Guideline sources The following summarized guidelines for the evaluation and management of hirsutism are prepared by our editorial team based on guidelines from the Endocrine Society (ES 2018), the American College of Obstetricians and Gynecologists (ACOG 2018), and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2017). 1 2 3 Guidelines 1. Screening and diagnosis Etiology: recognize that insulin resistance and hyperinsulinemia may lead to hyperandrogenism in patients with PCOS. B Show 2 more 2. Classification and risk stratification Classification: Consider classifying hirsutism into 1 of 3 following groups based on etiology: https://web.pathway.md/diseases/recFbebjJD55qgBNf 1/5 6/24/23, 12:44 PM Hirsutism Pathway hyperandrogenic hirsutism (including PCOS or androgen-secreting tumors) non-androgenic hirsutism (including medication-induced hirsutism) idiopathic hirsutism. C Severity assessment: Consider using the Ferriman-Gallwey score in the assessment of hirsutism to help quantify the problem and help assess response to treatment, with a score of 8 representing excessive hair growth, and classify into the following categories: Situation Guidance Mild hirsutism < 15 Moderate 16-25 Severe. C > 25 3. Diagnostic investigations Initial evaluation: Elicit a focused history, perform a physical examination and obtain appropriate investigations to differentiate among the possible etiologies in the evaluation of patients presenting with hirsutism. B Obtain a comprehensive evaluation and, when applicable, explore the long-term health sequelae of hyperandrogenism and PCOS, including abnormal uterine bleeding, infertility and metabolic syndrome. B Serum testosterone levels: As per ES 2018 guidelines, consider obtaining androgen level measurement in all patients with an abnormal hirsutism score. C Show 2 more As per SOGC 2017 guidelines, obtain total testosterone in patients with moderate-to-severe hirsutism, although the benefit in mild hirsutism is questionable. Obtain additional testing in patients with irregular menses and/or signs of hyperandrogenism or other endocrinopathies. B Screening for non-classic CAH: Consider obtaining early morning 17-hydroxyprogesterone levels in the follicular phase (or on a random day) to screen for nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency in patients with hyperandrogenemia and amenorrhea or infrequent menses. C Consider obtaining early morning 17-hydroxyprogesterone levels to screen for nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency in patients with hirsutism at high risk of congenital adrenal hyperplasia (positive family history, member of a high-risk ethnic group), even if serum total and free testosterone are normal. C https://web.pathway.md/diseases/recFbebjJD55qgBNf 2/5 6/24/23, 12:44 PM Hirsutism Pathway 4. Medical management General principles: As per ES 2018 guidelines, recognize that there is no clear primary treatment for hirsutism in patients with PCOS. B As per ES 2018 guidelines, consider initiating pharmacological therapy in most patients with patient-important hirsutism despite cosmetic measures. Consider offering direct hair removal methods in patients desiring additional cosmetic benefit. Consider offering either approach in patients with mild hirsutism with no evidence of an endocrine disorder. C Show 2 more As per SOGC 2017 guidelines, offer multimodal treatment including physical hair removal techniques and medical therapies in patients with hirsutism. Offer at least 6 month of medical therapy to see a significant improvement in hirsutism. B Systemic antiandrogen therapy: As per ES 2018 guidelines, avoid using antiandrogen monotherapy as initial therapy (because of the teratogenic potential of these medications) in most patients with hirsutism unless patients use adequate contraception. D Show 2 more As per SOGC 2017 guidelines, consider initiating antiandrogen therapy in patients with moderate-to-severe hirsutism or to ensure an optimal response in milder hirsutism, depending on patient's goals of treatment. B Show 2 more Topical antiandrogen therapy: avoid using topical antiandrogen therapy in patients with hirsutism. D Oral contraceptives: As per ES 2018 guidelines, consider offering oral contraceptives as initial therapy for the treatment of patient-important hirsutism in the majority of patients with hirsutism not seeking fertility. C Show 3 more As per SOGC 2017 guidelines, offer combined hormonal contraceptives, if not contraindicated, as first-line therapy in all patients with hirsutism desiring treatment. A Combination therapy: Consider initiating combination therapy with an oral contraceptive and antiandrogen in patients with severe hirsutism causing emotional distress and/or in patients used oral contraceptives in the past not resulted in sufficient improvement. Avoid initiating combination therapy as a standard first-line approach. C Consider adding an antiandrogen if patient-important hirsutism remains despite 6 months of monotherapy with an oral contraceptive. C Topical eflornithine cream: https://web.pathway.md/diseases/recFbebjJD55qgBNf 3/5 6/24/23, 12:44 PM Hirsutism Pathway As per ACOG 2018 guidelines, consider adding eflornithine to laser treatment for the treatment of hirsutism. B As per ES 2018 guidelines, consider adding eflornithine topical cream during treatment in patients desiring more rapid response to photoepilation. C Insulin-lowering drugs: avoid using insulin-lowering drugs for the sole indication of treating hirsutism. D Gonadotropin-releasing hormone agonists: avoid using GnRH agonists except in patients with severe forms of hyperandrogenemia (such as ovarian hyperthecosis) having a suboptimal response to oral contraceptives and antiandrogens. D 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 ES 2018 guidelines, consider offering photoepilation in patients choosing hair removal therapy with unwanted auburn, brown or black hair, and electrolysis in patients with white or blonde hair. C Show 2 more As per SOGC 2017 guidelines: Offer laser hair removal and electrolysis for permanent hair reduction, recognizing that hair growth tends to recur after stopping medical therapy. B Consider offering mechanical hair removal and/or topical therapy as first-line therapy or as an adjuvant to medical therapy. B 7. Specific circumstances Adolescent patients: recognize that adolescents may present with hirsutism but the diagnosis of PCOS in young patients is controversial given that the diagnostic features of PCOS may be normal pubertal physiologic events. B 8. Follow-up and surveillance Indications for specialist referral: Refer patients to an endocrinologist or reproductive endocrinologist for evaluation in the presence of any of the following: virilization https://web.pathway.md/diseases/recFbebjJD55qgBNf 4/5 6/24/23, 12:44 PM Hirsutism Pathway serum testosterone or DHEA sulfate levels more than twice the ULN signs or symptoms of Cushing's syndrome early menstrual phase serum 17-hydroxyprogesterone levels > 6 nmol/L. B References 1. Kimberly Liu, Tarek Motan, Paul Claman. No. 350 Hirsutism: Evaluation and Treatment. J Obstet Gynaecol Can. 2017 Nov;39 11 1054 1068. Open 2. Martin KA, Anderson RR, Chang RJ et al. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018 Apr 1;103 4 1233 1257. Open 3. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins Gynecology. ACOG Practice Bulletin No. 194 Polycystic Ovary Syndrome. Obstet Gynecol. 2018 Jun;131 6):e157-e171. Open https://web.pathway.md/diseases/recFbebjJD55qgBNf 5/5