Combined oral contraceptives for hirsutism

Combined oral contraceptives (COCs) are the preferred hirsutism treatment in premenopausal individuals, and in those with menstrual irregularity or amenorrhoea, since cycle control is a major benefit of COCs.

Combined oral contraceptives (COCs) treat hirsutism by suppressing gonadotrophin-driven androgen production. They also reduce bioavailable testosterone by increasing serum sex hormone–binding globulin (SHBG) concentration.

No specific types or doses of estrogen, progestogen or combinations are preferred for the treatment of hirsutism. Although COCs containing antiandrogenic progestogens (eg cyproterone, dienogest, drospirenone) may have added benefit compared to formulations with other progestogens, there are limited head-to-head comparisons and insufficient data to recommend specific formulations.

For treatment of hirsutism with a COC, use:

combined oral contraceptive orally, once daily (see Formulations of combined hormonal contraception available in Australia for formulations). Advise a tailored regimen if wishing to avoid or minimise withdrawal bleeding. hirsutism

If a nonoral method is preferred, the contraceptive vaginal ring can be used.

Progestogen-only contraceptives are not effective and may worsen hirsutism.

Note: Avoid progestogen-only contraceptives in females with hirsutism.

If hirsutism does not respond to COC after 6 months, consider repeating laboratory investigations. If biochemical hyperandrogenism has not responded, consider investigating for nonclassical congenital adrenal hyperplasia. Also consider imaging to exclude another cause such as an adrenal or ovarian tumour. If biochemical hyperandrogenism has been suppressed but clinical response is inadequate, consider adding an antiandrogen.