Hirsutism in PCOS: How Antiandrogens Help Reduce Unwanted Hair

When you have PCOS, unwanted facial or body hair isn’t just a cosmetic issue-it’s a constant reminder of something deeper going on inside your body. About 70 to 80% of women with PCOS deal with hirsutism, the growth of thick, dark hair in places like the upper lip, chin, chest, or back-areas where men typically grow hair. It’s not about grooming. It’s about hormones. And while birth control pills are often the first step, they don’t work for everyone. That’s where antiandrogens come in.

What Exactly Are Antiandrogens?

Antiandrogens are medications that block the effects of male hormones-like testosterone and DHT-in your body. They don’t eliminate these hormones, but they stop them from binding to receptors in your hair follicles. That’s key. Hair growth in hirsutism isn’t just about having too much testosterone; it’s about how your skin reacts to it. Some women with PCOS have hair follicles that are extra sensitive, even with normal hormone levels.

The most common antiandrogens used today are spironolactone, finasteride, and eflornithine cream. Spironolactone, originally a blood pressure pill, blocks androgen receptors and also reduces the enzyme that turns testosterone into its stronger form, DHT. Finasteride targets only that enzyme, making it more specific. Eflornithine is different-it’s a cream applied directly to the skin, slowing hair growth at the root without affecting hormones systemically.

Why Not Just Use Birth Control Pills?

Combined oral contraceptive pills (COCPs) are still the first-line treatment for hirsutism in PCOS. They work by lowering overall androgen production and increasing sex hormone-binding globulin, which traps free testosterone. But here’s the reality: about 30% of women don’t get enough improvement after six months of consistent use. Some can’t take them because of blood clots, migraines, or high blood pressure. Others feel worse-mood swings, bloating, low libido-so they stop.

That’s where antiandrogens fit. They’re not replacements for birth control. They’re add-ons-or alternatives when birth control fails or isn’t an option. A 2023 meta-analysis from Monash University found that when COCPs alone didn’t cut it, adding spironolactone or finasteride led to significantly better hair reduction. In one study, women’s modified Ferriman-Gallwey (mFG) scores dropped from 18 to 11 after six months on combo therapy. That’s noticeable. Not perfect, but enough to make a difference in daily life.

How Long Does It Take to See Results?

This is the hardest part for most patients: patience. Hair doesn’t vanish overnight. Hair grows in cycles, and antiandrogens don’t kill existing hairs-they make new ones finer, lighter, and slower-growing. You won’t see changes in the first month. Maybe not even in three. Most women start noticing a difference around six months. The best results come after 12 to 18 months of daily use.

That’s why so many people give up too soon. One Reddit user, PCOSWarrior2020, wrote: “I thought it wasn’t working until month 7. Then I looked at my chin in the mirror and realized I hadn’t threaded in weeks.” Another, HirsuteHannah, switched from spironolactone to finasteride because the dizziness was unbearable. She got results but paid $85 a month out of pocket.

Cost and side effects are real barriers. Spironolactone can cause fatigue, dizziness, or irregular periods. Finasteride is expensive without insurance. Eflornithine cream (Vaniqa) costs about $245 for a month’s supply. And none of them work if you’re not consistent. Missing doses slows progress dramatically. Daily use cuts hair growth twice as effectively as every-other-day dosing, according to the same 2023 study.

What About Safety?

All antiandrogens carry a major warning: they can harm a developing male fetus. That’s why you need two forms of birth control while taking them-even if you’re already on the pill. Spironolactone is Category B (no proven risk in humans), but finasteride is Category X (known to cause birth defects). If you’re sexually active and not using reliable contraception, don’t take these meds.

Spironolactone can also raise potassium levels, especially in people with kidney problems or those taking other meds like ACE inhibitors. Regular blood tests are recommended. Flutamide, once used, was pulled from the market because of liver damage. Bicalutamide is used off-label but still carries risks.

Eflornithine cream is the safest option for those who can’t take oral meds. It doesn’t enter your bloodstream. Side effects? Minor skin irritation, redness, or ingrown hairs. It won’t remove hair-it just slows regrowth. But when paired with laser therapy, it boosts results by 35% compared to laser alone.

Combination Therapy: The Real Game Changer

The most effective approach isn’t one drug-it’s a stack. Many dermatologists and endocrinologists now recommend combining treatments:

• COCPs to lower overall androgen production
• Spironolactone or finasteride to block hormone action in follicles
• Eflornithine cream to slow hair growth locally
• Laser or IPL for permanent reduction of existing dark hairs

This combo isn’t just theoretical. A 2023 review in the Journal of Clinical Endocrinology & Metabolism showed that patients on COCP + spironolactone had 1.7 points better improvement on the mFG scale than those on COCP alone. That’s a measurable, meaningful difference.

And here’s something most patients don’t know: you can still use hair removal methods while on antiandrogens. Waxing, threading, and shaving don’t interfere. In fact, they help you feel more in control while waiting for the meds to work. Laser is the only one that offers long-term reduction-and it works better when the hair is finer, which antiandrogens help achieve.

What’s Next? The Future of Hirsutism Treatment

The 2023 International PCOS Guideline was a turning point. For the first time, antiandrogens were formally recognized as second-line therapy after COCP failure. Before that, guidelines said there wasn’t enough evidence. Now, we know better.

Research is moving fast. New drugs called selective androgen receptor modulators (SARMs)-like enobosarm-are in Phase II trials. Early results show 28% greater hair reduction than placebo, with fewer side effects than spironolactone. These could become the next standard within five years.

There’s also growing interest in personalized medicine. Scientists are studying genetic markers that predict who will respond best to which drug. Maybe one day, a simple blood test will tell you whether spironolactone or finasteride is right for you.

For now, the best approach is simple: start with birth control. Wait six months. If no improvement, talk to your doctor about adding an antiandrogen. Don’t rush. Don’t quit early. And remember-you’re not alone. Thousands of women are on this same path, adjusting, waiting, and slowly gaining back control.

What to Expect If You Start Antiandrogens

If you’re considering this route, here’s what to plan for:

• Month 1-3: No visible change. You might feel side effects like dizziness or fatigue. Keep taking it.
• Month 4-6: Hair growth slows. You may notice less stubble between shaves or fewer dark hairs popping up.
• Month 7-12: Hair becomes finer and lighter. Some women report being able to skip threading.
• Month 12-24: Maximum benefit. Many see 30-50% reduction in hair density and coarseness.

Keep a photo journal. It’s hard to see progress day to day, but comparing photos from six months ago makes it obvious.

When to Avoid Antiandrogens

You should not use these medications if:

• You’re pregnant or planning to become pregnant
• You have severe kidney disease (especially with spironolactone)
• You’ve had liver damage from other medications
• You’re already on potassium-sparing diuretics or ACE inhibitors
• You can’t commit to daily dosing and reliable contraception

If you’re unsure, ask for a referral to an endocrinologist or a dermatologist who specializes in hormonal skin conditions. General practitioners often don’t have the time or training to manage this properly.

Bottom Line: It’s a Marathon, Not a Sprint

Hirsutism in PCOS isn’t something you fix in a month. It’s a chronic condition that responds best to consistent, layered treatment. Antiandrogens aren’t magic. But when used right-with contraception, patience, and medical support-they can change your life.

You don’t have to accept unwanted hair as your new normal. There are tools. There are options. And you’re not the first woman to walk this path. You just need to keep going, even when progress feels slow.