Hirsutism in Obesity and PCOS: What to Do When Oral Contraceptives Alone Are Not Enough

Clinical Scenario

Hirsute women with obesity — including those with polycystic ovary syndrome (PCOS) — who have completed an initial course of lifestyle modification together with oral contraceptive (OC) pharmacotherapy and have not achieved an adequate reduction in excess hair growth.

Previous Treatment — Insufficient Response

First-line management combined lifestyle changes (diet, exercise, and behavioural therapy) with oral contraceptives as the initial pharmacological step. When this regimen fails to produce a meaningful improvement in the Ferriman–Gallwey hirsutism score, escalation to a next-line approach is indicated.

Next-Line Approach

The structured protocol for this situation calls for augmenting oral contraceptive therapy by adding an antiandrogen agent. Which antiandrogen is appropriate — and which should be avoided — is specified in the full evidence-based regimen.

Goal: Reduction in Ferriman–Gallwey hirsutism score

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1210/jc.2018-00241

For hirsute women with obesity, including those with PCOS, we also recommend lifestyle changes. (1 |OO)

If patient-important hirsutism remains despite 6 months of monotherapy with an OC, we suggest adding an antiandrogen. (2 |OO)

However, we recommend against the use of flutamide because of its potential hepatotoxicity. (1 |OO)

The addition of antiandrogen therapy to OCs was slightly more effective for hirsutism than OC therapy alone (five trials) and was associated with incremental reduction of hirsutism scores—weighted mean difference, 21.73 [95% CI (23.32 to 20.13)].

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