This protocol targets women with hirsutism who are also obese or over age 39 years — a profile that carries higher risk for venous thromboembolism (VTE). These characteristics shape both the initial and the subsequent treatment choices.
In this higher-VTE-risk group, the recommended first step was an oral contraceptive selected to minimise thrombotic risk. After approximately 6 months of that hormonal therapy, hirsutism has not shown a meaningful improvement — specifically, the Ferriman–Gallwey hirsutism score has not fallen to a satisfactory degree. This failure to reach the target is the clinical trigger for the next line of management.
When oral contraceptive monotherapy is insufficient, the evidence-based next step involves adding an antiandrogen agent to the ongoing oral contraceptive. The full protocol specifies which antiandrogen options are appropriate — and why at least one class member is specifically avoided — based on efficacy and safety considerations.
For women with hirsutism at higher risk for VTE (e.g., those who are obese or over age 39 years), we suggest initial therapy with an OC containing the lowest effective dose of ethinyl estradiol (EE) (usually 20 mcg) and a low-risk progestin (Table 2). (2 |OOO)
If patient-important hirsutism remains despite 6 months of monotherapy with an OC, we suggest adding an antiandrogen. (2 |OO)
View source ↗