Research
Combination Therapy for Hirsutism: Pros and Cons
Explore the pros and cons of combination therapy for hirsutism, including the effectiveness of COCs and anti-androgens in managing symptoms.
June 17, 2025
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Explore the pros and cons of combination therapy for hirsutism, including the effectiveness of COCs and anti-androgens in managing symptoms.
Hirsutism, or excessive male-pattern hair growth in women, is often linked to PCOS, which accounts for over 70% of cases. Treatments typically involve hormonal therapies like Combination Oral Contraceptives (COCs), either alone or paired with anti-androgens for more severe cases. Here's a quick breakdown:
| Treatment | Benefits | Drawbacks | Best For |
|---|---|---|---|
| COCs Alone | Regulates cycles, reduces hair growth, acne; contraception | Risk of blood clots, mild side effects | Mild hirsutism, contraception needs |
| COCs + Anti-Androgens | Stronger hair reduction, long-term results | Liver risks, lipid changes, more side effects | Moderate-to-severe hirsutism cases |
Takeaway: COCs are a first-line option for mild cases, while combination therapy offers better results for severe hirsutism. Always consult a healthcare provider to weigh benefits and risks.
Combination oral contraceptives (COCs) are often the go-to treatment for managing hirsutism in women with polycystic ovary syndrome (PCOS). These pills combine estrogen and progestin to help correct hormonal imbalances, which can lead to noticeable improvements in symptoms like excessive hair growth.
Research shows that COCs can significantly reduce hirsutism in more than 85% of patients. In fact, the modified Ferriman-Gallwey score - a tool used to measure the severity of hirsutism - can drop by up to 67% within six months of treatment and by 78% after a year. This scoring system is a valuable way for healthcare providers to track progress and decide if additional treatments might be necessary for more severe cases.
COCs offer a range of benefits beyond treating hirsutism. They help regulate menstrual cycles, act as effective contraception, and improve other PCOS-related issues like acne (with a reported 79.3% improvement) and menstrual irregularities (82.7% improvement). Additionally, they lower the risk of developing endometrial and ovarian cancers, ease symptoms of dysmenorrhea and menorrhagia, and can even help manage conditions like premenstrual syndrome, menstrual migraines, and pelvic pain linked to endometriosis.
However, COCs aren’t without their downsides. Side effects may include occasional breakthrough bleeding (especially with low-dose pills), nausea, headaches, abdominal cramps, breast tenderness, and increased vaginal discharge. Some women also experience a drop in libido. More serious concerns include a slight increase in blood pressure (affecting 4–5% of healthy women) and a heightened risk of venous thromboembolism. According to one survey, 64.6% of women stopped using oral contraceptives due to side effects.
COCs are particularly beneficial for women with PCOS who need contraception while also addressing hirsutism, irregular periods, and acne. That said, they’re not suitable for everyone. Women with cardiovascular issues, smokers, or those with hereditary angioedema should approach COCs with caution because of the increased risks involved. For those dealing with moderate to severe hirsutism, COCs alone may not be enough, and combining them with systemic anti-androgens might be necessary. As always, it’s crucial to discuss options with a healthcare provider to weigh the potential benefits and risks based on individual health needs. COCs remain a key option within the broader landscape of hormonal treatments for managing hirsutism.
When combination oral contraceptives (COCs) alone don't sufficiently manage moderate to severe hirsutism, healthcare providers often introduce anti-androgen medications into the treatment plan. This dual approach tackles excessive hair growth from different angles, leading to better outcomes.
A systematic review and meta-analysis evaluated 27 articles, covering 20 studies with 961 participants, to assess the effectiveness of anti-androgens like finasteride, flutamide, spironolactone, and bicalutamide. The findings showed that daily use of anti-androgens was more effective than taking them every three days, though results varied depending on the specific medication and individual factors.
More than 40% of patients reported noticeable improvements in facial hair within nine months of using COCs with anti-androgens, and many saw reductions in hair growth on other parts of the body. For those on higher doses of cyproterone acetate, around 70% achieved effective results. Skin condition improvements may continue even after a year of treatment, highlighting the long-term potential of this approach.
The combination of COCs and anti-androgens offers more than just hair reduction. These medications work by blocking androgen receptors, reducing androgen production, or inhibiting the enzyme 5-α-reductase. This multi-faceted approach addresses the underlying hormonal causes of hirsutism more effectively than using either treatment alone.
In addition to managing hair growth, anti-androgens combined with ethinylestradiol can regulate irregular menstrual cycles and serve as contraception. This is particularly important since anti-androgens can harm fetal development. Furthermore, this combination may improve body composition and metabolic health in women with PCOS.
Studies also show that adding anti-androgens to a regimen that includes metformin and lifestyle changes leads to lower testosterone levels compared to metformin and lifestyle adjustments alone. Anti-androgens combined with lifestyle modifications have also been found to outperform metformin in treating hirsutism.
Dr. Camille A. Clare, MD, MPH, highlights the importance of this approach:
"The most effective treatment includes a long-term approach that reduces androgen receptor activity, thus decreasing new terminal hair development, and the removal of existing terminal hairs."
While effective, combining COCs with anti-androgens isn't without risks. Current evidence suggests that anti-androgens shouldn't replace COCs as the primary treatment for hyperandrogenism in PCOS. Additionally, this combination may negatively affect lipid profiles compared to using COCs alone.
Common side effects include nausea, headaches, menstrual irregularities, and mood changes. More serious complications, such as electrolyte imbalances, liver problems, or low white blood cell counts, can also occur, increasing the risk of infection. Some of these side effects overlap with those seen with COCs alone, but the addition of anti-androgens may heighten the risks.
This combination therapy isn't typically the first choice for everyone with hirsutism. It's usually considered when COCs alone are ineffective, not tolerated, or contraindicated after six months of use. Treatment decisions should factor in how distressing the condition is for the patient. As Dr. Clare points out, moderate to severe hirsutism often requires the addition of systemic anti-androgens to COCs.
For hirsutism linked to PCOS, this combined approach aligns with individualized treatment strategies. Anti-androgens are particularly recommended when COCs or cosmetic solutions like laser treatments fail to deliver results or aren't an option.
Patients on this therapy need regular follow-ups and blood tests to monitor their response to the medication. Physical hair removal methods can also be used alongside the treatment for a more comprehensive approach to managing unwanted hair growth.
This summary breaks down the main advantages and disadvantages of each treatment option, helping you and your healthcare provider make informed decisions.
| Treatment Option | Key Advantages | Main Disadvantages | Best For |
|---|---|---|---|
| COCs Alone | First-line treatment; reduces endometrial cancer risk by 50%-70%; improves quality of life; provides contraception | Increases risk of VTE by 55%-226%; may worsen metabolic effects; potential cardiovascular risks | Women with mild hirsutism; those seeking contraception and menstrual regulation |
| COCs + Anti-Androgens | More effective for moderate-to-severe hirsutism; improves hyperandrogenic symptoms | Adverse lipid changes; increased side effect risks; requires regular monitoring | Women with an inadequate response to COCs alone after 6 months |
This table highlights how treatment can be tailored to individual needs, balancing benefits and risks based on personal health goals.
COCs (Combined Oral Contraceptives) remain the go-to treatment for mild hirsutism. As Poli Mara Spritzer explains:
"Combined oral contraceptive (COC) is the first-line pharmacological treatment for the management of menstrual irregularities in PCOS, offering, in addition to contraception, protection of the endometrium".
COCs work by lowering androgen levels and boosting sex hormone–binding globulin (SHBG), which reduces the amount of active androgens in your body. Another major benefit is their ability to lower the risk of endometrial cancer by 50%-70%, a critical consideration for women with PCOS.
When COCs alone don’t deliver results after six months, anti-androgens are often added. Studies show that daily anti-androgen use is more effective than intermittent dosing, improving hirsutism scores by -3.48 points compared to every-three-day usage. However, combining anti-androgens with COCs can lead to adverse changes in lipid profiles, such as increased triglycerides, LDL cholesterol, and total cholesterol levels.
Safety profiles differ between the two approaches. While COCs alone carry risks like potential weight gain and mood changes, the combination therapy introduces additional concerns, such as electrolyte imbalances, liver issues, and a higher risk of infections due to low white blood cell counts.
Anti-androgens are generally reserved for cases where COCs fail to show sufficient improvement after six months. The choice of treatment should consider factors like individual risk profiles, the severity of hirsutism, and contraceptive needs. As noted in the Fertility and Sterility Journal:
"hormonal contraceptives (oral, patch, and vaginal ring) as first-line management for concurrent treatment of menstrual abnormalities and clinical signs of hyperandrogenism in women with PCOS".
Regular health screenings and ongoing monitoring are crucial for safe and effective management. These summarized insights emphasize the importance of tailoring treatment plans to suit each individual’s specific health needs and circumstances.
Deciding between using combination oral contraceptives (COCs) alone or pairing them with anti-androgens depends largely on individual needs and the severity of hirsutism. For women with mild hirsutism who also require contraception and menstrual regulation, COCs are often the best first-line treatment. They also provide the added benefit of protecting the endometrium.
For more severe cases, treatment often needs to be stepped up. Women with moderate to severe hirsutism may benefit from adding anti-androgens if COCs alone don’t show sufficient results after at least six months of consistent use. Research shows that around 75% of women experience clinical improvement with this combination. However, this approach requires closer monitoring due to potential side effects, such as liver-related issues.
When selecting a treatment plan, individual factors matter greatly. For example, women with metabolic syndrome might need a cardiovascular evaluation before starting COCs. The emotional toll of hirsutism is another critical aspect to address. As UCLA Health emphasizes:
"A successful management plan for unwanted hair addresses a woman's own concerns and allows for an individualized strategy that balances time spent on mechanical hair removal with prevention of further hair growth through medical therapy".
Managing expectations is equally important. Hormonal therapies primarily work to prevent new hair growth rather than remove existing hair. Improvements often take time - typically 6 to 8 months of consistent treatment. Because of this, combining medical therapy with mechanical hair removal methods, like laser or electrolysis, often yields the best results.
A team-based approach often leads to better outcomes. Effective management of hirsutism frequently involves collaboration between healthcare providers, aestheticians, laser specialists, and electrologists. Weight management is another key factor. Losing weight can improve hormone balance by increasing sex hormone–binding globulin levels and reducing both insulin resistance and androgen levels. This comprehensive approach highlights the importance of tailoring care to each individual’s needs.
For more clinically supported insights into managing hirsutism and PCOS, visit PCOSHelp.
Long-term use of combination therapy to manage hirsutism can sometimes come with liver-related concerns and cholesterol changes. Medications like flutamide and bicalutamide have been associated with liver toxicity, meaning regular liver function tests might be necessary during treatment to catch any issues early.
On top of that, some therapies can impact cholesterol levels by lowering HDL (the "good" cholesterol) and increasing LDL (the "bad" cholesterol), which could raise the risk of heart problems over time. It's essential to talk with your healthcare provider about these possible side effects to ensure your treatment plan balances effectiveness with safety.
Anti-androgens work alongside combination oral contraceptives (COCs) to more effectively manage moderate to severe hirsutism by addressing the hormones responsible for excessive hair growth. These medications block androgen receptors and lower the production of key androgens like testosterone and dihydrotestosterone, which reduces the stimulation of hair follicles.
When used together with COCs, anti-androgens not only decrease circulating androgen levels but also curb ovarian production of these hormones. This two-pronged approach helps correct hormonal imbalances commonly associated with Polycystic Ovary Syndrome (PCOS), offering a more targeted way to manage hirsutism symptoms.
Lifestyle adjustments can make a big difference in managing hirsutism, especially when paired with hormonal treatments. Incorporating regular exercise, maintaining a healthy weight, eating a balanced diet with a low glycemic index, and finding ways to manage stress can improve insulin sensitivity and support hormonal balance, potentially easing hirsutism symptoms.
For additional support, treatments like topical creams (such as eflornithine), laser hair removal, electrolysis, or medications like anti-androgens (e.g., spironolactone) can be effective. These options can be customized to fit individual needs, so it’s essential to consult a healthcare provider to determine the best approach.
