Treatment of Severe Hirsutism with Emotional Distress or Insufficient Response to Oral Contraceptives

This protocol addresses the management of severe hirsutism — specifically in women experiencing emotional distress related to the condition, or in those who have previously used oral contraceptives without achieving sufficient improvement.

Clinical Scenario

This approach applies when one or more of the following is present:

Severe hirsutism
Emotional distress attributable to hirsutism
Prior use of oral contraceptives with insufficient improvement

Approach

The recommended strategy moves beyond oral contraceptive monotherapy to combination treatment, pairing an oral contraceptive with an antiandrogen agent. The full protocol details which antiandrogen options are indicated for this population, and identifies one agent that is recommended against on safety grounds.

Treatment Goal

The primary clinical target is measurable improvement in hirsutism, assessed by a reduction in the Ferriman–Gallwey hirsutism score.

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References

DOI: 10.1210/jc.2018-00241

In patients with severe hirsutism causing emotional distress and/or in those women who have used OCs in the past and have not experienced sufficient improvement, we suggest initiating combination therapy with an OC and antiandrogen (2 |OO).
However, we recommend against the use of flutamide because of its potential hepatotoxicity. (1 |OO)
The addition of antiandrogens to OCs was slightly more effective than OCs alone for hirsutism.

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