A Hairy Topic – Hirsutism

Do you know the 3 most common etiologies and the SOGC 3-pronged approach?

Hirsutism can be a really frustrating condition for a large number of patients, and having a solid approach to the condition can really benefit patients.

A key tip you will want to counsel your patients on the exam and in real life is that at least 6-9 months of pharmacological therapy are required to produce improvement in many cases.

What’s the hirsutism score?

A number of medical conditions have scoring scales and hirsutism is one of them. The modified Ferriman-Gallwey Score (mFG) is a good way to document and then follow progress in patients.

Can you list the 3 categories?

The 3 most common categories of hirsutism are:

1. Hyperandrogenic (PCOS [MOST COMMON], Androgen secreting tumour)

2. Non-androgenic (Medication-induced, anabolic steroids) 3. Idiopathic

What are 3 things you would recommend to your patient?

The new SOGC guidelines recommend a 3-pronged approach:

1. Mechanical hair removal

2. Suppression of androgen production

3. Androgen receptor blockade

For bonus points – can you list a medication for # 2 and # 3? Read on! But before you do, in addition to the above don’t forget LIFESTYLE changes, specifically weight loss and exercise especially in patients with polycystic ovary syndrome.

The SOGC recommends combined hormonal contraceptive therapy as first-line treatment for women that desire treatment and depending on the patient’s goals an anti-androgen for moderate to severe hirsutism or to ensure an optimal response in milder hirsutism. Medications for these include: spironolactone, cyproterone acetate (combined with ethinyl estradiol, also known as Diane 35), finasteride, and flutamide.

Topical medications include Eflornithine hydrochloride, an ornithine decarboxylase inhibitor.

References:

SOGC Guideline No. 444: Hirsutism: Evaluation and Treatment (2023) SOGC Guideline No. 350-Hirsutism: Evaluation and Treatment (2017)

Am Fam Physician. 2019;100(3):168-175 https://www.aafp.org/pubs/afp/issues/2019/0801/p168.html