Ans. is a i.e. OCP Friends, all the options given in the question are used for treatment of PCOS but only OCP and spironolactone are used for managing hirsutism. The first step done in general practise in OPD's when a patient of PCOS comes is : Advise : Weight reduction. 'Weight reduction in obese patients is the initial recommendation because it reduces insulin, SHBG and androgen levels (mainly calculated or bioavailable testosterone) and may restore ovulation either alone or combined with ovulation induction agents." Drug therapy If a patient has hirsutism primary goal is lowering androgen levels to halt futher conversion of vellus hairs to terminal ones. Drugs used are : i. OCP's ? "Combination OC's decrease adrenal and ovarian steroid production and reduce hair growth in nearly two - third of hirsute patients." "Combined oral contraceptive - COC's are effective in establishing regular menses and lowering ovarian androgen production. As an additional effect, the estrogen component of these pills leads to increased SHBG levels. With higher SHBG levels, a greater amount of free testosterone is bound and thus becomes biologically unavailable at the hair follicle." Gonadotropin releasing horomone agonists - "GnRH agonists effectively lower Gonadotropin levels over time, and in turn subsequently lower androgen levels. Despite their effectiveness in treating hirsutism, administration of these agents is not a preferred long term treatment method due to associated bone loss. high cost and menopausal side effects." iii Androgne receptor antagonists - like spirono lactone, cyproterone acetate and flut amide. These antiandrogens are competitive inhibitors of androgen binding to the androgen receptor. "Although these agents are effective in the treatment of hirsutism, they carry a risk of several side effects. Metrorrhagia may frequently develop. In addition, as antiandrogens, these drugs bear a theoretical risk of pseudo hermaphroditism in male fetuses of women using such medication in early pregnancy. None of these antiandrogen agents are approved by the FDA for treatment of hyperandrogenism and thus are used off-label." iv. 5 a reductase inhibitor : Conversion of testosterone to dihydro testosterone can be decreased by 5 a reductase inhibitor, Finasteride. It is modestly effective in treating hirsutism and similar to other antiandrogens the risk of male fetus teratogenecity is present. So, friends after such a detailed discussion on the management of hirsutism. You can very well understand that the first line therapy for management of hirsutism are combined oral contraceptive pills. Also know Other methods of treating hirsutism : Eflornithine hydrochloride cream : It is an irreversible inhibitor of ornithine decarboxylase enzyme. This enzyme is necessary for hair follicle cell division and function, and its inhibition results in slower hair growth. Its main disadvantage is that it does not permanantly remove hair. Mechanical methods : -- In includes : depilation creams Depilation methods i.e. hair removal Epilation methods i.e. methods which remove the above the skin surface eg. - entire hair shaft and root. -- shaving Mechanical methods Thermal destruction using -- plucking electrolysis or laser -- waxing Note : While prescribing OCP's in a case of hirsutism : Do not prescribe OCP's containing norgestrel and norethindrone acetate as they have androgenic activity. OCP's containing Illrdeg generation progestins like gestodene, Desogestrel, norgestimate drospirenone are the best, as they have minimum androgenic activity.