Women with hirsutism may be too embarrassed to discuss the condition or what they
have been doing to remove the excess hair. Hirsutism can have a major impact on quality
of life, and many women will be anxious, have a low self-esteem, or have concerns about
sexual self-worth.
Although there is no single easy answer, treatments can make a difference, and most
women will value the opportunity to talk to a sensitive physician about what can be done.
Any underlying cause of androgen excess should be controlled, and drugs contributing to
hirsutism withdrawn. The choice of treatment for reducing or removing hair will depend
on the patient’s preference, the distribution and severity of hirsutism, and the cost of
treatment (most are not provided through the NHS).
Topical treatments
• Bleaching with hydrogen peroxide preparations may make dark facial hair less obvious
but can be irritant.
• Depilatory creams or foams containing thioglycolates that dissolve hair are widely
available but smell unpleasant, are irritant, and are not very effective for coarse hair.
• Eflornithine cream (inhibitor of ornithine decarboxylase) applied bd reduces the rate of
growth of hair after 6–8 weeks. May irritate or induce acne. Once treatment is
discontinued, the hair growth returns to pretreatment levels. Eflornithine is helpful in
combination with mechanical treatments.
Mechanical treatments
• Shaving: regrowing hairs have a blunt tip which may make them look thicker than
before. Although women are prepared to shave their legs or axillae, most do not find it
acceptable to shave the face. Shaving may cause a folliculitis, particularly on the thighs.
• Epilation: plucking, waxing, threading, or sugaring to extract hairs. Contrary to popular
opinion, epilation does not make hairs grow back more thickly. Epilation is
uncomfortable. Irritation and folliculitis are common. Post-inflammatory
hyperpigmentation may be a problem in dark skin.
• Electrolysis is effective and can permanently destroy some hair follicles (about 60%),
but the outcome depends on the skill of the operator. Complications include scarring and
infection.
• Laser hair removal (photoepilation) is most effective for dark hairs on fair skin (laser
energy is absorbed by melanin in the hair follicle, and not the surrounding epidermis).
Treatment interrupts hair growth temporarily, but regrowing hairs may be finer and
lighter. Some permanent hair loss may be achieved after repeated treatments. Laser
treatment is considerably more expensive than electrolysis but is also more effective and
faster.
Oral therapy
– Combined oral contraceptive containing the progestin cyproterone acetate (2mg).
– Spironolactone
– Finasteride
– Ensure that premenopausal women taking anti-androgens always use effective
contraception to avoid the potential risk of feminization of a male fetus. Explain anti-
androgens can be effective in the absence of abnormal androgen levels. Benefits lost
within months of treatment withdrawal.
– Insulin-sensitizing drugs, e.g. metformin, lower insulin levels in hyperinsulinaemia by
increasing sensitivity to insulin. Metformin also attenuates both hyperinsulinaemia and
hyperandrogenaemia, and may reduce hirsutism in patients with PCOS but is less
effective than spironolactone.