Hirsutism medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Hirsutism}}
{{Hirsutism}}
{{CMG}}; {{AE}}{{Ochuko}},{{RHN}}
{{CMG}}; {{AE}}{{EG}}


==Overview==
==Overview==


Pharmacologic medical therapies for hirsituism include [[oral contraceptives]], [[antiandrogen therapy|androgen receptor blockers]], [[5-alpha-reductase inhibitor|5-alpha reductase inhibitors]], [[GnRH|gonadotrophin-releasing hormone]] ([[GnRH agonist]]), [[adrenal]] suppressive [[glucocorticoids]], [[insulin]]-sensitising agents, and biological modifiers of hair follicular growth. Treatment options are [[systemic therapy]] and [[topical|topical therapy]].
Pharmacologic medical therapies for hirsituism include [[oral contraceptives]], [[antiandrogen therapy|androgen receptor blockers]], [[5-alpha-reductase inhibitor|5-alpha reductase inhibitors]], [[GnRH|gonadotrophin-releasing hormone]] ([[GnRH agonist]]), [[adrenal]] suppressive [[glucocorticoids]], [[insulin]]-sensitising agents, and biological modifiers of hair follicular growth. Treatment options are [[systemic therapy]] and [[topical|topical therapy]].
==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapies for hirsituism include:<ref name="pmid20418968">{{cite journal| author=Sachdeva S| title=Hirsutism: evaluation and treatment. | journal=Indian J Dermatol | year= 2010 | volume= 55 | issue= 1 | pages= 3-7 | pmid=20418968 | doi=10.4103/0019-5154.60342 | pmc=2856356 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20418968  }} </ref>  
*Pharmacologic medical therapies for hirsituism include:<ref name="pmid20418968">{{cite journal| author=Sachdeva S| title=Hirsutism: evaluation and treatment. | journal=Indian J Dermatol | year= 2010 | volume= 55 | issue= 1 | pages= 3-7 | pmid=20418968 | doi=10.4103/0019-5154.60342 | pmc=2856356 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20418968  }} </ref>  
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*1. '''Adult'''
*1. '''Adult'''
**1.1 '''Systemic therapy'''
**1.1 '''Systemic therapy'''
*** Preferred regimen (1): [[Ethinyl estradiol]] 30 μg '''''PLUS''''' [[norethindrone]] l mg PO daily over a 9-month period<ref name="pmid2136834">{{cite journal |vauthors=Murphy A, Cropp CS, Smith BS, Burkman RT, Zacur HA |title=Effect of low-dose oral contraceptive on gonadotropins, androgens, and sex hormone binding globulin in nonhirsute women |journal=Fertil. Steril. |volume=53 |issue=1 |pages=35–9 |year=1990 |pmid=2136834 |doi= |url=}}</ref>   
*** Preferred regimen (1): [[Ethinyl estradiol]] 30 μg '''''PLUS''''' [[norethindrone]] 1 mg PO daily over a 9-month period<ref name="pmid2136834">{{cite journal |vauthors=Murphy A, Cropp CS, Smith BS, Burkman RT, Zacur HA |title=Effect of low-dose oral contraceptive on gonadotropins, androgens, and sex hormone binding globulin in nonhirsute women |journal=Fertil. Steril. |volume=53 |issue=1 |pages=35–9 |year=1990 |pmid=2136834 |doi= |url=}}</ref>   
*** Preferred regimen (2): [[Mestranol]] 100 μg '''''PLUS''''' [[norethindrone]] 2 mg PO daily for about 2 weeks<ref name="GivensAndersen1974">{{cite journal|last1=Givens|first1=James R.|last2=Andersen|first2=Richard N.|last3=Wiser|first3=Winfred L.|last4=Fish|first4=Stewart A.|title=Dynamics of Suppression and Recovery of Plasma FSH, LH, Androstenedione and Testosterone in Polycystic Ovarian Disease Using an Oral Contraceptive|journal=The Journal of Clinical Endocrinology & Metabolism|volume=38|issue=5|year=1974|pages=727–735|issn=0021-972X|doi=10.1210/jcem-38-5-727}}</ref>
*** Preferred regimen (2): [[Mestranol]] 100 μg '''''PLUS''''' [[norethindrone]] 2 mg PO daily for about 2 weeks<ref name="GivensAndersen1974">{{cite journal|last1=Givens|first1=James R.|last2=Andersen|first2=Richard N.|last3=Wiser|first3=Winfred L.|last4=Fish|first4=Stewart A.|title=Dynamics of Suppression and Recovery of Plasma FSH, LH, Androstenedione and Testosterone in Polycystic Ovarian Disease Using an Oral Contraceptive|journal=The Journal of Clinical Endocrinology & Metabolism|volume=38|issue=5|year=1974|pages=727–735|issn=0021-972X|doi=10.1210/jcem-38-5-727}}</ref>
*** Preferred regimen (3): [[Ethinyl estradiol]] 30 μg '''''PLUS''''' [[desogesterol]] 150 mcg PO daily for 4-7 months<ref name="pmid3156694">{{cite journal |vauthors=Dewis P, Petsos P, Newman M, Anderson DC |title=The treatment of hirsutism with a combination of desogestrel and ethinyl oestradiol |journal=Clin. Endocrinol. (Oxf) |volume=22 |issue=1 |pages=29–36 |year=1985 |pmid=3156694 |doi= |url=}}</ref>
*** Preferred regimen (3): [[Ethinyl estradiol]] 30 μg '''''PLUS''''' [[desogestrel]] 150 mcg PO daily for 4-7 months<ref name="pmid3156694">{{cite journal |vauthors=Dewis P, Petsos P, Newman M, Anderson DC |title=The treatment of hirsutism with a combination of desogestrel and ethinyl oestradiol |journal=Clin. Endocrinol. (Oxf) |volume=22 |issue=1 |pages=29–36 |year=1985 |pmid=3156694 |doi= |url=}}</ref>
*** Preferred regimen (4): [[Spironolactone]] starting dose of 50 mg PO q12h; may be increased to 200 mg PO daily.<ref name="pmid1826112">{{cite journal |vauthors=Shaw JC |title=Spironolactone in dermatologic therapy |journal=J. Am. Acad. Dermatol. |volume=24 |issue=2 Pt 1 |pages=236–43 |year=1991 |pmid=1826112 |doi= |url=}}</ref>  
*** Preferred regimen (4): [[Spironolactone]] starting dose of 50 mg PO q12h; may be increased to 200 mg PO daily.<ref name="pmid1826112">{{cite journal |vauthors=Shaw JC |title=Spironolactone in dermatologic therapy |journal=J. Am. Acad. Dermatol. |volume=24 |issue=2 Pt 1 |pages=236–43 |year=1991 |pmid=1826112 |doi= |url=}}</ref>  
*** Alternative regimen (1): [[Cyproterone|Cyproterone Acetate]] 50-100 mg PO daily<ref name="pmid12749435">{{cite journal |vauthors=Lumachi F, Rondinone R |title=Use of cyproterone acetate, finasteride, and spironolactone to treat idiopathic hirsutism |journal=Fertil. Steril. |volume=79 |issue=4 |pages=942–6 |year=2003 |pmid=12749435 |doi= |url=}}</ref>
*** Alternative regimen (1): [[Cyproterone|Cyproterone Acetate]] 50-100 mg PO daily<ref name="pmid12749435">{{cite journal |vauthors=Lumachi F, Rondinone R |title=Use of cyproterone acetate, finasteride, and spironolactone to treat idiopathic hirsutism |journal=Fertil. Steril. |volume=79 |issue=4 |pages=942–6 |year=2003 |pmid=12749435 |doi= |url=}}</ref>
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*** Preferred regimen (1): [[Eflornithine|Eflornithine hydrochloride]] 13.9% cream topical q12h<ref name="pmid18252793">{{cite journal |vauthors=Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, Shapiro J, Montori VM, Swiglo BA |title=Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline |journal=J. Clin. Endocrinol. Metab. |volume=93 |issue=4 |pages=1105–20 |year=2008 |pmid=18252793 |doi=10.1210/jc.2007-2437 |url=}}</ref>  
*** Preferred regimen (1): [[Eflornithine|Eflornithine hydrochloride]] 13.9% cream topical q12h<ref name="pmid18252793">{{cite journal |vauthors=Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, Shapiro J, Montori VM, Swiglo BA |title=Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline |journal=J. Clin. Endocrinol. Metab. |volume=93 |issue=4 |pages=1105–20 |year=2008 |pmid=18252793 |doi=10.1210/jc.2007-2437 |url=}}</ref>  
*** Preferred regimen (2): [[Finasteride]] 0.25% or 0.5% cream topical daily<ref name="pmid22658123">{{cite journal |vauthors=Farshi S, Mansouri P, Rafie F |title=A randomized double blind, vehicle controlled bilateral comparison study of the efficacy and safety of finasteride 0.5% solution in combination with intense pulsed light in the treatment of facial hirsutism |journal=J Cosmet Laser Ther |volume=14 |issue=4 |pages=193–9 |year=2012 |pmid=22658123 |doi=10.3109/14764172.2012.699680 |url=}}</ref>
*** Preferred regimen (2): [[Finasteride]] 0.25% or 0.5% cream topical daily<ref name="pmid22658123">{{cite journal |vauthors=Farshi S, Mansouri P, Rafie F |title=A randomized double blind, vehicle controlled bilateral comparison study of the efficacy and safety of finasteride 0.5% solution in combination with intense pulsed light in the treatment of facial hirsutism |journal=J Cosmet Laser Ther |volume=14 |issue=4 |pages=193–9 |year=2012 |pmid=22658123 |doi=10.3109/14764172.2012.699680 |url=}}</ref>


{| class="wikitable"
{| class="wikitable"
!Type of amenorrhea
!Group
! colspan="2" |Medicine
!Medicine
!Dosage
!Dosage
!Treatment duration
!Mechanism of action
!Bone mineral density (BMD) site
!Side effect
!Outcome
!Notes
|-
|-
| rowspan="21" |[[Exercise]]-associated
| rowspan="3" |[[Oral contraceptive|Oral Contraceptive Pills (OCPs)]]
functional amenorrhea
|[[Ethinyl estradiol]]/<br>[[Norethindrone]]
| colspan="2" |[[Ethinyl estradiol]]
|30 μg /<br> 1.0 mg
|0.035 mg
| rowspan="3" |
| rowspan="2" |12 months
* Inhibiting [[androgen]] secretion by the [[ovaries]]
| rowspan="2" |[[Lumbar spine]] and [[femoral neck]]
* Increasing [[sex hormone binding globulin|sex hormone binding globulin (SHBG)]] production by the [[liver]]
| rowspan="2" |Increased [[Bone mineral density|BMD]] in all sites<ref name="pmid9166162">{{cite journal |vauthors=Hergenroeder AC, Smith EO, Shypailo R, Jones LA, Klish WJ, Ellis K |title=Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone, or placebo over 12 months |journal=Am. J. Obstet. Gynecol. |volume=176 |issue=5 |pages=1017–25 |year=1997 |pmid=9166162 |doi= |url=}}</ref>
* Inhibiting adrenal [[androgen]] production
| rowspan="3" |
* Increased risk of [[venous thromboembolism]]
* [[Breast]] tenderness
* [[Headache]]
* [[Gastrointestinal]] symptoms
| rowspan="3" |
*Absolute contraindications
**[[Smoking]] over the age of 35 (>15 cigarettes per day)
**[[Hypertension]]
**[[Ischemic heart disease]]
**[[Migraine]] headache with [[focal neurological symptoms]]
**[[Breast cancer]] (current)
**[[Diabetes]] with [[retinopathy]]/[[nephropathy]]/[[neuropathy]]
**Severe [[cirrhosis]]
**[[Liver tumour]] ([[adenoma]] or [[hepatoma]])
|-
|-
| colspan="2" |[[Norethindrone]]
|[[Mestranol]]/[[norethindrone]]  
[[Medroxyprogesterone]]
|100 μg / 2mg
|0.5-1.0 mg
10 mg
|-
|-
| colspan="2" |[[Ethinyl estradiol]]
|[[Ethinyl estradiol]]/<br>[[desogestrel]]  
|0.03 or 0.02 mg
|30 μg /<br> 150 mcg
| rowspan="2" |12 months
| rowspan="2" |[[Lumbar spine]]
| rowspan="2" |Increased [[Bone mineral density|BMD]] in all sites<ref name="pmid11725730">{{cite journal |vauthors=Castelo-Branco C, Vicente JJ, Pons F, Martínez de Osaba MJ, Casals E, Vanrell JA |title=Bone mineral density in young, hypothalamic oligoamenorrheic women treated with oral contraceptives |journal=J Reprod Med |volume=46 |issue=10 |pages=875–9 |year=2001 |pmid=11725730 |doi= |url=}}</ref>
|-
|-
| colspan="2" |[[Desogestrel]]
| rowspan="5" |[[Antiandrogens]]
|0.15 mg
|[[Spironolactone]]
|100-200 mg
|
* [[Antagonist]] of both [[aldosterone]] and [[androgen]] receptor
* Competes with [[Dihydrotestosterone|dihydrotestosterone (DHT)]] for binding to the [[androgen]] receptor
* Variable progestational activity
* Decreases production of [[ovarian]] [[androgens]]
* Inhibitory effect on 5 alpha-reductase activity (5-RA)
* Competes with [[androgens]] for binding to [[sex hormone binding globulin|SHBG]]
|
* [[Abnormal uterine bleeding|Irregular menstrual bleeding]]
* [[Headache]]
* [[Hypotension]]
* [[Nausea]]
* Decreased [[libido]]
|
*Contraindications
**[[Renal insufficiency]]
**[[Hyperkalaemia]]
|-
|-
| colspan="2" |[[Ethinyl estradiol]]
|[[Cyproterone|Cyproterone Acetate]]
|0.030 mg
|50-100 mg
| rowspan="2" |10 months
| rowspan="2" |
| rowspan="2" |[[Lumbar spine]] and legs
*Competes with [[dihydrotestosterone]] for the [[androgen]] receptor
| rowspan="2" |Increase [[Bone mineral density|BMD]] in [[lumbar spine]] not in legs<ref name="pmid15328063">{{cite journal |vauthors=Rickenlund A, Carlström K, Ekblom B, Brismar TB, Von Schoultz B, Hirschberg AL |title=Effects of oral contraceptives on body composition and physical performance in female athletes |journal=J. Clin. Endocrinol. Metab. |volume=89 |issue=9 |pages=4364–70 |year=2004 |pmid=15328063 |doi=10.1210/jc.2003-031334 |url=}}</ref>
*Inhibits 5α-reductase
*Decrease in circulating [[testosterone]] and [[androstenedione]] levels through a reduction in circulating [[luteinizing hormone|luteinizing hormone (LH)]]
| rowspan="2" |
*[[Liver]] toxicity
*[[Abnormal uterine bleeding|Irregular menstrual bleeding]]
*[[Nausea]]
*Decreased [[libido]]
| rowspan="2" |
-
|-
|-
| colspan="2" |[[Levonorgestrel]]
|[[Cyproterone|Cyproterone Acetate]]/<br>[[ethinyl estradiol]]
|0.150 mg
| 2 mg /<br> 35 μg
|-
|-
| colspan="2" |[[Ethinyl estradiol]]
|[[Flutamide]]
|0.05 mg
|125-250 mg
| rowspan="2" |8 months
| rowspan="2" |
| rowspan="2" |[[Lumbar spine]] and [[radius]]
*Non-steroidal, [[competitive inhibitors]] of [[androgen]] receptor binding
| rowspan="2" |Increase [[Bone mineral density|BMD]] in [[lumbar spine]] not in [[radius]]<ref name="pmid2970444">{{cite journal |vauthors=De Crée C, Lewin R, Ostyn M |title=Suitability of cyproterone acetate in the treatment of osteoporosis associated with athletic amenorrhea |journal=Int J Sports Med |volume=9 |issue=3 |pages=187–92 |year=1988 |pmid=2970444 |doi= |url=}}</ref>
| rowspan="2" |
*[[Hepatotoxicity]]
*[[Fulminant liver failure]]
| rowspan="2" |
* Contraindication
**[[Fulminant liver failure]]
|-
|-
| colspan="2" |[[Cyproterone acetate]]
|[[Bicalutamide ]]
|2 mg
|25 mg
|-
|-
| colspan="2" |Conjugated [[estrogen]]
| rowspan="2" |[[5-alpha-reductase inhibitor|5-alpha reductase inhibitors]]
|0.0625 mg
|[[Finasteride]]  
| rowspan="2" |24 months
|1-5 mg
| rowspan="2" |[[Lumbar spine]] and [[femoral neck]]
| rowspan="2" |
| rowspan="2" |Increased [[Bone mineral density|BMD]] in all sites<ref name="pmid8885817">{{cite journal |vauthors=Cumming DC |title=Exercise-associated amenorrhea, low bone density, and estrogen replacement therapy |journal=Arch. Intern. Med. |volume=156 |issue=19 |pages=2193–5 |year=1996 |pmid=8885817 |doi= |url=}}</ref>
*Type II inhibitor of the [[5-alpha-reductase|5α-reductase enzyme]]
|-
*Reduces the conversion of [[testosterone]] into [[dihydrotestosterone]]
| colspan="2" |[[Transdermal]] [[estradiol]]
| rowspan="2" |
|0.05 mg
*[[Feminisation]] of the male fetus
|-
*[[Liver dysfunction]]
| rowspan="2" |12 days
| rowspan="2" |
|[[Estriol]]
-
|1 mg
| rowspan="7" |9.3 months
| rowspan="7" |[[Lumbar spine]], [[femoral neck]], and [[trochanter]]
| rowspan="7" |No change [[Bone mineral density|BMD]] in any sites<ref name="pmid10692976">{{cite journal |vauthors=Gibson JH, Mitchell A, Reeve J, Harries MG |title=Treatment of reduced bone mineral density in athletic amenorrhea: a pilot study |journal=Osteoporos Int |volume=10 |issue=4 |pages=284–9 |year=1999 |pmid=10692976 |doi=10.1007/s001980050228 |url=}}</ref>
|-
|[[Estradiol]]
|2 mg
|-
| rowspan="3" |10 days
|[[Estriol]]
|1 mg
|-
|[[Estradiol]]
|2 mg
|-
|[[Norethisterone]]
|1 mg
|-
|-
| rowspan="2" |6 days
|[[Dutasteride]]
|[[Estriol]]
|0.5 mg
|0.5 mg
|-
|-
|[[Estradiol]]
|[[GnRH|Gonadotrophin-releasing hormone]] ([[GnRH agonist]])
|1 mg
|[[Leuprolide]]  
|-
|7.5 mg
| colspan="2" |[[Premarin]]
|
|0.625 mg
*Suppress the [[hypothalamic-pituitary-gonadalaxis|hypothalamic-pituitary-ovarian axis]]
| rowspan="2" |24 months
*Inhibiting [[luteinising hormone|luteinising hormone (LH)]] and [[follicle-stimulating hormone|follicle-stimulating hormone (FSH)]]
| rowspan="2" |[[Lumbar spine]], [[wrist]], and [[foot]]
*Decreasing the secretion of [[androgens]] by the [[ovaries]]
| rowspan="2" |Increase [[Bone mineral density|BMD]] in [[lumbar spine]], neither in [[wrist]] nor in [[foot]]<ref name="pmid12909505">{{cite journal |vauthors=Warren MP, Brooks-Gunn J, Fox RP, Holderness CC, Hyle EP, Hamilton WG, Hamilton L |title=Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study |journal=Fertil. Steril. |volume=80 |issue=2 |pages=398–404 |year=2003 |pmid=12909505 |doi= |url=}}</ref>
|
|-
*If not combined with [[estrogen]]
| colspan="2" |[[Provera]]
**[[Menopausal]] symptoms
|10 mg
**[[Hot flushes]]
|-
**[[Osteoporosis]]
| colspan="2" |[[Ethinyl estradiol]]
|
|0.035 mg
*[[GnRH analogues]] not suggested for most women with hirsutism, because of:
| rowspan="2" |10 months
**Not seem to have advantages over other therapies
| rowspan="2" |[[Lumbar spine]] and [[femoral neck]]
**High price
| rowspan="2" |Increase [[Bone mineral density|BMD]] in [[lumbar spine]] not in [[femoral neck]]<ref name="pmid16102557">{{cite journal |vauthors=Warren MP, Miller KK, Olson WH, Grinspoon SK, Friedman AJ |title=Effects of an oral contraceptive (norgestimate/ethinyl estradiol) on bone mineral density in women with hypothalamic amenorrhea and osteopenia: an open-label extension of a double-blind, placebo-controlled study |journal=Contraception |volume=72 |issue=3 |pages=206–11 |year=2005 |pmid=16102557 |doi=10.1016/j.contraception.2005.03.007 |url=}}</ref>
**Need additional [[estrogen]] to prevent [[bone loss]] and [[menopausal]] symptoms
|-
| colspan="2" |[[Norgestimate]]
|0.180–0.250 mg
|-
| rowspan="16" |[[Anorexia]]-associated
functional amenorrhea
| colspan="2" |[[Ethinyl estradiol]]
|0.020–0.035 mg
| rowspan="2" |12 months
| rowspan="2" |[[Lumbar spine]] and [[femoral neck]]
| rowspan="2" |No change [[Bone mineral density|BMD]] in any sites<ref name="pmid12106749">{{cite journal |vauthors=Golden NH, Lanzkowsky L, Schebendach J, Palestro CJ, Jacobson MS, Shenker IR |title=The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa |journal=J Pediatr Adolesc Gynecol |volume=15 |issue=3 |pages=135–43 |year=2002 |pmid=12106749 |doi= |url=}}</ref>
|-
|-
| colspan="2" |[[Norgestimate]]
|[[Adrenal]] suppressive [[glucocorticoids]]
[[Norgestrel]]
|[[Prednisone]]  
 
|5-10 mg
[[Norethindrone acetate]]
|
 
*Used in cases of non-classic [[congenital adrenal hyperplasia]]
[[Levonorgestrel]]
*Suppress [[adrenocorticotropic hormone]] dependent [[adrenal]] [[androgen]] synthesis
|0.180–0.250 mg
|
0.5 mg
*[[Weight gain]]
 
*[[Osteoporosis]]
0.5-1.0 mg
*[[Adrenal suppression]]
 
|
-
-
|-
|-
| colspan="2" |[[Ethinyl estradiol]]
| rowspan="3" |[[Insulin]]-sensitising agents
|0.05 mg
|[[Metformin]]  
| rowspan="2" |12 months
|500-1000 mg
| rowspan="2" |[[Lumbar spine]]
| rowspan="3" |
| rowspan="2" |No change [[Bone mineral density|BMD]]<ref name="pmid11751066">{{cite journal |vauthors=Muñoz MT, Morandé G, García-Centenera JA, Hervás F, Pozo J, Argente J |title=The effects of estrogen administration on bone mineral density in adolescents with anorexia nervosa |journal=Eur. J. Endocrinol. |volume=146 |issue=1 |pages=45–50 |year=2002 |pmid=11751066 |doi= |url=}}</ref>
*Decrease [[hyperinsulinaemia]] by increasing [[insulin sensitivity]]
|-
*Lower [[insulin]] levels result in an increase of [[sex hormone binding globulin|SHBG]], thereby reducing the levels of circulating free [[androgens]]
| colspan="2" |[[Norgestrel]]
| rowspan="3" |
|0.5 mg
*[[Gastrointestinal]] distress
|-
*Increased risk of [[cardiovascular events]]
| colspan="2" |[[Premarin]]
*[[Liver dysfunction]]
|0.625 mg
*[[Lactic acidosis]]
| rowspan="3" |18 months
| rowspan="3" |
| rowspan="3" |[[Lumbar spine]]
*These are best choices for hirsutism along with [[insulin resistance]]
| rowspan="3" |No change [[Bone mineral density|BMD]]<ref name="pmid7883849">{{cite journal |vauthors=Klibanski A, Biller BM, Schoenfeld DA, Herzog DB, Saxe VC |title=The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=3 |pages=898–904 |year=1995 |pmid=7883849 |doi=10.1210/jcem.80.3.7883849 |url=}}</ref>
*It is not suggested to prescribe these [[drugs]] just for hirsutism
|-
| colspan="2" |[[Provera]]
|5 mg
|-
| colspan="2" |[[Ethinyl estradiol]]
|0.035 mg
|-
| colspan="2" |[[Premarin]]
|0.3–0.625 mg daily
|4.3 years
|[[Lumbar spine]] and [[femoral neck]]
|Increased [[Bone mineral density|BMD]] in all sites<ref name="pmid10999805">{{cite journal |vauthors=Karlsson MK, Weigall SJ, Duan Y, Seeman E |title=Bone size and volumetric density in women with anorexia nervosa receiving estrogen replacement therapy and in women recovered from anorexia nervosa |journal=J. Clin. Endocrinol. Metab. |volume=85 |issue=9 |pages=3177–82 |year=2000 |pmid=10999805 |doi=10.1210/jcem.85.9.6796 |url=}}</ref>
|-
| colspan="2" |[[Ethinyl estradiol]]
|0.020 mg
| rowspan="3" |12 months
| rowspan="3" |[[Lumbar spine]] and [[femoral neck]]
| rowspan="3" |No change [[Bone mineral density|BMD]] in any sites<ref name="pmid12414853">{{cite journal |vauthors=Gordon CM, Grace E, Emans SJ, Feldman HA, Goodman E, Becker KA, Rosen CJ, Gundberg CM, LeBoff MS |title=Effects of oral dehydroepiandrosterone on bone density in young women with anorexia nervosa: a randomized trial |journal=J. Clin. Endocrinol. Metab. |volume=87 |issue=11 |pages=4935–41 |year=2002 |pmid=12414853 |doi=10.1210/jc.2002-020545 |url=}}</ref>
|-
| colspan="2" |[[Levonorgestrel]]
|0.1 mg
|-
| colspan="2" |[[DHEA|Dihydroepiandrostendion (DHEA)]]
|50 mg daily
|-
| colspan="2" |[[Recombinant]] [[Insulin-like growth factor 1|IGF-1]]
|30 mg/kg twice daily
| rowspan="3" |9 months
| rowspan="3" |[[Lumbar spine]], [[femoral neck]], and [[radius]]
| rowspan="3" |No change [[Bone mineral density|BMD]] in any sites<ref name="pmid12050268">{{cite journal |vauthors=Grinspoon S, Thomas L, Miller K, Herzog D, Klibanski A |title=Effects of recombinant human IGF-I and oral contraceptive administration on bone density in anorexia nervosa |journal=J. Clin. Endocrinol. Metab. |volume=87 |issue=6 |pages=2883–91 |year=2002 |pmid=12050268 |doi=10.1210/jcem.87.6.8574 |url=}}</ref>
|-
| colspan="2" |[[Ethinyl estradiol]]
|0.035 mg
|-
| colspan="2" |[[Norethindrone]]
|0.4 mg
|-
|-
| colspan="2" |[[Ethinyl estradiol]]
|[[Rosiglitazone]]  
|0.035 mg
|4-8 mg
| rowspan="2" |13 cycles
| rowspan="2" |[[Lumbar spine]] and [[femoral neck]]
| rowspan="2" |No significant change [[Bone mineral density|BMD]] in any sites<ref name="pmid17116511">{{cite journal |vauthors=Strokosch GR, Friedman AJ, Wu SC, Kamin M |title=Effects of an oral contraceptive (norgestimate/ethinyl estradiol) on bone mineral density in adolescent females with anorexia nervosa: a double-blind, placebo-controlled study |journal=J Adolesc Health |volume=39 |issue=6 |pages=819–27 |year=2006 |pmid=17116511 |doi=10.1016/j.jadohealth.2006.09.010 |url=}}</ref>
|-
|-
| colspan="2" |[[Norgestimate]]
|[[Pioglitazone]]  
|0.180–0.250 mg
|10-30 mg
|}
|}
==Medical Therapy==
===Pharmacologic Treatment===
====Hormonal Therapy====
* [[Oral contraceptives]] : Suppresses free [[testosterone]] level eg Yasmin which contains 30 microgram of [[estradiol]] and 3mg of drospirenone or Yaz (20microgram of estradiol and 3mg of drospirenone).
* [[Gonadotropin-releasing hormone agonist]]<nowiki/>s :An  alternative to [[oral contraceptives]]<ref name="Rosenfield2005">{{cite journal|last1=Rosenfield|first1=Robert L.|title=Hirsutism|journal=New England Journal of Medicine|volume=353|issue=24|year=2005|pages=2578–2588|issn=0028-4793|doi=10.1056/NEJMcp033496}}</ref>
If a [[tumor]] of [[ovaries]] or [[adrenal gland]]<nowiki/>s is the underlying cause of hirsutism, surgery may be the treatment option.
* Parenteral long acting gonadotropin-releasing hormone analogues <ref name="pmid20198556">{{cite journal| author=Klotz RK, Müller-Holzner E, Fessler S, Reimer DU, Zervomanolakis I, Seeber B et al.| title=Leydig-cell-tumor of the ovary that responded to GnRH-analogue administration - case report and review of the literature. | journal=Exp Clin Endocrinol Diabetes | year= 2010 | volume= 118 | issue= 5 | pages= 291-7 | pmid=20198556 | doi=10.1055/s-0029-1225351 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20198556  }} </ref> combined with OCPs containing estrogen and progestin for severe hirsutism not respinding to OCPs and antiandrogen e.g Leuprolide.
====Adrenal Suppression====
* Oral [[glucocorticoids]] : In patients with [[CAH]] eg Prednisone or Dexamethasone.
* Metformin for infertile women with [[PCOS]].
====Antiandrogens====
* [[Finasteride]]: A 5α-reductase inhibitor, 2.5mg daily. (this is rarely used because it causes fatal hepatitis with a high risk of being teratogenic.
* Eflornithine hydrochloride cream (Vaniqa): Applied twice daily to the face.
===Non-Pharmacologic Treatment===
* Cosmetic therapy : Bleaching, shaving, depilating agents, plucking, waxing treatments.
* Electrosurgical methods include electrosurgical [[epilation]] and [[Laser therapy]] which can remove unwanted hair for some women specially for women with dark hair and light skin.<ref name="Franks2012">{{cite journal|last1=Franks|first1=Stephen|title=The investigation and management of hirsutism|journal=Journal of Family Planning and Reproductive Health Care|volume=38|issue=3|year=2012|pages=182–186|issn=1471-1893|doi=10.1136/jfprhc-2011-100175}}</ref>
Light-source-assisted hair reduction (photoepilation) is a common method in the treatment of unwanted hair and is more effective than shaving, waxing and electrolysis.<ref name="pmid9681347">{{cite journal |vauthors=Dierickx CC, Grossman MC, Farinelli WA, Anderson RR |title=Permanent hair removal by normal-mode ruby laser |journal=Arch Dermatol |volume=134 |issue=7 |pages=837–42 |year=1998 |pmid=9681347 |doi= |url=}}</ref>
{| class="wikitable"
!Skin/hair color 
!Choice of photoepilation device
|-
|Light skin/dark hair 
|Relatively short wavelength 
|-
|Dark skin/dark hair 
|Relatively long wavelength or IPL(intense pulsed light)
|-
|Light/white hair 
|IPL + [[radiofrequency]]
|}<ref name="pmid14660273">{{cite journal |vauthors=Goh CL |title=Comparative study on a single treatment response to long pulse Nd:YAG lasers and intense pulse light therapy for hair removal on skin type IV to VI--is longer wavelengths lasers preferred over shorter wavelengths lights for assisted hair removal |journal=J Dermatolog Treat |volume=14 |issue=4 |pages=243–7 |year=2003 |pmid=14660273 |doi=10.1080/09546630310004171 |url=}}</ref>


==References==
==References==

Latest revision as of 22:59, 7 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Pharmacologic medical therapies for hirsituism include oral contraceptives, androgen receptor blockers, 5-alpha reductase inhibitors, gonadotrophin-releasing hormone (GnRH agonist), adrenal suppressive glucocorticoids, insulin-sensitising agents, and biological modifiers of hair follicular growth. Treatment options are systemic therapy and topical therapy.

Medical Therapy

Hirsutism

Group Medicine Dosage Mechanism of action Side effect Notes
Oral Contraceptive Pills (OCPs) Ethinyl estradiol/
Norethindrone 		30 μg /
1.0 mg
Mestranol/norethindrone 100 μg / 2mg
Ethinyl estradiol/
desogestrel 		30 μg /
150 mcg
Antiandrogens Spironolactone 100-200 mg
Cyproterone Acetate 50-100 mg

-

Cyproterone Acetate/
ethinyl estradiol 		2 mg /
35 μg
Flutamide 125-250 mg
Bicalutamide 25 mg
5-alpha reductase inhibitors Finasteride 1-5 mg

-

Dutasteride 0.5 mg
Gonadotrophin-releasing hormone (GnRH agonist) Leuprolide 7.5 mg
Adrenal suppressive glucocorticoids Prednisone 5-10 mg

-

Insulin-sensitising agents Metformin 500-1000 mg
  • These are best choices for hirsutism along with insulin resistance
  • It is not suggested to prescribe these drugs just for hirsutism
Rosiglitazone 4-8 mg
Pioglitazone 10-30 mg

References

  1. ↑ Sachdeva S (2010). "Hirsutism: evaluation and treatment". Indian J Dermatol. 55 (1): 3–7. doi:10.4103/0019-5154.60342. PMC 2856356. PMID 20418968.
  2. ↑ Murphy A, Cropp CS, Smith BS, Burkman RT, Zacur HA (1990). "Effect of low-dose oral contraceptive on gonadotropins, androgens, and sex hormone binding globulin in nonhirsute women". Fertil. Steril. 53 (1): 35–9. PMID 2136834.
  3. ↑ Givens, James R.; Andersen, Richard N.; Wiser, Winfred L.; Fish, Stewart A. (1974). "Dynamics of Suppression and Recovery of Plasma FSH, LH, Androstenedione and Testosterone in Polycystic Ovarian Disease Using an Oral Contraceptive". The Journal of Clinical Endocrinology & Metabolism. 38 (5): 727–735. doi:10.1210/jcem-38-5-727. ISSN 0021-972X.
  4. ↑ Dewis P, Petsos P, Newman M, Anderson DC (1985). "The treatment of hirsutism with a combination of desogestrel and ethinyl oestradiol". Clin. Endocrinol. (Oxf). 22 (1): 29–36. PMID 3156694.
  5. ↑ Shaw JC (1991). "Spironolactone in dermatologic therapy". J. Am. Acad. Dermatol. 24 (2 Pt 1): 236–43. PMID 1826112.
  6. ↑ Lumachi F, Rondinone R (2003). "Use of cyproterone acetate, finasteride, and spironolactone to treat idiopathic hirsutism". Fertil. Steril. 79 (4): 942–6. PMID 12749435.
  7. ↑ Van der Spuy ZM, le Roux PA (2003). "Cyproterone acetate for hirsutism". Cochrane Database Syst Rev (4): CD001125. doi:10.1002/14651858.CD001125. PMID 14583927.
  8. ↑ Faloia E, Filipponi S, Mancini V, Di Marco S, Mantero F (1998). "Effect of finasteride in idiopathic hirsutism". J. Endocrinol. Invest. 21 (10): 694–8. doi:10.1007/BF03350800. PMID 9854686.
  9. ↑ Castelo-Branco C, Cancelo MJ (2010). "Comprehensive clinical management of hirsutism". Gynecol. Endocrinol. 26 (7): 484–93. doi:10.3109/09513591003686353. PMID 20218823.
  10. ↑ Paparodis R, Dunaif A (2011). "The Hirsute woman: challenges in evaluation and management". Endocr Pract. 17 (5): 807–18. doi:10.4158/EP11117.RA. PMID 21856600.
  11. ↑ Blume-Peytavi U (2013). "How to diagnose and treat medically women with excessive hair". Dermatol Clin. 31 (1): 57–65. doi:10.1016/j.det.2012.08.009. PMID 23159176.
  12. ↑ Bode D, Seehusen DA, Baird D (2012). "Hirsutism in women". Am Fam Physician. 85 (4): 373–80. PMID 22335316.
  13. ↑ Escobar-Morreale HF, Carmina E, Dewailly D, Gambineri A, Kelestimur F, Moghetti P, Pugeat M, Qiao J, Wijeyaratne CN, Witchel SF, Norman RJ (2012). "Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society". Hum. Reprod. Update. 18 (2): 146–70. doi:10.1093/humupd/dmr042. PMID 22064667.
  14. ↑ Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, Shapiro J, Montori VM, Swiglo BA (2008). "Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline". J. Clin. Endocrinol. Metab. 93 (4): 1105–20. doi:10.1210/jc.2007-2437. PMID 18252793.
  15. ↑ Farshi S, Mansouri P, Rafie F (2012). "A randomized double blind, vehicle controlled bilateral comparison study of the efficacy and safety of finasteride 0.5% solution in combination with intense pulsed light in the treatment of facial hirsutism". J Cosmet Laser Ther. 14 (4): 193–9. doi:10.3109/14764172.2012.699680. PMID 22658123.

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