What can be done about PCOS hair growth and hair loss?

Hirsutism and female pattern hair loss in PCOS are both androgen-driven, and both respond slowly. The 2023 International Evidence-based Guideline puts the combined oral contraceptive pill first for hirsutism, adds mechanical laser and light therapies, and reserves anti-androgens for an inadequate response after at least six months of the pill or cosmetic therapy. Nothing here works in weeks. A terminal hair follicle takes months to cycle out.

The first six months

The pill lowers ovarian androgen output and raises sex hormone binding globulin, so free testosterone falls. Existing hairs still have to grow out. The Endocrine Society hirsutism guideline suggests oral contraceptives as initial therapy for most women not seeking fertility, and suggests adding an anti-androgen only after six months of pill monotherapy without adequate improvement. Judging the pill at eight weeks is the commonest reason women conclude it failed.

Spironolactone, and why contraception is mandatory

Spironolactone blocks the androgen receptor and is the anti-androgen most used in the United States. The 2023 PCOS guideline positions anti-androgens "in combination with effective contraception" and requires counselling about "the risks of incomplete development of external genital structures of male fetuses (undervirilisation)". The FDA label for spironolactone states the drug "may affect sex differentiation of the male during embryogenesis" and advises avoiding it in pregnancy. The Endocrine Society guideline suggests against anti-androgen monotherapy unless adequate contraception is used.

Hair removal and scalp thinning

Mechanical laser and light therapy should be considered for facial hirsutism in PCOS, and the guideline notes benefits for related depression, anxiety and quality of life. The Endocrine Society suggests photoepilation for auburn, brown or black hair and electrolysis for white or blonde hair, since laser targets pigment. Scalp hair loss in PCOS is female pattern hair loss and is treated separately, usually with topical minoxidil, with anti-androgens as an adjunct. Scalp regrowth is slower and less complete than facial hair reduction.

Set the review date when you start, not when you are frustrated. Take a photograph at baseline in the same light. If there has been no change at six months on a pill plus cosmetic therapy, that is the point at which adding spironolactone is a guideline-supported step, with contraception in place.