What are the first-line treatment options for managing hirsutism in women, and how do they differ based on underlying causes?

First-line treatment options for managing hirsutism in women primarily include combined oral contraceptives (COCs) and topical eflornithine, with the choice influenced by the underlying cause and patient factors.

For premenopausal women, COCs containing ethinylestradiol are generally offered first-line to reduce hyperandrogenism by suppressing luteinizing hormone secretion and increasing sex hormone-binding globulin, thereby lowering free androgen levels. COCs with non-androgenic or antiandrogenic progestogens (such as desogestrel, norgestimate, cyproterone acetate, or drospirenone) may be more effective, although differences between formulations are often not clinically significant. COCs containing cyproterone acetate (e.g., Dianette®) are licensed for moderate to severe hirsutism but should be avoided in women with a history of meningioma due to a plausible risk association. The risk of venous thromboembolism (VTE) with COCs should be discussed, especially in women over 39 years or those with obesity, and the lowest effective estrogen dose should be considered in higher-risk individuals ¹.

For women with facial hirsutism, topical eflornithine cream is licensed and recommended as an adjunct or alternative, particularly when COCs are contraindicated or not preferred. It requires continuous use to maintain benefits and is not suitable for pregnant or breastfeeding women or those under 19 years ¹.

Management varies depending on underlying causes:

• In women with polycystic ovary syndrome (PCOS), weight loss is strongly encouraged as it can improve hirsutism by reducing androgen levels and improving metabolic parameters ¹.
• If hirsutism is mild and does not significantly impact quality of life, reassurance and advice on hair removal methods (shaving, waxing, bleaching) may suffice without pharmacological treatment ¹.
• When COCs are contraindicated or ineffective after a 6-month trial, referral to secondary care for specialist treatments such as anti-androgens (spironolactone, finasteride), insulin-sensitizing drugs, or gonadotrophin-releasing hormone analogues may be considered ¹.

In summary, first-line treatment is usually a COC tailored to patient risk and preferences, with topical eflornithine for facial hair, alongside lifestyle advice, especially weight management in PCOS. Treatment choice and escalation depend on severity, impact on quality of life, and underlying endocrine disorders ¹.