Interventions for Hirsutism Excluding Laser and Photoepilation Therapy Alone

Abridged Cochrane Systematic Review Including GRADE Assessments

E.J. van Zuuren; Z. Fedorowicz


The British Journal of Dermatology. 2016;175(1):45-61. 

In This Article

Abstract and Introduction


Hirsutism is a common disorder with a major impact on quality of life. The most frequent cause is polycystic ovary syndrome. Effects of interventions (except laser and light-based therapies) were evaluated, including Grading of Recommendations Assessment, Development and Evaluation assessments. Searches included Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, Medline, Embase and five trials registers to June 2014. We included 157 randomized controlled trials (RCTs) with 10 550 participants. The majority were assessed as having a 'high risk' of bias (123 of 157). The quality of evidence was rated moderate to very low for most outcomes. Pooled data for an oral contraceptive (OCP) (ethinyl oestradiol and cyproterone acetate) compared with another OCP (ethinyl oestradiol and desogestrel) demonstrated that both treatments were effective in reducing Ferriman–Gallwey scores, but the mean difference (MD) was not statistically significant [−1·84, 95% confidence interval (CI): −3·86–0·18]. Flutamide was more effective than placebo in two studies (MD −7·60, 95% CI: −10·53 to −4·67 and MD −7·20, 95% CI: −10·15 to −4·25), as was spironolactone (MD −7·69, 95% CI: −10·12 to −5·26). Spironolactone appeared to be as effective as flutamide (two studies) and finasteride (two studies). However, finasteride and the gonadotropin-releasing analogues showed discrepant results in several RCTs. Metformin was ineffective. Cyproterone acetate combined with OCPs demonstrated greater reductions in Ferriman–Gallwey scores. Lifestyle interventions reduced body mass index but did not show improvement in hirsutism, and although cosmetic measures are frequently used, no RCTs investigating cosmetic treatments were identified. RCTs investigating OCPs in combination with antiandrogens or finasteride vs. OCP alone, or the different antiandrogens and 5α-reductase inhibitors are warranted.


Hirsutism is a common disorder occurring in 5–11% of women of childbearing age, typified by excessive terminal hair growth in androgen sensitive areas (male-pattern).[1,2] Polycystic ovary syndrome (PCOS) is the most frequent cause (70–80%) with obesity, acne, infertility, insulin resistance and female-pattern hair loss as additional characteristics.[3] In idiopathic hyperandrogenism (6–15% of cases), hirsutism occurs combined with elevated androgen levels but with normal menstrual cycles and no ovary abnormalities.[4] Idiopathic hirsutism (4–7% of cases) is characterized by regular menses without androgen excess.[4,5] Other causes of hirsutism include; nonclassic congenital adrenal hyperplasia, androgen-secreting tumours, Cushing syndrome, thyroid dysfunction, hyperprolactinaemia and the use of specific drugs (e.g. danazol, testosterone, anabolic steroids).[3,6] The Ferriman–Gallwey (FG) score is the most widely used hirsutism scoring system. This system evaluates 11 body sites (upper lip, chin, chest, upper and lower back, upper and lower abdomen, upper arm, forearm, thigh and lower leg) with each site rated from 0 (no hair) to 4 (frankly virile). An FG score of < 8 is considered normal, mild hirsutism (8–15), moderate hirsutism (16–25) and a score > 25 indicates severe hirsutism.[2,7]

Smooth hairless bodies and faces are increasingly seen as the social norm of femininity[8,9] and thus women with hirsutism may perceive themselves to be less sexually attractive, and will expend time, energy and money to rid themselves of superfluous hair. Hirsutism can lead to psychological distress, low self-esteem, negative self-image, feelings of shame and embarrassment, social disabilities and even depression with a significant impact on quality of life.[1,10–14]

Hair growth cycles vary for different body parts, and therefore treatment for at least 6–12 months is essential for optimal effect, but continuous treatment may be required.[2]

There are numerous treatments for hirsutism, but it is unclear which are the most effective and it is well known that the side-effects of several treatments can be debilitating. This article is a summary of a Cochrane review evaluating the effects of interventions (except laser and light-based therapies alone) for hirsutism.[15]