Hirsutism may signal underlying disorder

National report - Hirsutism may signal an underlying medical condition including polycystic ovary syndrome (PCOS) or Cushing's syndrome that dermatologists can help detect without laboratory tests, says Marcelle Cedars, M.D., who also suggests several treatment plans available to the dermatologist.

"It is mostly a matter of evaluating menstrual cycles," says Dr. Cedars, who is professor of obstetrics and gynecology and reproductive sciences, University of California, San Francisco School of Medicine.

For instance, irregular cycles are likely to have an underlying condition like PCOS, which if unchecked has long-term risks, including diabetes, cardiovascular disease and endometrial carcinoma.

"Irregular menstrual cycles and hypertension would be the two symptoms that would be the most significant," she says.

Androgen-secreting tumors should be suspected if there is new onset, rapid progression and virilism.

In addition, researchers at the University of Alabama at Birmingham, support Dr. Cedars' recommendations. They suggest excluding associated disorders, such as ovulary dysfunction, adrenal hyperplasia, diabetes and thyroid hormone abnormalities, and using a combination of treatment options for hirsutism.

Management options

"You need medical modalities (such as oral contraceptives and anti-androgens) to stop new hair growth and a mechanical modality (depilatories, electrolysis or laser treatments) to get rid of the hair that's already there.

"Neither technique alone will solve the problem," Dr. Cedars tells Dermatology Times.

Removing current hair is a matter of patient preference. Waxes and creams are effective but painful. The long available electrolysis is slipping in popularity to laser removal.

However, she says, "I am not sure for the majority of women that there is a lot of data to suggest the laser is better than electrolysis."

Free testosterone suppression is most needed to manage hirsutism caused by either a known condition or idiopathic, but it takes a combination of methods to be effective. Oral contraceptives are often a first line drug treatment. They suppress testosterone either through increasing sex hormone-binding globulin (SHBG) or regulating luteinizing hormone (LH) overproduction.

Another approach includes the use of the spironolactone and, more recently, finasteride and flutamide.

"Really neither of those have any benefit over spironolactone, which is less expensive and probably safer," Dr. Cedars says.

International research

Turkish researchers followed 65 hirsute women randomly assigned to take spironolactone alone (100 mg/day) or combined with finasteride (5 mg/day).

After one year, hirsutism scores decreased significantly in both groups, however, the percentage of change was higher among the double therapy group (51 percent) than spironolactone alone (36 percent). Adverse effects were similar in both groups leading investigators to conclude that the combination of spironolactone plus finasteride was safe and effective to treat hirsutism.

An Italian study group randomized 40 hirsute women to take one of three drugs or placebo in a double blind study. Patients in the treatment groups received either spironolactone (100 mg/day), finasteride (5 mg/day) or flutamide (250 mg/day). After six months all three were equally effective at reducing hair diameters and Ferriman-Gallwey scores.

However, another Italian group concluded that spironolactone is dose-dependent with higher doses (200 mg/day) more effective against hirsutism. The trade-off is increased adverse effects, including dysfunctional uterine bleeding, which, in turn, should be treated with combined oral contraceptives. Hepatoxicity is a risk at high doses of flutamide and dry skin at all strengths, which appeared as effective in treating hirsutism within six to 12 months. Finasteride patients showed no adverse effects, but the authors felt the five-alpha reductase type two inhibitor was also the least effective anti-androgen while still showing improvement.

Dermatology gateway

"Dermatologists are the entrance to the medical system for a lot of these women, and I think that's an important role," says Dr. Cedars, who is part of a collaborative PCOS treatment group that includes a dermatologist as a core partner.