Hirsutism - from diagnosis to use of antiandrogens

Hirsutism affects 5-8% of the whole female population. It results either from an increase in circulating androgen concentrations, an increase in the sensitivity of the pilosebaceous unit to normal androgen concentrations or a combination of these factors. Polycystic ovary syndrome is the underlying cause in the vast majority of patients with hirsutism; however, it should be kept in mind that it can only be diagnosed after exclusion of some other diseases such as non-classical congenital adrenal hyperplasia, Cushing's syndrome, hyperprolactinemia and acromegaly. The most important purpose for investigation is to identify those women with pathologies that can be potentially life threatening either due to their systemic effects or malignant potential. Specific causes of hirsutism such as Cushing's syndrome and adrenal/ovarian tumors should be treated by surgical excision of the tumor. In the other patients, pharmacological approach is the mainstay of the therapy. Antiandrogens can be competitive antagonists of the androgen receptor (spironolactone, cyproterone acetate, flutamide) or inhibitors of 5-α reductase, which decrease the conversion of testosterone to the more potent androgen 5-α dihydrotestosterone (finasteride). Antiandrogens should be used only after ensuring safe nonhormonal contraception to avoid fetal male pseudohermaphroditism in case of unplanned pregnancy.