SOGC Clinical Practice Guideline| Volume 39, ISSUE 11, P1054-1068, November 2017

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No. 350-Hirsutism: Evaluation and Treatment

  • Kimberly Liu
    Corresponding Author: Dr. Kimberly Liu; University of Toronto, Department of Obstetrics and Gynecology, Toronto ON
    Toronto, ON
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  • Tarek Motan
    Edmonton, AB
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  • Paul Claman
    Ottawa, ON
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  • Author Footnotes
    ∗ Members of the Reproductive Endocrinology and Infertility Committee: Belina Carranza-Mamane, MD, Sherbrooke, QC; Anthony Cheung (Co-chair), MD, Vancouver, BC; Catherine Dwyer, RN, Toronto, ON; James Graham, MD, Calgary, AB; Sarah Healey, MD, St. John’s, NL; Robert Hemmings, MD, Montréal, QC; Kimberly Liu, MD, Toronto, ON; Tarek Motan, MD, Edmonton, AB; Sony Sierra (Co-chair), MD, Toronto, ON; David Smithson, MD, Ottawa, ON; Tannys Vause, MD, Ottawa, ON; Benjamin Wong, MD, Calgary, AB. Disclosure statements have been received from all principal authors.



      To review the etiology, evaluation, and treatment of hirsutism.


      A thorough history and physical examination plus selected laboratory evaluations will confirm the diagnosis and direct treatment.


      Pharmacologic interventions can suppress ovarian or adrenal androgen production and block androgen receptors in the hair follicle. Hair removal methods and lifestyle modifications may improve or hasten the therapeutic response.


      At least 6 to 9 months of therapy are required to produce improvement in hirsutism.


      The quality of evidence reported in this guideline has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.


      Hirsutism can be slowly but dramatically improved with a 3-pronged approach to treatment: mechanical hair removal, suppression of androgen production, and androgen receptor blockade. Lifestyle changes, including weight loss and exercise, will lower serum androgen levels and improve self-esteem in patients with polycystic ovary syndrome. The patient should be educated regarding the associated health problems or long-term medical consequences of hyperandrogenism, particularly in the context of polycystic ovary syndrome, including obesity, irregular menses, anovulation, infertility, pregnancy-induced hypertension, diabetes, hyperlipidemia, hypertension, and heart disease.

      Summary Statements

      • 1.
        The Ferriman-Gallwey score can be used in the assessment of hirsutism to help quantify the problem and help assess response to treatment. A score ≥8 represents excessive hair growth, with mild hirsutism <15, moderate 16 to 25, and severe >25 (II-2).
      • 2.
        Insulin resistance and hyperinsulinemia may lead to hyperandrogenism in women with polycystic ovary syndrome (PCOS) (II).
      • 3.
        Non-classical congenital adrenal hyperplasia often presents with hirsutism and has a clinical picture similar to that of PCOS. However, the prevalence of non-classical congenital adrenal hyperplasia is very low outside of specific high-risk ethnic groups (II-2).
      • 4.
        Hirsutism can be classified into 1 of 3 groups based on etiology: hyperandrogenic hirsutism (including polycystic ovarian syndrome or androgen-secreting tumours), non-androgenic hirsutism (including medication-induced hirsutism), and idiopathic hirsutism (II-3).
      • 5.
        Polycystic ovarian syndrome is the most common cause of hirsutism, with idiopathic hirsutism being the second most common cause (II-2).
      • 6.
        Although adolescents may present with hirsutism, the diagnosis of PCOS in these young women is controversial given that the diagnostic features of PCOS may be normal pubertal physiologic events (III).
      • 7.
        The most effective therapy for hirsutism is multimodal and combines physical hair removal techniques and medical therapies. At least 6 months of medical therapy are required to see a significant improvement in hirsutism (II-2).
      • 8.
        Only laser hair removal and electrolysis produce permanent hair reduction, and hair growth tends to recur after stopping medical therapy (II-2).


      • 1.
        Women presenting with hirsutism should be evaluated with a focused history, physical examination, and appropriate investigations to differentiate among the possible etiologies (III-B).
      • 2.
        Laboratory investigations for women with moderate to severe hirsutism should include total testosterone, although the benefit in mild hirsutism is questionable. Additional testing is indicated for women with irregular menses and/or signs of hyperandrogenism or other endocrinopathies (III-B).
      • 3.
        Referral for evaluation by an endocrinologist or reproductive endocrinologist is indicated in the presence of the following: (1) virilisation, (2) serum testosterone or dehydroepiandrosterone sulfate levels more than twice the upper limit of normal, (3) signs or symptoms of Cushing's syndrome, or (4) early menstrual phase serum 17-hydroxyprogesterone levels >6 nmol/L (III-B).
      • 4.
        All patients experiencing hirsutism who desire treatment should be offered combined hormonal contraceptive therapy as first-line therapy, provided they have no contraindications (I-A).
      • 5.
        Mechanical hair removal and/or topical therapy can be offered as first-line therapy or as an adjuvant to medical therapy (I-A).
      • 6.
        Depending on a woman's goals of treatment, anti-androgens should be considered for moderate to severe hirsutism or to ensure an optimal response in milder hirsutism (I-A).
      • 7.
        Anti-androgens can be used in conjunction with combined hormonal contraceptive therapy to enhance treatment efficacy (I-A).
      • 8.
        If a woman on anti-androgen therapy wishes to conceive, anti-androgen therapy should be stopped prior to discontinuing the use of contraception to prevent the potential feminization of a male fetus if pregnancy were to occur (III-B).
      • 9.
        Health care providers assessing women with hirsutism should complete a comprehensive evaluation and, when applicable, explore the long-term health sequelae of hyperandrogenism and polycystic ovary syndrome, including abnormal uterine bleeding, infertility, and metabolic syndrome (III-B).

      Key Words


      17-OHP (17-hydroxyprogesterone), AN (acanthosis nigricans), CAH (congenital adrenal hyperplasia), CHC (combined hormonal contraceptives), CPA (cyproterone acetate), MPA (medroxyprogesterone acetate), NCAH (non-classical congenital adrenal hyperplasia), OC (oral contraceptive), PCOS (polycystic ovary syndrome), SHBG (sex hormone–binding globulin)
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