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What is best treatment for hirsutism?

QWhat is the best approach for a slim young woman with marked hirsutism and normal testosterone?

AHirsutism in a woman is coarse terminal hairs in a male secondary sexual distribution. There is considerable variation in hair growth between individuals. Many 'normal' women have some terminal hairs on the face, chest or lower abdomen.

Idiopathic hirsutism is commoner than rarer causes such as polycystic ovary syndrome, ovarian tumours, prolactinoma or Cushing's syndrome.

Management of the hirsute female patient should include inquiry as to menstrual irregularity, menorrhagia, subfertility, acne or alopecia. A drug history is important since glucocorticoid or anabolic steroids may increase hair growth. Features of androgenisation such as clitoromegaly and voice deepening should be sought.

Investigations include measurement of the luteinising hormone: follicle-stimulating hormone (LH:FSH) ratio (elevated in polycystic ovarian syndrome), prolactin, testosterone, androstenedione and oestradiol.

Simple physical methods of hair removal are useful but temporary. Weight loss reduces testosterone activity and should be advised in the obese patient. Electrolysis and laser hair removal are both semi-permanent, but can be expensive and uncomfortable.

Systemic anti-androgen therapy can be effective even in women with normal testosterone levels.

Cyproterone acetate is combined with oestrogen in the contraceptive pill Dianette. The contraceptive pill Marvelon also reduces hirsutism.

Spironolactone 50-200mg daily can be effective but is not licensed for hirsutism. It feminises a male fetus and long-term use in rodents is carcinogenic.

Finasteride, also with feminising effects on male fetuses and not licensed for hirsutism in women, can also be effective, as can flutamide. Metformin can also be used.

Any systemic therapy is slow in onset and only partially effective; its effects will slowly wear off after it is stopped. Careful patient selection and counselling is important.

Dr Victoria Swale is a specialist registrar in dermatology at the Royal Free Hospital, London

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