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Hirsutism

Key sources
The following summarized guidelines for the evaluation and management of hirsutism are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023), the American Academy of Family Physicians (AAFP 2019), the Endocrine Society (ES 2018), and the American College of Obstetricians and Gynecologists (ACOG 2018).
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Guidelines

1.Screening and diagnosis

Etiology: recognize that:
hyperandrogenism in patients with PCOS may result from several mechanisms, including insulin resistance, hyperinsulinemia, elevated LH-related increases in theca cell androgen production, and increased adrenal androgen output
PCOS is the most common cause of hirsutism, with idiopathic hirsutism being the second most common
hirsutism is not a diagnosis but a symptom/sign requiring evaluation for the underlying etiology. (high)
A
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2.Classification and risk stratification

Classification: consider classifying hirsutism into 1 of 3 following groups based on etiology:
hyperandrogenic hirsutism, including PCOS, nonclassical congenital adrenal hyperplasia, or androgen-secreting tumors
non-androgenic hirsutism, including medication-induced hirsutism
idiopathic hirsutism
C

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  • Severity assessment

3.Diagnostic investigations

History and physical examination: elicit a focused history, perform a physical examination with anthropometric measurements, and obtain appropriate investigations to differentiate between the possible etiologies in patients presenting with hirsutism.
B

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  • Serum testosterone levels

  • Screening for non-classic congenital adrenal hyperplasia

4.Medical management

General principles
As per SOGC 2023 guidelines:
Offer therapy in all patients with hirsutism desiring treatment.
E
Offer multimodal treatment combining physical hair removal techniques and medical therapies in patients with hirsutism. Offer at least 6 months of medical therapy to observe a significant improvement in hirsutism.
B

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  • Oral contraceptives

  • Antiandrogens

  • Combination therapy

  • GnRH agonists

  • Insulin-lowering drugs

5.Nonpharmacologic interventions

Lifestyle modifications: advise lifestyle changes in patients with hirsutism and obesity, including patients with PCOS.
B

6.Therapeutic procedures

Hair removal
As per SOGC 2023 guidelines:
Consider offering mechanical hair removal and/or topical treatments as first-line therapy or as an adjuvant to medical therapy in patients with hirsutism.
B
Recognize that hair growth tends to recur after discontinuing medical therapy, while laser hair removal, intense pulsed light, and electrolysis produce permanent hair reduction.
B

7.Follow-up and surveillance

Indications for specialist referral: refer patients to a reproductive endocrinologist (or another practitioner with similar expertise) for evaluation in the presence of any of the following:
virilization
serum testosterone or DHEAS levels more than twice the ULN
signs or symptoms of Cushing's syndrome
early menstrual phase serum 17-hydroxyprogesterone levels > 6 nmol/L
A