Hirsutism in PCOS: How Antiandrogens Help Reduce Unwanted Hair
When you have PCOS, excess hair growth on your face, chest, or back isn’t just a cosmetic issue-it’s a sign your body is producing too much androgen. About 70 to 80% of women with PCOS deal with this, called hirsutism. It’s not about being hairy-it’s about coarse, dark hair showing up where it shouldn’t. And while birth control pills are usually the first step, many women find they don’t work well enough. That’s where antiandrogens come in.
What Antiandrogens Actually Do
Antiandrogens don’t remove hair. They don’t kill follicles. What they do is block the hormones that make hair grow thick and dark. In PCOS, your ovaries and adrenal glands make too much testosterone and other androgens. These hormones turn fine, light vellus hairs into thick, dark terminal hairs. Antiandrogens step in to stop that process.
Spironolactone is the most common. It blocks androgen receptors and also lowers the enzyme that turns testosterone into its stronger form, DHT. Finasteride does something similar but only targets that one enzyme. Both are taken daily. Eflornithine cream, sold as Vaniqa, works differently-it slows hair growth right at the skin level by blocking an enzyme in the follicle. It’s not a hormone blocker, but it helps reduce the speed of regrowth.
None of these work overnight. You need at least six months to see any real change. Most women report noticeable improvement between 9 and 18 months. That’s why many give up too soon. If you’re not seeing results after six months, don’t assume it’s not working. Give it time-and stick with it.
Why Birth Control Isn’t Always Enough
Combined oral contraceptives (COCPs) are the first-line treatment because they lower overall androgen production. But here’s the problem: not everyone responds. About 30 to 40% of women with PCOS don’t get enough hair reduction from birth control alone. Some can’t take them due to blood clot risks, migraines, or high blood pressure. Others have side effects like nausea, mood swings, or weight gain that make them stop.
That’s where antiandrogens become useful-not as replacements, but as add-ons. When COCPs aren’t enough, adding spironolactone or finasteride can push hirsutism scores down further. One study showed that combining them led to 1.7 points better improvement on the modified Ferriman-Gallwey scale than birth control alone. That might sound small, but for someone with 18 points of hirsutism, dropping to 11 means fewer shaving sessions, less threading, and more confidence.
The Real Side Effects Nobody Talks About
Spironolactone can cause dizziness, especially when you first start. Some women report fatigue or frequent urination. It can also mess with your period-making it heavier, lighter, or irregular. That’s why it’s never prescribed alone. You must be on a reliable form of birth control. Spironolactone is pregnancy category B, meaning it’s not proven safe in pregnancy. Finasteride is category X-absolutely dangerous if you get pregnant. Even one missed pill can risk birth defects.
One Reddit user, PCOSWarrior2020, shared: “I went from 18 to 11 on my hirsutism score after 6 months on spironolactone. But I was dizzy all day for the first two months. I had to take it at night.” Another, HirsuteHannah, switched to finasteride after spironolactone made her feel terrible-but then she hit a new problem: cost. At $85 a month out of pocket, it’s not cheap.
Eflornithine cream doesn’t have systemic side effects, but it’s expensive. A 30-tube pack costs over $245. It also requires twice-daily application, and if you skip days, the effect fades fast. One user on RealSelf said: “I loved the results, but I kept forgetting to put it on. After a week off, my chin hair was back.”
What Works Best Together
Combination therapy is where things get powerful. The best results come from stacking treatments. For example:
- Birth control pill + spironolactone (daily)
- Plus eflornithine cream (twice a day on affected areas)
- Plus laser hair removal (every 4-8 weeks)
A clinical study found that adding eflornithine to laser treatment gave 35% more hair reduction than laser alone. That’s huge. Laser doesn’t stop new hair growth-it removes what’s already there. Antiandrogens stop the new growth. Together, they’re a one-two punch.
Metformin, often prescribed for insulin resistance in PCOS, doesn’t help much with hair growth on its own. One meta-analysis showed antiandrogens + lifestyle changes beat metformin + lifestyle for reducing hirsutism. So if your main goal is hair reduction, focus on antiandrogens, not just diabetes meds.
What to Expect Over Time
Here’s a realistic timeline:
- Month 1-3: No visible change. You might feel side effects like dizziness or cramps. Don’t quit yet.
- Month 4-6: Hair may feel finer. Less coarse growth. Some women notice less frequent shaving.
- Month 7-12: Clear reduction in density. Dark hairs start thinning. Skin looks smoother.
- Month 12-24: Maximum benefit. Many women report needing to thread or wax only every 6-8 weeks instead of every 2-3.
It’s not about getting rid of all hair. It’s about making it manageable. You’re not aiming for bare skin-you’re aiming for a life where you don’t feel ashamed to wear a tank top or show your neck.
Cost, Access, and Real-World Barriers
Spironolactone is cheap-$45 for a 60-day supply of generic 100mg. Finasteride? Not so much. Generic is around $30, but insurance often won’t cover it for hirsutism since it’s not FDA-approved for that use. Vaniqa? Insurance rarely covers it either. That leaves many women paying out of pocket.
Doctors vary in how they handle this. Some endocrinologists will prescribe off-label without hesitation. Others hesitate because of the “lack of evidence” label from older guidelines. The 2023 International PCOS Guideline changed that-it now clearly says antiandrogens are acceptable second-line options. But not every provider has caught up.
Also, you need regular blood tests. Spironolactone can raise potassium, especially if you have kidney issues or take NSAIDs like ibuprofen. Your doctor should check your electrolytes every 3-6 months.
What’s Coming Next
Researchers are working on new drugs called SARMs-selective androgen receptor modulators. These aim to block hair growth without affecting muscles, mood, or heart health. One drug, enobosarm, showed 28% better reduction than placebo in early trials. Results are expected in 2024.
Meanwhile, laser and light therapies are getting better and cheaper. At-home IPL devices are now FDA-cleared for facial hair. They won’t replace antiandrogens, but they’re a great complement.
The future is personalized: genetic tests to predict who responds best to spironolactone vs. finasteride, and algorithms that match treatment to your hormone profile. But for now, the tools we have work-if you use them right.
When to Talk to Your Doctor
Ask for antiandrogens if:
- You’ve been on birth control for 6+ months with no improvement in hair growth
- You can’t take birth control due to health reasons
- You’re tired of constant shaving, waxing, or threading
- You’re ready to commit to daily medication and regular checkups
Don’t try to self-medicate. Finasteride and spironolactone need medical oversight. And never take them without reliable contraception.
Remember: this isn’t a quick fix. But for many women, it’s the first treatment that actually gives them back control over their bodies.
How long does it take for antiandrogens to work on hirsutism in PCOS?
Visible results usually take 6 to 12 months. Maximum improvement often occurs between 18 and 24 months of consistent daily use. Hair growth slows gradually, so patience is key. Stopping early means losing progress.
Is spironolactone safe for long-term use in PCOS?
Yes, when monitored. Long-term use is common and generally safe under medical supervision. Regular blood tests for potassium and kidney function are needed. Side effects like dizziness or menstrual changes usually improve after the first few months. It’s not recommended for women who are pregnant or planning pregnancy without dual contraception.
Can I use finasteride instead of spironolactone for PCOS hirsutism?
Yes, finasteride is an effective alternative, especially for women who can’t tolerate spironolactone’s side effects. It’s more targeted to DHT, which drives facial hair growth. But it’s not FDA-approved for hirsutism, so insurance may not cover it. It’s also strictly contraindicated in pregnancy due to fetal risks.
Does eflornithine cream really help with PCOS hair growth?
Yes, but it’s not a standalone solution. Eflornithine slows hair growth by blocking an enzyme in follicles. Studies show it improves appearance in about 60% of users after 6 months. It works best when combined with laser or antiandrogens. You must apply it twice daily, every day, or results fade quickly.
Why aren’t antiandrogens the first treatment for PCOS hirsutism?
Combined oral contraceptives (COCPs) are more effective at lowering overall androgen levels and treating other PCOS symptoms like irregular periods and acne. Antiandrogens are targeted only to hair growth. Guidelines recommend COCPs first because they offer broader benefits. Antiandrogens are added only if COCPs fail or aren’t tolerated.
Can I stop taking antiandrogens once my hair improves?
If you stop, hair growth will likely return to pre-treatment levels within 6 to 12 months. Antiandrogens don’t cure PCOS-they manage symptoms. Most women continue treatment long-term, especially if they’re not on birth control. Some switch to lower doses or combine with laser to maintain results with less medication.
Karl Rodgers
Hi, I'm Caspian Harrington, a pharmaceutical expert with a passion for writing about medications. With years of experience in the industry, I've gained a deep understanding of various drugs and their effects on the human body. I enjoy sharing my knowledge and insights with others, helping them make informed decisions about their health. In my spare time, I write articles and blog posts about medications, their benefits, and potential side effects. My ultimate goal is to educate and empower people to take control of their health through informed choices.