| name | endo-hirsutism-add-antiandrogen-after-6months |
| description | This skill guides clinicians to add an antiandrogen after six months of monotherapy with an oral contraceptive when patient‑important hirsutism shows an inadequate response. Trigger phrases include “patient‑important hirsutism”, “6 months of OC monotherapy”, and “suboptimal hirsutism response”. |
Add an antiandrogen after six months of inadequate OC response
STEP 1 — Gather Information
Document baseline Ferriman–Gallwey (FG) score, current OC formulation and dose, duration of OC monotherapy, patient‑reported hirsutism distress, menstrual regularity, and contraceptive use. Action: Record these data and proceed to step 2.
STEP 2 — Rule In / Rule Out
Is the patient on OC monotherapy for at least 6 months with inadequate or suboptimal hirsutism improvement?
- Yes: Proceed to step 3.
- No: Continue OC monotherapy and reassess response in 3 months. Decision: End of algorithm for now.
STEP 3 — Classify or Stratify
Classify hirsutism severity using FG score (mild 8‑15, moderate 16‑25, severe >25) and patient‑important distress level. Also confirm need for effective contraception if of child‑bearing potential. Action: Assign severity tier and contraception status, then move to step 4.
STEP 4 — Decide
Add an antiandrogen (e.g., spironolactone 100‑200 mg daily in divided doses, finasteride 2.5‑5 mg daily, or dutasteride) while ensuring effective contraception; avoid flutamide due to hepatotoxicity risk. Decision: Prescribe selected antiandrogen and schedule follow‑up in 3 months to assess response.
Clinical Guardrails / Mimics / Pitfalls
Do not initiate antiandrogen monotherapy without reliable contraception because of teratogenic risk; avoid flutamide unless hepatotoxicity monitoring is in place; do not add antiandrogen before 6 months of OC monotherapy unless there is rapid progression or virilization; monitor liver enzymes if flutamide is ever considered.
Concrete Clinical Example
A 24‑year‑old woman with PCOS has been on EE 20 mcg + levonorgestrel OC for 8 months, FG score 18, reports persistent facial hair distress despite shaving. She uses condoms for contraception. According to the guideline, add spironolactone 100 mg BID and continue OC; reassess FG score and symptoms in 3 months.
Source: Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, DOI:10.1210/jc.2018-00241
TODO: consider adding scripts/calc.py for the endo-hirsutism-add-antiandrogen-after-6months calculator
