Sandbox:SMMM

S.Mojdeh Mirmomen

Treatment

Shown below is an algorithm summarizing the treatment of hirsutism according the Endocrine Society Clinical Practice guidelines.

Initial therapy for patient with hirsutism

Mild hirsutism and no evidence of an endocrine disorder

Moderate or patient-important hirsutism

Severe hirsutism

Direct hair removal methods

Pharmacological therapy

Pharmacological therapy (add direct hair removal if needed)

Combined pharmacological therapy

• Photoepilation for women with auburn, brown, or black unwanted hair • Electrolysis for women with white or blonde hair

• Start oral contraceptives in women who are not seeking fertility ** Use oral contraceptives containing the lowest effective dose of ethinyl estradiol and a low-risk progestin for women at higher risk for venous thromboembolism (e.g., obese or >39 years old) • Start either oral contraceptives or anti-androgens in women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception

Oral contraceptives and antiandrogens

Add an antiandrogen if hirsutism remains despite 6 months of monotherapy with an oral contraceptive

Diagnosis

Shown below is an algorithm summarizing the diagnosis of disease name according the Endocrine Society Clinical Practice guideline.

Initial evaluation & diagnosis of hirsutism

History & physical examination including pelvic examination

Medication use? *Ask for anabolic or androgenic steroids (in athletes, patients who are using dietary supplements, patients with sexual dysfunction, or in patients with a partner who uses testosterone gel) and valproic acid (in patient with neurologic disorders

Discontinue medication

Isolated local hair growth

Direct hair removal methods

Improvement or stable

Normal variant

Abnormal hirsutism score or local hair growth with symptoms suggesting hyperandrogenic endocrine disorder*? *menstrual irregularity, infertility, galactorrhea, signs or symptoms of hypothyroidism, Cushing syndrome, acromegaly, central obesity,acanthosis nigricans, clitoromegaly, or sudden-onset or rapid-progression hirsutism suggests the presence of a hyperandrogenic endocrine disorder

Early morning total testosterone blood level

Progression or unstable

Normal

Elevated

Mild isolated hirsutism

Moderate to severe hirsutism or presence of hyperandrogenic endocrine disorder

Direct hair removal methods or oral contraceptive