Treatment of hirsutism in PCOS

Journal Watch:

THERAPY OF ENDOCRINE DISEASE: 

Treatment of hirsutism in the polycystic ovary syndrome
Renato Pasquali and Alessandra Gambineri
Published online before print November 22, 2013, doi:10.1530/EJE-13-0585Eur J Endocrinol February 1, 2014170 R75-R90Highlights of an excellent review on the subject, recently accepted for publication:

• Hirsutism must be distinguished from Hypertrichosis and Virilisation
• Hirsutism (excess terminal hair in androgen sensitive area of the female body: upper lip, chin, chest, back, abdomen, arms& thighs) occurs in 3-15% of the normal population but occurs in almost 75% of women with PCOS. It is also more severe in obese women, especially those with abdominal fat.
• Women with a sudden, recent and rapid onset of hirsutism at any age must be evaluated to rule out tumors or drug interference. Slow onset mild hirsutism around puberty is usually due to PCOS.
• Androgens are also synthesized within the hair follicle. Thus, levels of androgens circulating in the blood correlates only partially but significantly with the modified Ferriman-Gallway score (mFG). However, it is important to test the circulating androgen levels in all women with hirsutism.
• The management of hirsutism depends, among other factors, on the age and severity and on how much it bothers the woman. Treatment may vary widely in different groups and may include lifestyle modifications, weight management, bariatric surgery, cosmetic and pharmacological intervention (topical and sytemic drugs.)
• A recent Cochrane review noted that Alexandrite and Diode Lasers may cause almost 50% reduction in unwanted hair in a few months of treatment. These work by exerting a folliculocitic effect.
• Topical Eflornithine may provide additional benefit in some women though it does not remove hair.
• Oral medication may include various Antiandrogens, Estrogen-Progestin compounds, Metformin etc.
• In morbidly obese women, when other conditions for bariatric surgery are met, such a surgery may give a significant weight reduction and thereby may resolve the phenotype of PCOS.
• Exercise and lifestyle interventions along with weight loss play an important role in the treatment of hirsutism. The presence of obesity reduces the clinical efficacy of various medications.
• The article explores the evidence backing the selection of oral medication in various groups of women with hirsutism, depending on their age, weight, stage in reproductive cycle, whether planning a pregnancy or not and other metabolic factors such as glucose intolerance and diabetes mellitus.