changes induced by pioglitazone in polycystic ovary syndrome: a randomized, placebo-controlled clinical trial. J Clin Endocrinol Metab. 2009;94(2):469–76.

    CAS  PubMed Central  PubMed  Google Scholar 

  103. Lam PM, Tam WH, Ma RC, Cheung LP, Tsui MH, et al. The reproductive and metabolic effect of rosiglitazone on Chinese women with polycystic ovarian syndrome—a double-blind randomized placebo-controlled study. Fertil Steril. 2011;96(2):445–451 e1.

    CAS  PubMed  Google Scholar 

  104. Du Q, Wang YJ, Yang S, Wu B, Han P, et al. A systematic review and meta-analysis of randomized controlled trials comparing pioglitazone versus metformin in the treatment of polycystic ovary syndrome. Curr Med Res Opin. 2012;28(5):723–30.

    CAS  PubMed  Google Scholar 

  105. Naka KK, Kalantaridou SN, Kravariti M, Bechlioulis A, Kazakos N, et al. Effect of the insulin sensitizers metformin and pioglitazone on endothelial function in young women with polycystic ovary syndrome: a prospective randomized study. Fertil Steril. 2011;95(1):203–9.

    CAS  PubMed  Google Scholar 

  106. Ortega-Gonzalez C, Luna S, Hernandez L, Crespo G, Aguayo P, et al. Responses of serum androgen and insulin resistance to metformin and pioglitazone in obese, insulin-resistant women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2005;90(3):1360–5.

    CAS  PubMed  Google Scholar 

  107. Ortega-Gonzalez C, Cardoza L, Coutino B, Hidalgo R, Arteaga-Troncoso G, et al. Insulin sensitizing drugs increase the endogenous dopaminergic tone in obese insulin-resistant women with polycystic ovary syndrome. J Endocrinol. 2005;184(1):233–9.

    CAS  PubMed  Google Scholar 

  108. Zhang N, Guo L, Lv C, et al. Comparison of clinical effects between pioglitazone and metformin plus Diane-35 on polycystic ovary syndrome with insulin resistance. Prog Obstet Gynecol. 2008;17:440–4.

    Google Scholar 

  109. Yilmaz M, Karakoc A, Toruner FB, Cakir N, Tiras B, et al. The effects of rosiglitazone and metformin on menstrual cyclicity and hirsutism in polycystic ovary syndrome. Gynecol Endocrinol. 2005;21(3):154–60.

    CAS  PubMed  Google Scholar 

  110. Morin-Papunen LC, Vauhkonen I, Koivunen RM, Ruokonen A, Martikainen HK, et al. Endocrine and metabolic effects of metformin versus ethinyl estradiol-cyproterone acetate in obese women with polycystic ovary syndrome: a randomized study. J Clin Endocrinol Metab. 2000;85(9):3161–8.

    CAS  PubMed  Google Scholar 

  111. Morin-Papunen L, Vauhkonen I, Koivunen R, Ruokonen A, Martikainen H, et al. Metformin versus ethinyl estradiol-cyproterone acetate in the treatment of nonobese women with polycystic ovary syndrome: a randomized study. J Clin Endocrinol Metab. 2003;88(1):148–56.

    CAS  PubMed  Google Scholar 

  112. Lemay A, Dodin S, Turcot L, Dechene F, Forest JC. Rosiglitazone and ethinyl estradiol/cyproterone acetate as single and combined treatment of overweight women with polycystic ovary syndrome and insulin resistance. Hum Reprod. 2006;21(1):121–8.

    CAS  PubMed  Google Scholar 

  113. Luque-Ramirez M, Alvarez-Blasco F, Botella-Carretero JI, Martinez-Bermejo E, Lasuncion MA, et al. Comparison of ethinyl-estradiol plus cyproterone acetate versus metformin effects on classic metabolic cardiovascular risk factors in women with the polycystic ovary syndrome. J Clin Endocrinol Metab. 2007;92(7):2453–61.

    CAS  PubMed  Google Scholar 

  114. Allen HF, Mazzoni C, Heptulla RA, Murray MA, Miller N, et al. Randomized controlled trial evaluating response to metformin versus standard therapy in the treatment of adolescents with polycystic ovary syndrome. J Pediatr Endocrinol Metab. 2005;18(8):761–8.

    CAS  PubMed  Google Scholar 

  115. Meyer C, McGrath BP, Teede HJ. Effects of medical therapy on insulin resistance and the cardiovascular system in polycystic ovary syndrome. Diabetes Care. 2007;30(3):471–8.

    CAS  PubMed  Google Scholar 

  116. Hoeger K, Davidson K, Kochman L, Cherry T, Kopin L, et al. The impact of metformin, oral contraceptives, and lifestyle modification on polycystic ovary syndrome in obese adolescent women in two randomized, placebo-controlled clinical trials. J Clin Endocrinol Metab. 2008;93(11):4299–306.

    CAS  PubMed Central  PubMed  Google Scholar 

  117. Harborne L, Fleming R, Lyall H, Sattar N, Norman J. Metformin or antiandrogen in the treatment of hirsutism in polycystic ovary syndrome. J Clin Endocrinol Metab. 2003;88(9):4116–23.

    CAS  PubMed  Google Scholar 

  118. Costello M, Shrestha B, Eden J, Sjoblom P, Johnson N. Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome. Cochrane Database Syst Rev. 2007;(1):CD005552.

  119. Costello MF, Shrestha B, Eden J, Johnson NP, Sjoblom P. Metformin versus oral contraceptive pill in polycystic ovary syndrome: a Cochrane review. Hum Reprod. 2007;22(5):1200–9.

    CAS  PubMed  Google Scholar 

  120. Ganie MA, Khurana ML, Eunice M, Gupta N, Gulati M, et al. Comparison of efficacy of spironolactone with metformin in the management of polycystic ovary syndrome: an open-labeled study. J Clin Endocrinol Metab. 2004;89(6):2756–62.

    CAS  PubMed  Google Scholar 

  121. Ibanez L, Valls C, Ferrer A, Ong K, Dunger DB, et al. Additive effects of insulin-sensitizing and anti-androgen treatment in young, nonobese women with hyperinsulinism, hyperandrogenism, dyslipidemia, and anovulation. J Clin Endocrinol Metab. 2002;87(6):2870–4.

    CAS  PubMed  Google Scholar 

  122. Frank-Raue K, Junga G, Raue F, Vecsei P, Ziegler R. Therapy of hirsutism in females with adrenal enzyme defects of steroid hormone biosynthesis: comparison of dexamethasone with cyproterone acetate [in German]. Klin Wochenschr. 1990;68(12):597–601.

    CAS  PubMed  Google Scholar 

  123. Spritzer P, Billaud L, Thalabard JC, Birman P, Mowszowicz I, et al. Cyproterone acetate versus hydrocortisone treatment in late-onset adrenal hyperplasia. J Clin Endocrinol Metab. 1990;70(3):642–6.

    CAS  PubMed  Google Scholar 

  124. Emans SJ, Grace E, Woods ER, Mansfield J, Crigler JF Jr. Treatment with dexamethasone of androgen excess in adolescent patients. J Pediatr. 1988;112(5):821–6.

    CAS  PubMed  Google Scholar 

  125. Prezelj J, Kocijancic A, Andolsek L. Dexamethasone and spironolactone in the treatment of non-tumorous hyperandrogenism. Gynecol Endocrinol. 1989;3(4):281–8.

    CAS  PubMed  Google Scholar 

  126. Carmina E, Lobo RA. The addition of dexamethasone to antiandrogen therapy for hirsutism prolongs the duration of remission. Fertil Steril. 1998;69(6):1075–9.

    CAS  PubMed  Google Scholar 

  127. Devoto E, Aravena L, Rios R. Treatment of hirsutism with spironolactone and with spironolactone plus dexamethasone [in Spanish]. Rev Med Chil. 2000;128(8):868–75.

    CAS  PubMed  Google Scholar 

  128. Practice Committee of the American Society for Reproductive Medicine. The evaluation and treatment of androgen excess. Fertil Steril. 2006;86(5 Suppl 1):S241–7.

  129. Moghissi KS. A clinician’s guide to the use of gonadotropin-releasing hormone analogues in women. Medscape Womens Health. 2000;5(1):5.

    CAS  PubMed  Google Scholar 

  130. van der Spuy ZM, Alster TS. Gonadotropin-releasing hormone analogues for hirsutism (Protocol). Cochrane Database Syst Rev. 2008.

  131. Carmina E, Lobo RA. Gonadotrophin-releasing hormone agonist therapy for hirsutism is as effective as high dose cyproterone acetate but results in a longer remission. Hum Reprod. 1997;12(4):663–6.

    CAS  PubMed  Google Scholar 

  132. Moran LJ, Hutchison SK, Norman RJ, Teede HJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2011;(7):CD007506.

  133. Stener-Victorin E, Jedel E, Janson PO, Sverrisdottir YB. Low-frequency electroacupuncture and physical exercise decrease high muscle sympathetic nerve activity in polycystic ovary syndrome. Am J Physiol Regul Integr Comp Physiol. 2009;297(2):R387–95.

    CAS  PubMed  Google Scholar 

  134. Vigorito C, Giallauria F, Palomba S, Cascella T, Manguso F, et al. Beneficial effects of a three-month structured exercise training program on cardiopulmonary functional capacity in young women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2007;92(4):1379–84.

    CAS  PubMed  Google Scholar 

  135. van Zuuren EJ, Fedorowicz Z, Carter B. Interventions for hirsutism excluding laser and photoepilation therapy (protocol). Cochrane Database Syst Rev. 2013;(1): CD010334.

  136. Banaszewska B, Pawelczyk L, Spaczynski RZ, Duleba AJ. Effects of simvastatin and metformin on polycystic ovary syndrome after six months of treatment. J Clin Endocrinol Metab. 2011;96(11):3493–501.

    CAS  PubMed Central  PubMed  Google Scholar 

  137. Johnson NP, Wang K. Is ovarian surgery effective for androgenic symptoms of polycystic ovarian syndrome? J Obstet Gynaecol. 2003;23(6):599–606.

    CAS  PubMed  Google Scholar 

  138. Cheong CY, Metwally M, Shreeve N, Sadek K, Farquhar C. Ovarian surgery for symptom relief in women with polycystic ovary syndrome (protocol). Cochrane Database Syst Rev. 2011;(12): CD009526.

  139. Thomson RL, Spedding S, Buckley JD. Vitamin D in the aetiology and management of polycystic ovary syndrome. Clin Endocrinol (Oxf). 2012;77(3):343–50.

    CAS  Google Scholar 

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Acknowledgments

No sources of funding were used to prepare this review. Najwa Somani and Diane Turvy have no conflicts of interest that are directly relevant to the content of this review.

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  1. Department of Dermatology, Indiana University School of Medicine, 550 N. University Blvd., Suite 3240, Indianapolis, IN, 46202, USA

    Najwa Somani & Diane Turvy

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Correspondence to Najwa Somani.

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Somani, N., Turvy, D. Hirsutism: An Evidence-Based Treatment Update. Am J Clin Dermatol 15, 247–266 (2014). https://doi.org/10.1007/s40257-014-0078-4

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