This protocol addresses hirsutism in women presenting with severe hyperandrogenemia — including those with ovarian hyperthecosis — who have had a suboptimal response to oral contraceptives and antiandrogens.
In this specific sub-population, the combination of a severe androgenic state and inadequate benefit from standard hormonal therapies defines the clinical picture and guides escalation.
Ovarian hyperthecosis is a recognised cause of severe hyperandrogenemia. Current evidence-based guidance specifically identifies this condition — together with a suboptimal response to oral contraceptives and antiandrogens — as the clinical setting where more targeted hormonal intervention is appropriate.
The treatment approach in this scenario centres on a gonadotropin-releasing hormone agonist, used alongside hormonal add-back therapy. The clinical target is a meaningful reduction in the Ferriman–Gallwey hirsutism score.
The complete evidence-based regimen — including the add-back options, patient-specific considerations, and full treatment algorithm — is available in the structured protocol below.
DOI: 10.1210/jc.2018-00241
We suggest against using GnRH agonists except in women with severe forms of hyperandrogenemia (such as ovarian hyperthecosis) who have a suboptimal response to OCs and antiandrogens. (2 |OOO)
Because GnRH agonists alone result in severe hypoestrogenism and eventual bone loss (116), clinicians prescribe low doses of estrogen or estrogen plus progestin (in women with a uterus) as add-back therapy (117, 118).
Uncontrolled trials of GnRH agonist therapy in women with ovarian hyperandrogenism have reported significant reductions in luteinizing hormone, ovarian androgens, and Ferriman–Gallwey scores.
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