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Polycystic ovary syndrome - Management
How should I treat hirsutism?
- Rule out other causes of hirsutism.
- Measure serum testosterone and seek specialist advice if the level is greater than 5 nanomol/L (see Diagnostic investigations).
- Advise the woman to lose weight, if appropriate.
- Advise about cosmetic measures.
- Mild hirsutism can usually be managed by cosmetic measures alone.
- For more severe hirsutism, drug treatment may be required in addition to cosmetic measures.
- If additional treatment is required, offer co-cyprindiol (Dianette®) or a combined oral contraceptive (COC) containing drospirenone (for example Yasmin®).
- Co-cyprindiol (Dianette®; a combination of ethinylestradiol and the anti-androgen cyproterone acetate) is licensed for the treatment of moderately-severe hirsutism but should be stopped three or four menstrual cycles after the woman's hirsutism has completely resolved because of an increased risk of venous thromboembolism.
- Yasmin® (a combination of ethinylestradiol and drospirenone) is not licensed specifically for hirsutism but is an alternative to co-cyprindiol for women who require long-term treatment. Yasmin® is more expensive than co-cyprindiol.
- See the CKS topic on Contraception for a full discussion of the risks of COCs.
- Advise the woman that hirsutism may take 6–9 months (or longer) to improve on hormonal treatment.
- Co-cyprindiol should be stopped three or four menstrual cycles after the woman's hirsutism has resolved (on advice from the Committee on Safety of Medicines). Other COCs can be continued indefinitely.
- Relapse is likely once treatment with co-cyprindiol is stopped. Options include:
- Intermittent use of co-cyprindiol — stopping treatment after resolution occurs, and starting again if symptoms reappear (licensed use).
- Switching to a COC containing drospirenone (Yasmin®).
- Some experts recommend continuing treatment with co-cyprindiol if the above measures fail. This may be the best option for otherwise healthy young women, as hirsutism causes considerable distress.
- Consider offering topical eflornithine for facial hirsutism if hormonal treatment is contraindicated, ineffective, or inappropriate.
- The cream should be applied thinly twice a day. Advise the woman that transient stinging may occur, that she must wait at least 5 minutes before applying any makeup, and that eflornithine cream can sometimes cause acne.
- Benefit may be noticed after 8 weeks.
- Relapse is rapid once treatment is stopped. However, there are no safety data on long-term use.
- Refer the woman if:
- Excess hair growth is particularly severe.
- Hair growth is of recent onset and rapidly progressive.
- A COC, co-cyprindiol, or topical eflornithine combined with cosmetic measures is not adequate (as there are further options for treatment available in secondary care).
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