Definitions for the quality of the evidence (++++, +++O, ++OO, +OOO) and strength of recommendations (strong: 1, weak: 2) are provided at the end of the "Major Recommendations" field.
1.1. Diagnosis of hirsutism
1.1.1. We suggest against testing for elevated androgen levels in women with isolated mild hirsutism because the likelihood of identifying a medical disorder that would change management or outcome is low (2|+OOO).
1.1.2. We suggest testing for elevated androgen levels in women with (2|+OOO):
- Moderate or severe hirsutism
- Hirsutism of any degree when it is sudden in onset, rapidly progressive, or when associated with any of the following:
- Menstrual irregularity or infertility
- Central obesity
- Acanthosis nigricans
- Rapid progression
- Clitoromegaly
2.0. Treatment of hirsutism in premenopausal women
2.0. For women with patient-important hirsutism despite cosmetic measures, we suggest either pharmacological therapy or direct hair removal methods (2|+OOO). The choice between these options depends on (a) patient preferences, (b) the extent to which the area of hirsutism that affects wellbeing is amenable to direct hair removal, and (c) access to and affordability of these alternatives.
2.1. Pharmacological treatments
2.1.1. Monotherapy
2.1.1.1. For the majority of women, we suggest oral contraceptives to treat patient-important hirsutism (2|+OOO); because of its teratogenic potential, we recommend against antiandrogen monotherapy unless adequate contraception is used (1|+OOO).
2.1.1.2. For women who cannot or choose not to conceive, we suggest the use of either oral contraceptive preparations (OCPs) or antiandrogens (2|+OOO). The choice between these options depends on patient preferences regarding efficacy, side effects, and costs.
2.1.1.3. We suggest against the use of flutamide therapy (2|+OOO).
2.1.1.4. We suggest against the use of topical antiandrogen therapy for hirsutism (2|+OOO).
2.1.1.5. We suggest against using insulin-lowering drugs as therapy for hirsutism (2|+OOO).
2.1.1.6. For women with hirsutism who do not have classic or nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CYP21A2), we suggest against glucocorticoid therapy (2|+OOO). We suggest glucocorticoids for women with hirsutism due to nonclassic congenital adrenal hyperplasia (NCCAH) who have a suboptimal response to oral contraceptive preparations (OCPs) and/or antiandrogens, cannot tolerate them, or are seeking ovulation induction (2|+OOO).
2.1.1.7. We suggest against using gonadotropin-releasing hormone (GnRH) agonists except in women with severe forms of hyperandrogenemia, such as ovarian hyperthecosis, who have a suboptimal response to oral contraceptive preparations and antiandrogens (2|+OOO).
2.1.1.8. For all pharmacologic therapies for hirsutism, we suggest a trial of at least 6 months before making changes in dose, changing medication, or adding medication (2|+OOO).
2.1.2. Combination Therapy
2.1.2.1. If patient-important hirsutism remains despite 6 or more months of monotherapy with an oral contraceptive, we suggest adding an antiandrogen (2|++OO).
2.2. Direct hair removal methods
2.2.1. For women who choose hair removal therapy, we suggest laser/photoepilation (2|++OO). For women undergoing photoepilation therapy who desire a more rapid initial response, we suggest adding eflornithine cream during treatment (2|++OO). For women with known hyperandrogenemia who choose hair removal therapy, we suggest pharmacologic therapy to minimize hair regrowth (2|+OOO).
Definitions:
Quality of Evidence
High: ++++
Moderate: +++O
Low: ++OO
Very Low: +OOO
Strength of Recommendation
Strong: 1
Weak: 2
