Hirsutism: An Evidence-Based Treatment Update.
Somani N1Indiana University School
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.
PMID: 24889738
The role of vitamin D deficiency in the etiology of polycystic ovary syndrome disorders.
[Article in Polish] Ginekol Pol. 2013 Jun;84(6):456-60. Brzozowska M1, Karowicz-Bilińska A.
Vitamin D deficiency connected with insufficient production in the skin and limited alimentation delivery disrupts the function of all systems of the body and increases the risk of chronic diseases. Many studies have reported associations between low serum 25-hydroxyvitamin D [25(OH)D] level and symptoms of the polycystic ovary syndrome (PCOS) - insulin resistance, hirsutism, and infertility associated with both, ovulatory disorders and abnormal endometrial receptivity. The beneficial effects of vitamin D supplementation on insulin resistance, ovarian follicles maturation, ovulation and menstrual regularity were confirmed. Due to limited evidence, the additional randomized trials are required to establish the correct dose of vitamin D and confirm the effectiveness of vitamin D treatment in PCOS disorders. However; it seems evident that correct supplementation of vitamin D is beneficial in the management of women with PCOS and low 25(OH)D serum levels, and that it could be helpful in improving the effects of PCOS treatment.
PMID: 24032264
See also VitaminDWiki
- Endocrine problems and low vitamin D – review May 2014 Hirsutism is associated with low vitamin D, even after compensating for BMI
- Search vitaminDWiki for "polycystic ovary syndrome" OR PCOS 65 items as of June 2014
See also web
- Vitamin D in the Aetiology and Management of Polycystic Ovary Syndrome Medscape 2012 which has the following chart
