Guideline No. 444: Hirsutism: Evaluation and Treatment

Abstract

Objective

This guideline reviews the etiology, diagnosis, evaluation, and treatment of hirsutism.

Target Population

Women with hirsutism.

Options

Three approaches to management include: 1) mechanical hair removal; 2) suppression of androgen production; and 3) androgen receptor blockade.

Outcomes

The main limitations of the management options include the adverse effects, costs, and duration of treatment.

Benefits, Harms, and Costs

Implementation of the recommendations in this guideline may improve the management of hirsutism in women with this condition. Adverse effects and a potential long duration of treatment are the main drawbacks to initiating treatment, as is the possibility of significant financial costs for certain treatments.

Evidence

A comprehensive literature review was updated to April 2022, following the same methods as for the prior Society of Obstetricians and Gynaecologists of Canada (SOGC) Hirsutism guidelines. Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials.

Validation Methods

The authors rated the quality of evidence and strength of recommendations using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

Intended Audience

Primary care providers, family medicine physicians, obstetricians and gynaecologists, reproductive endocrinologists and others who manage the care of patients with hirsutism.

Tweetable Abstract

Management of hirsutism involves a 3-pronged approach of mechanical hair removal, suppression of androgen production, and androgen receptor blockade.

SUMMARY STATEMENTS

• 1.The modified Ferriman-Gallwey score can be used in the assessment of hirsutism to help quantify the problem and assess the response to treatment. Cut-off scores defining hirsutism will vary by racial background. Modified Ferriman-Gallwey scores from 3 to 15 represent mild hirsutism, 16–25 represent moderate hirsutism, and >25 indicate severe hirsutism (moderate).
• 2.Hyperandrogenism in women with polycystic ovary syndrome may result from several mechanisms, including insulin resistance, hyperinsulinemia, elevated luteinizing hormone–related increases in theca cell androgen production, and increased adrenal androgen output. (high).
• 3.Non-classical congenital adrenal hyperplasia often presents with hirsutism and has a similar clinical picture as polycystic ovary syndrome. However, the prevalence of non-classical congenital adrenal hyperplasia is very low outside of specific high-risk ethnic groups (high).
• 4.Hirsutism can be classified into 1 of 3 groups based on etiology: hyperandrogenic hirsutism (including polycystic ovarian syndrome, non-classical congenital adrenal hyperplasia, or androgen-secreting tumours), non-androgenic hirsutism (including medication-induced hirsutism), and idiopathic hirsutism (moderate).
• 5.Polycystic ovary syndrome is the most common cause of hirsutism, with idiopathic hirsutism being the second most common (high).
• 6.Most patients with hirsutism have normal androgen levels. That said, high androgen levels should be investigated immediately, as some impacts will be permanent, such as voice changes and clitoromegaly (high).
• 7.Hirsutism is not a diagnosis, but a symptom or sign, and an underlying etiology should be sought (high).
• 8.The most effective therapy for hirsutism is multimodal and combines physical hair removal techniques with medical therapies. At least six months of medical therapy is required to see a significant improvement in hirsutism. Unfortunately, many permanent physical hair removal procedures are considered cosmetic and the costs can be a barrier to treatment (moderate).
• 9.Hair growth tends to recur after stopping medical therapy, while laser hair removal, intense pulsed light, and electrolysis produce permanent hair reduction (moderate).

RECOMMENDATIONS

• 1.Patients presenting with hirsutism should be evaluated with a focused history taking, physical examination with anthropometric measurements, and appropriate investigations to differentiate between the possible etiologies (strong, moderate).
• 2.Patients with moderate to severe hirsutism should undergo blood testing to determine total testosterone and sex hormone–binding globulin levels; however, the benefit of testing in mild hirsutism is questionable. Additional testing is indicated for patients with irregular cycles and signs of hyperandrogenism or other endocrinopathies (conditional, low).
• 3.Patients with hyperandrogenic hirsutism should have serum levels of dehydroepiandrosterone sulfate and 17-hydroxyprogesterone measured (strong, moderate).
• 4.Referral for evaluation by a medical or reproductive endocrinologist (or another practitioner with similar expertise) is indicated in the presence of 1) virilization; 2) serum testosterone or dehydroepiandrosterone sulfate levels more than twice the upper limit of normal; 3) signs or symptoms of Cushing syndrome; or 4) early follicular phase serum 17-hydroxyprogesterone levels >6 nmol/L (strong, high).
• 5.Therapy should be offered to all patients with hirsutism who desire treatment (good practice point).
• 6.Combined hormonal contraceptives should be offered as first-line therapy if there are no contraindications (strong, high).
• 7.Mechanical hair removal and/or topical treatments can be offered as first-line therapy or as an adjuvant to medical therapy (strong, high).
• 8.Antiandrogens can be considered as monotherapy or in addition to combined hormonal contraceptives to enhance efficacy (strong, high).
• 9.Patients on antiandrogens require an effective method of contraception and should be counselled regarding the risk of feminization of a male fetus if pregnancy were to occur (good practice point).