Question 8

A 20-year old with longstanding hirsutisim is not satisfied with the use of combined oral contraceptives to control her facial hair and acne. In addition to taking oral contraceptives, the medical therapy that would be most beneficial would be:

Answer Choices:

Spironolactone

Eflornithine hydrochloride cream (Vaniqa)

GnRH agonist (leuprolide)

Progestin-only contraceptive

Metformin (Glucophage)

Correct Answer:

Spironolactone

Explanation:

  • Combined OCPs are usually first line for hirsutism. These work by inhibiting gonadotropin secretion, increasing sex hormone binding globulin and reducing serum total and free testosterone concentrations

  • Avoid OCPs with the most androgenic progestin (levonorgestrel)

  • If no improvement in 6 months on OCPs, consider adding an antiandrogen

  • Don’t advise antiantrogen as monotherapy because of potential adverse effects on a developing male fetus in utero (need reliable contraceptive method)

  • Antiandrogens can include spironolactone (aldosterone and androgen receptor antagonist) or finasteride (5-alpha-reductase inhibitor)

  • Flutamide is usually avoided due to hepatotoxicity