Hirsutism

Endocrine causes of hirsutism include:

• Ovarian cysts such as in polycystic ovary syndrome (PCOS), the most common cause in women.[12]
• Adrenal gland tumors, adrenocortical adenomas, and adrenocortical carcinoma, as well as adrenal hyperplasia due to pituitary adenomas (as in Cushing's disease).[13]
• Inborn errors of steroid metabolism such as in congenital adrenal hyperplasia, most commonly caused by 21-hydroxylase deficiency.[13]
• Acromegaly and gigantism (growth hormone and IGF-1 excess), usually due to pituitary tumors.[13]

Causes of hirsutism not related to hyperandrogenism include:

• Familial: Family history of hirsutism with normal androgen levels.[14]
• Drug-induced: medications were used before the onset of hirsutism. The recommendation is to stop the medication and replace it with another.[15]
  • Minoxidil[16][17]
  • Androgens like testosterone, anabolic steroids, and androgenic progestins[14][15]
• Valproic acid and methyldopa[14][15]
• Pregnancy: Due to changes in hormone production[18]
• Idiopathic: When no other cause can be attributed to an individual's hirsutism, the cause is considered idiopathic by exclusion.[15] In these cases, menstrual cycles and levels of conventionally tested androgens (testosterone, androstenedione, and dehydroepiandrosterone sulfate) are normal.[19] Around 10 to 15% of women with hirsutism have idiopathic hirsutism.[10] Idiopathic hirsutism may be due to increased production of dihydrotestosterone (DHT) in hair follicles and hence may actually still be due to hyperandrogenism.[10] It may be detectable by measurement of DHT or DHT metabolites.[10]

Common medications consist of antiandrogens, insulin sensitizers, and oral contraceptive pills. All three types of therapy have demonstrated efficacy on their own, however insulin sensitizers are shown to be less effective than antiandrogens and oral contraceptive pills.[30] The therapies may be combined, as directed by a physician, in line with the patient's medical goals. Antiandrogens are drugs that block the effects of androgens like testosterone and dihydrotestosterone (DHT) in the body.[13] They are the most effective pharmacologic treatment for patient-important hirsutism, however they have teratogenic potential, and are therefore not recommended in people who are pregnant or desire pregnancy. Current data does not favor any one type of oral contraceptive over another.[30]

List of medications:

• Bicalutamide: A pure antiandrogen.[31][32][33] It is effective similarly to flutamide but is much safer as well as better-tolerated.[31][32][33]
• Birth control pills that consist of an estrogen, usually ethinylestradiol, and a progestin are supported by the evidence.[34][1] They are functional antiandrogens. In addition, certain birth control pills contain a progestin that also has antiandrogenic activity.[35] Examples include birth control pills containing cyproterone acetate, chlormadinone acetate, drospirenone, and dienogest.[35][36]
• Cyproterone acetate: A dual antiandrogen and progestogen.[37] In addition to single form, it is also available in some formulations of combined oral contraceptives at a low dosage (see below).[37] It has a risk of liver damage.
• Eflornithine: Blocks putrescine that is necessary for the growth of hair follicles.[38]
• Finasteride and dutasteride: 5α-Reductase inhibitors.[36] They inhibit the production of the potent androgen DHT.[36] A meta-analysis showed inconsistent results of finasteride in the treatment of hirsutism.[34]
• Flutamide: A pure antiandrogen.[37] It has been found to possess equivalent or greater effectiveness than spironolactone, cyproterone acetate, and finasteride in the treatment of hirsutism.[39][37] However, it has a high risk of liver damage and hence is no longer recommended as a first- or second-line treatment.[40][41][36][42] Flutamide is safe and effective.[34]
• GnRH analogues: Suppress androgen production by the gonads and reduce androgen concentrations to castrate levels.[43]
• Metformin: Insulin sensitizer. Antihyperglycemic drug used for diabetes mellitus and treatment of hirsutism associated with insulin resistance (e.g. polycystic ovary syndrome). Metformin appears ineffective in the treatment of hirsutism, although the evidence was of low quality.[34]
• Spironolactone: An antimineralocorticoid with additional antiandrogenic activity at high dosages[44][37]

• Electrology
• Epilation
• Laser hair removal
• Lifestyle change, including reducing excessive weight and addressing insulin resistance, may be beneficial. Insulin resistance can cause excessive testosterone levels in women, resulting in hirsutism.[45]
• Shaving
• Waxing