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Oral contraceptives and anti-androgens most effective for hirsutism pharmacotherapy
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 anti-androgen, such as finasteride, if there is an inadequate response within 6 months. The guideline also recommends avoiding monotherapy with an anti-androgen and avoiding the use of insulin sensitizers such as metformin because of the inconsistency of the evidence (J Clin Endocrinol Metab 2018;103:1233-57). 1a-
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Foundation
Setting: Various (meta-analysis)
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 3 databases, the authors found 43 randomized trials that evaluated a treatment for hirsutism compared with either placebo or another active treatment. Eight studies only compared different oral contraceptive pills (OCPs) with one another and 3 studies provided only 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 felt 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 9 trials (albeit with heterogeneity); finasteride in 3 trials; flutamide in 2; and OCPs, spironolactone, troglitazone, and OCP plus flutamide in one each. The network meta-analysis concluded that there was the strongest evidence for efficacy of combination estrogen-progestin OCPs, anti-androgens (primarily for women who are using long-acting contraception or who have been sterilized), and metformin. All OCPs appeared to be similarly effective.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
good poem
if I need this info
This study is poorly designed. Therefore, not very useful for clinical application.
I have been using OCP's but not in conjuction with Finasteride. Usually have added Metformin next. Good info to know and I will certainly change what I am doing!