Clinical Question

What are the most effective drug therapies for hirsutism?

Bottom Line

Combination oral contraceptive pills (OCPs) are an excellent treatment option for women desiring medical therapy for hirsutism. Based on this meta-analysis, an accompanying practice guideline recommends adding an antiandrogen, such as finasteride (Propecia), if there is an inadequate response within six months. The guideline also recommends avoiding monotherapy with an antiandrogen and avoiding the use of insulin sensitizers such as metformin because of the inconsistency of the evidence (J Clin Endocrinol Metab. 2018;103(4):1233–1257). (Level of Evidence = 1a–)

Synopsis

This is a network meta-analysis from the Mayo Clinic Evidence-Based Practice Center. It was methodologically sound, although the risks of comparing apples to bananas, and oranges to bananas, and using the results to extrapolate about apples to oranges has inherent limitations. After a search of three databases, the authors found 43 randomized trials that evaluated a treatment for hirsutism compared with either placebo or another active treatment. Eight studies compared different OCPs with one another and three studies provided qualitative data, leaving 32 for the network meta-analysis. The median age of participants was approximately 25 years, and the studies included women with a fairly wide range of hirsutism severity. Most trials were believed to be at high risk of bias due to inadequate allocation concealment during randomization, a failure to mask participants and/or outcome assessors, and financial conflicts of interest of the investigators. The strongest evidence comes from direct comparisons. Regarding comparisons with placebo, metformin was studied in nine trials (albeit with heterogeneity); finasteride in three trials; flutamide (Eulexin) in two; and OCPs, spironolactone, troglitazone, and OCP plus flut-amide in one each. The network meta-analysis concluded that there was the strongest evidence for efficacy of combination estrogen-progestin OCPs, antiandrogens (primarily for women who are using long-acting contraception or who have been sterilized), and metformin. All OCPs appeared to be similarly effective.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Foundation

Setting: Various (meta-analysis)

Reference: Barrionuevo P, Nabhan MA, ltayar O, et al. Treatment options for hirsutism: a systematic review and network meta-analysis. J Clin Endocrinol Metab. 2018;103(4):1258–1264.

Editor's Note: Dr. Mark H. Ebell is Deputy Editor for Evidence-Based Medicine in AFP and cofounder and Editor-in-Chief of Essential Evidence Plus, published by Wiley-Blackwell, Inc.