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Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline

Harvard Medical School (K.A.M.), Massachusetts General Hospital, Boston, Massachusetts 02114; University of California School of Medicine-San Diego (R.J.C.), La Jolla, California 92093; University of Chicago General Clinical Research Center (D.A.E.), Chicago, Illinois 60637; University of Barcelona (L.I.), E-08950 Barcelona, Spain; Columbia University Medical Center (R.A.L.), New York, New York 10032; University of Chicago Comer Children’s Hospital (R.L.R.), Chicago, Illinois 60637; University of British Columbia (J.S.), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada V5Z 4E8; and Mayo Clinic (V.M.M., B.A.S.), Rochester, Minnesota 55905

Address all correspondence to: The Endocrine Society, 8401 Connecticut Avenue, Suite 900, Chevy Chase, Maryland 20815. E-mail: govt-prof{at}endo.society.org. Telephone: 301-941-0200. Address all reprint requests for orders of 101 and more to: Heather Edwards, Reprint Sales Specialist, Cadmus Professional Communications, Telephone: 410-691-6214, Fax: 410-684-2789 or by E-mail: endoreprints{at}cadmus.com. Address all reprint requests for orders of 100 or less to Society Services, Telephone: 301-941-0210 or by E-mail: societyservices{at}endo-society.org.

Objective: Our objective was to develop clinical practice guidelines for the evaluation and treatment of hirsutism in premenopausal women.

Participants: The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, two methodologists, and a medical writer. The Task Force received no corporate funding or remuneration.

Evidence: Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations, and "suggest" for weak recommendations.

Consensus Process: Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and e-mail communications. The drafts prepared by the Task Force with the help of a medical writer were reviewed successively by The Endocrine Society’s CGS, Clinical Affairs Core Committee (CACC), and Council. The version approved by the CGS and CACC was placed on The Endocrine Society’s Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes.

Conclusions: We suggest testing for elevated androgen levels in women with moderate or severe hirsutism or hirsutism of any degree when it is sudden in onset, rapidly progressive, or associated with other abnormalities such as menstrual dysfunction, obesity, or clitoromegaly. For women with patient-important hirsutism despite cosmetic measures, we suggest either pharmacological therapy or direct hair removal methods. For pharmacological therapy, we suggest oral contraceptives for the majority of women, adding an antiandrogen after 6 months if the response is suboptimal. We recommend against antiandrogen monotherapy unless adequate contraception is used. We suggest against using insulin-lowering drugs. For women who choose hair removal therapy, we suggest laser/photoepilation.