Thursday, September 20, 2018

Weight-Neutral PCOS Series: A Quick Guide

This blog has an ongoing series on Polycystic Ovarian Syndrome (PCOS). Because so much information has been gathered about it, I am putting up this Quick Guide to the PCOS Series so the information is more searchable and easier to use. Keep checking back periodically. More posts will be added as they are finished.

This PCOS series is unique on the internet because it is weight-neutral. 

There are many other sites with information on PCOS, but most emphasize weight loss or strict dietary restrictions as cornerstones of treatment. (More on that below.) This series does not push weight loss or a particular diet as a treatment, but rather discusses approaches that are not weight-centric. Weight loss as an approach is mentioned on occasion because doctors recommend it so often, but it is not promoted, and its pros and cons are critically examined. No one is shamed because they do or do not choose weight loss as a treatment.

I encourage you to review many different sites on PCOS and to think critically about the information you find from them. Ultimately your treatment choices are up to you.

In this PCOS series so far you will find an introduction to PCOS as a health concern:
Many people with PCOS have high levels of insulin, so one of the mainstays of treatment is to lower insulin levels. You will find a mini-series on insulin-sensitizing medications here, including:
Other hallmarks of PCOS include high levels of androgens (male hormones) and irregular periods. Therefore I also have information on medications for these things, including:
In addition, there are articles that discuss specific conditions associated with PCOS and the treatments available for them. This includes:
  • The risk for endometrial cancer with PCOS and the weight loss dilemma
  • Hirsutism (facial and body hair in PCOS women in typically "male" patterns) 
One of the least-discussed conditions associated with PCOS is Alopecia Androgenetica (AGA, also called female-pattern hair loss or FPHL). I did a 3-part mini-series on it:
The blog also has an occasional post reviewing recent research studies on PCOS, like one on inositols for ovulation, inositols in general, or inositols for preventing gestational diabetes. Sometimes I publish an opinion piece/rant about weight bias and fertility treatment discrimination and how it impacts people with PCOS.

As more posts are added to the series, this list will be updated. Please feel free to share a link to this series on your social media platforms or on PCOS forums. As always, you may read this information for free. However, if you quote an article or use its information elsewhere, you must give credit to me and link back to the original article. I do not give permission for these articles to be reposted elsewhere. Just give a brief comment and link back to the original article with proper citation.

PCOS Sites: Caution Needed

Polycystic Ovarian Syndrome (PCOS) affects many higher weight women, but sadly many don't know they have it. Among those who do know about PCOS, there are many gaps in knowledge. Even among medical professionals who treat people with PCOS, there is a great deal of misinformation and mismanagement due to ignorance and weight stigma. There is a pressing need for good, research-based information about treating PCOS.

There are now many resources online about PCOS but unfortunately, not all of them are very evidence-based. Some do quote research but only selectively, without giving a full picture of the pros and cons of a particular treatment. Others promote all kinds of alternative treatments as if they are proven, but with only anecdotal evidence to support it.

This PCOS series is designed to take an evidence-based look at PCOS and its various treatments, both traditional and alternative. Links to research are placed in each blog post, and the most important studies are summarized at the bottom of most posts. Anecdotal stories are not immaterial so they are considered too, but they are not seen as proof.

Financial conflicts of interest contaminate many PCOS resources. Remember that the weight loss and diet business is highly lucrative, and many scientific researchers and doctors are biased by grants and ties to obesity treatment programs and drug companies. They are often not even aware of their own biases and conflicts of interest. Even consumer-run PCOS resources often promote and make money off a particular dietary approach, supplement, or personal health coaching business. Therefore, when researching PCOS, look for conflicts of interest and question conclusions.

Every source of information is subject to bias, even when no financial incentive exists. Be aware of the bias of the sites you read. That includes this resource. Its weight-neutral approach makes it unique among PCOS resources, but some would charge it might be biased against weight loss. On the other hand, unlike many PCOS resources, this series has no financial incentive towards any particular treatment. I make no money from the blog and do not benefit from people choosing non-weight loss treatments. I consider evidence for weight loss and try to be as fair as I can in its evaluation, but I won't pull punches about when it doesn't measure up. It's up to you to decide if I'm writing about it fairly and what the right course is for yourself.

If you are new to this site, I strongly suggest reading the Terminology Page and the Health At Every Size® information to understand the language and philosophy of a weight-neutral approach.

A Weight-Neutral Emphasis

As noted, most PCOS websites have a tremendous weight-loss emphasis. Some are run by people who are selling "lifestyle coaching" or various supplements for PCOS and are profiting from their PCOS connections. In essence, they have monetized their diagnosis. There is nothing necessarily wrong with this, but it does inherently bias the information they have available and the treatments they promote.

The strong weight loss emphasis on many sites also alienates people who have moved beyond dieting and embrace a size acceptance point of view. People like this often avoid typical PCOS sites because of the weight emphasis and so miss important information about treating the condition. There is a strong need for good, in-depth information without pushing weight loss as the cornerstone of all treatment, something that is very missing in most PCOS resources.

Of course, the weight-centric paradigm is very strong in PCOS circles, both among consumers and medical professionals. Even the mere suggestion that dieting could be counter-productive is heresy to some. The idea of a PCOS resource that does not promote weight loss will immediately discredit this series in some eyes.

But remember, you are your own boss. No one is telling you what to do. It doesn't hurt you to consider an weight-neutral point of view. If you decide it's nonsense, you can certainly pursue weight loss as a treatment for your PCOS. No one is going to stop you. Certainly, there is some research that weight loss can be helpful for some things in PCOS, though I would point out it's usually temporary. If you want to pursue that, go ahead. There are plenty of PCOS resources friendly to that approach and no shortage of weight loss advice online.

The problem is that PCOS and weight loss research, like most research on weight loss, is short in duration (usually less than 24 months), has very poor long-term success, and completely ignores the risks that can be associated with weight loss/weight cycling. Does a 5-10% (or larger) weight loss really benefit your health if you end up heavier afterwards and with more eating-disordered behaviors? Or if you end up with gallstones, kidney cancer, or endometrial cancer from weight cycling?

Given the overwhelming evidence of poor long-term success with weight loss and the significant harms that can come from yo-yo dieting, it's important to know that there is an alternative. You can treat your PCOS without having to go on yet another diet that is likely to fail. That doesn't mean that lifestyle is irrelevant to treating PCOS, but simply that an emphasis on weight loss is not required. This blog examines lifestyle as an intervention for PCOS, but without an emphasis on guilt or pressure for any particular approach. Nor do we measure success by the scale.

This series does not ignore the possibility of weight loss as treatment, but promoting weight loss is not its focus, unlike most other PCOS resources. The decision on whether or not to lose weight is left up to the individual.

As with any medical situation, readers will have to carefully consider the pros and cons of all their choices and decide what is right for themselves. That might involve intentional weight loss, but it might mean choosing a Health At Every Size® paradigm instead, which emphasizes healthy habits guided by lab results and symptoms instead of the scale. Whatever you decide on the weight loss question for you is fine; just make that decision from an informed place.

Please remember that this blog is meant to be a safe space. If you decide on weight loss, that's fine, but respect other people's right to have a diet-free space. Do not promote diets, weight loss surgery, eating-disordered behaviors, or body-shaming on this site, and treat everyone politely. You are allowed to disagree with my point of view if it's done respectfully. I can and do restrict comments when necessary. No fat hate is allowed.

This series exists because it's important that people know that there are evidence-based treatment approaches that can help mitigate the risks of PCOS without adding in the risks and emotional roller-coaster of weight loss. The decision about how to approach your weight, however, is entirely up to you.

Remember, you can have a good life, even with health challenges like PCOS. But it pays to be proactive and learn as much as you can about the condition and your treatment choices.

Friday, September 14, 2018

PCOS and Hirsutism: Treatment Options

Every September, we discuss Polycystic Ovarian Syndrome (PCOS) in honor of PCOS Awareness Month. Today we discuss PCOS and abnormal facial and body hair (hirsutism).

To review, in our PCOS series so far you will find an introduction to PCOS as a health concern:
You will also find a mini-series on insulin-sensitizing medications, including:
There is a mini-series on other medications for PCOS, including:
In addition, we discuss specific conditions associated with PCOS and have an occasional post reviewing recent research studies on PCOS:
We also have a mini-series on the least-discussed symptom associated with PCOS, Alopecia Androgenetica (AGA, also called female-pattern hair loss or FPHL):
Now it's time to address the topic of hirsutism (excess facial and body hair) and various medical and cosmetic treatment options for it.

What is Hirsutism?

Images from Karen Figgett, 2014
originally posted at
Hisutism is excess facial or body hair growth in women that occurs in a so-called male pattern. In other words, it occurs on parts of women's bodies where terminal hair growth (long, dark, thick hairs) is not expected or is normally very minimal.

If the hair growth is all over everywhere, it is called hypertrichosis. This is very rare and quite different from hirsutism, which is hairiness limited to "male" areas (like the upper lip, the chin, the chest).

Many women with PCOS have hair above their lips, like a mustache, as well as fine hair growing on their chin, cheeks, or neck. Some have just a few hairs sprouting on the face, while others can have quite a bit. Excess hair can also grow on the abdomen, chests, back, upper legs, and arms of women with PCOS. 

Women with PCOS tend to have high rates of hirsutism. Although not all women with PCOS experience hirsutism, it is considered one of the most classic symptoms of PCOS.

Possible Causes and Diagnosis

Hirsutism from PCOS is usually caused by an endocrine (hormonal) imbalance involving the over production of male hormones (androgens). It may also result from an increased sensitivity of the hair follicles to these hormones. Most of the time the source of the increased male hormones is from the ovaries, the adrenal glands, or the brain.

Hirsutism most commonly results from:
  • Polycystic ovary syndrome (PCOS) (cysts on the ovaries giving off androgens)
  • Insulin resistance, which increases testosterone production
  • Congenital adrenal hyperplasia, mostly caused by 21-α hydroxylase deficiency
  • Adrenal problems like Cushing's Syndrome, adrenal gland cancer, non-classical adrenal hyperplasia
  • Hyperprolactinemia
  • Thyroid dysfunction
  • Growth hormone excess (acromegaly, gigantism) from benign tumors near the pituitary gland
  • Ovarian tumors
  • Menopause, which decreases female hormones but continues to produce male hormones
Every woman with significant hirsuitism should seek out a medical evaluation to determine the cause. At their appointment, they should undergo a complete physical exam and have some blood labs run. These may include DHEA-S, testosterone, androstenedione, various thyroid levels, blood sugar, insulin, prolactin, and 17α-hydroxyprogesterone.

A medical history should also be taken, including menstrual regularity and development of hirsutism. A critical question is how fast the hirsutism developed. If it is sudden and marked, it's more likely to be related to adrenal problems such as a tumor on the adrenal gland. If this is the cause, it needs immediate follow-up.

If the hirsutism has been slow to develop, it's more likely due to high androgen levels from PCOS or insulin resistance. If it's associated with irregular menstrual cycles, it is most likely tied to PCOS. Most cases of hirsutism are caused by PCOS or are idiopathic (cause unknown) and are not alarming, just annoying.

A full discussion of hirsutism in all its forms is beyond the scope of this blog. This blog post discusses only PCOS and hirsutism.

Ferriman-Gallwey Score

Doctors use the Ferriman-Gallwey score to evaluate and quantify body hair growth. Although other measures are available, this remains the standard of care in most practices for evaluating hirsutism in women.

In the original method, 11 body areas were assessed for hair growth, including upper lip, chin, chest (especially along the midline), upper back, lower back, upper abdomen, lower abdomen, thighs, forearms (not used anymore), and legs (not used anymore).

According to Wikipedia, forearms and legs were deleted in the modified version of this scale. Some medical professionals use a further modification of the scale to consider 19 total locations, including spots like sideburns, neck, buttocks, feet, and fingers. However, most seem to still use the 9-location scale.

Hair growth is graded on a scale from 0 (no excessive growth of terminal hair) to 4 (extensive terminal hair growth). If the 9-location version of the scale is used, that means that there is a maximum score of 36 points.

Ethnicity plays a role in how much hair is expected. Each patient's ethnic background should be considered in the scale evaluation. In Caucasian women, a score of 8 or more is considered hirsutism, although some care providers use 6 as a diagnostic threshold instead.

There is great debate about the proper diagnostic levels for other ethnicities; this discussion is beyond the scope of this blog post but rest assured, hirsutism happens in every ethnic group. If in doubt, look at others of the same group around you. If your symptoms seem worse than theirs, you probably have some degree of hirsutism.

The most common ways to treat hirsutism include:
  • Oral contraceptive pills (OCPs) to regulate androgen production
  • Gonadotrophin Releasing Hormone analogs (GnRHa) to regulate androgens by suppressing ovulation
  • Anti-androgen drugs like spironolactone or flutamide 
  • 5 alpha-reductase suppressants like finasteride
  • Insulin-sensitizing agents like metformin or pioglitazone
  • Epilation (removal of hair by the roots) with cosmetic methods like bleaching or chemical depilation, plucking, waxing, shaving and more permanent methods like laser, electrolysis etc.
  • Topical treatment with medications like Eflornithine 11.5% or 13.9% cream etc.
Let's take a look at each of these and a quick overview of their pros and cons. 

Oral Contraceptive Pills for Hirsutism

Some birth control pills can have a major anti-androgenic effect and lessen many PCOS symptoms, which is why they are the most commonly prescribed medication for PCOS. However, there are some drawbacks.

Not all oral contraceptives have an anti-androgenic effect, and some significantly worsen androgens. Combined oral contraceptives, especially the ones that lessen androgenic effects, also increase the risk for blood clots, and may have lower birth control efficacy in high-BMI women. Some argue that OCPs merely put a band-aid on symptoms while not adequately addressing the underlying causes of PCOS issues.

Combined Oral Contraceptives (Dianette, Yasmin, etc.)

As we have discussed before, certain combination oral contraceptives (using both estrogen and progestin) have strong anti-androgen effects. As a result, they are often the first-line treatment for PCOS and for hirsutism in general. One OB website sums up the mechanism of action:
Oral contraceptives...suppress pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which in turn suppress ovarian androgen production. OCs also may reduce adrenal androgen production, although the mechanism of action is unclear.
The estrogen component in OCs increases hepatic production of sex hormone-binding globulin (SHBG), thereby decreasing free testosterone levels. The progestin component antagonizes 5α-reductase and the androgen receptor; it also may increase hepatic metabolism of testosterone and can increase SHBG when the OC has low androgenic activity. However, the strength of anti-androgenic effect in oral contraceptives varies. Some birth control pills (second generation, especially those involving levonorgestrel) have strong androgenic effects, which can make symptoms worse in some women with PCOS.

Many of the later oral contraceptives (third- and fourth-generation) have a stronger anti-androgenic effect. These can be used on their own or in combination with other anti-androgenic drugs (usually spironolactone) to treat hirsutism and acne.

Unfortunately, the oral contraceptives with the strongest anti-androgenic effects tend to have the strongest risk of blood clots, particularly for women of size and/or women with PCOS. Each woman's unique medical history and risk factors must be considered very carefully before use of these oral contraceptives. You can read more about these risks herehere, and here.

Here are further details of two of the most commonly-prescribed anti-androgenic oral contraceptives, those using droperinone and those using cyproterone acetate.

Drospirenone (brand names: Yasmin, Yaz, Angeliq)

Drospirenone (also known as 1,2-dihydrospirorenone) is a synthetic steroidal progestin which has weak anti-androgenic properties. Structurally, it is similar to spironolactone.

When combined with ethinyl estradiol, it becomes the combination birth control pill called Yasmin, sometimes called a "fourth-generation" oral contraceptive. It has a modest effect against hirsutism and acne. It was marketed as a treatment for acne. (In a slightly different formulation, drosperinone plus estradiol is called Angeliq, and is sometimes used for menopausal symptoms.)

Yasmin is contraindicated in people with a history of liver, kidney, or adrenal insufficiency. Potassium levels must be carefully monitored in anyone on this medication.

People with a history of depression or family depression might want to avoid this OCP because anxiety and depression are possible side effects. Migraine is another possible side effect.

The biggest concern, however, is blood clots. Research suggests that the risk for blood clots is significantly increased in people on Yasmin, both compared to those not on any birth control pills at all, and in those on other types of birth control pills. Certain risk factors (obesity, high blood pressure, family history of blood clots, diabetes, etc.) may raise the risk even more.

Still, doctors point out that the absolute risk remains relatively low, and certainly lower than the risk of blood clots during pregnancy. And it reportedly does a good job of lessening hirsutism.

Cyproterone Acetate (CPA; in oral contraceptives, Dianette or Diane-35)

CPA is another progestin that has anti-androgenic properties and may be used alone or as part of certain birth control pills. It inhibits production of androgens in ovarian theca cells, and also competes with androgens at receptor sites.

From its Wikipedia entry:
Cyproterone a synthetic steroidal antiandrogen drug with additional progestogen and antigonadotropic properties. Its primary action is to suppress the activity of the androgen hormones such as testosterone and its more potent metabolite dihydrotestosterone (DHT) in the body, effects which it mediates via competitive antagonism of the androgen receptor and inhibition of enzymes in the androgen biosynthesis pathway.CPA is most often used as an anti-androgen treatment for men with prostate cancer. In PCOS women, it is an effective treatment for significant hirsutism and acne. It may be even more effective for this when combined with metformin.
In the U.K. and Canada, CPA has been combined into the oral contraceptives known as Dianette and Diane-35. CPA and the Diane birth control pills are not available in the U.S.

The amount of CPA in most birth control pills is fairly small, and has only a modest effect on hirsutism. Higher doses of CPA tend to have more impact on hirsutism. However, it takes quite a while for the CPA in birth control pills to affect hirsutism; a trial of at least 6 months is needed, and often the maximum effect is not attained until 2-3 years later.

CPA can have significant liver toxicity. Liver enzymes, cortisol and electrolyte levels must be monitored when on CPA. A woman's ability to absorb vitamin B12 may also be impaired, while iron-binding abilities may be enhanced. B12 and ferritin levels should be monitored when on this medication long-term.

Nausea, vomiting, headache, depression, weight changes, edema, increased blood pressure, gallstones, and skin spots are potential side effects. Again, birth defects can occur with this drug, so effective birth control is needed, which is why it is usually administered in oral contraceptive form.

Blood clots are also a significant risk; women on birth control pills with CPA have a higher risk for blood clots than women on certain other types of the Pill, but some OB organizations feel that they can be worth the risk. Like Yasmin, the absolute risk of a blood clot is fairly low, but may be increased in women with certain risk factors.

If you consider use of CPA, a CPA oral contraceptive (like Dianette), or a drosperinone oral contraceptive (Yasmin), be sure to consult with your care providers carefully about your health history, risk factors, and the benefit/risk ratio of these medications. Generally speaking, on their own, OCPs are not that effective for hirsutism, but combined with other medications like an anti-androgen they are far more effective. Still, they often involve significant side effects and must be considered carefully.

You can read more about Dianette oral contraceptives here and the newer oral contraceptives in general here.

Gonadotrophin Releasing Hormone analogs (GnRHa) 

GnRHa medications work by suppressing ovulation, which in turn lowers the androgens in the body. According to one source:
Gonadotrophin Releasing Hormone Analogs suppress gonadal hormone synthesis by imitating GnRH and attaching to target pituitary receptors with ‘high affinity’. The commonly used analogs are potent GnRH agonists (GnRHa). A long-term treatment with a GnRHa like leuprolide acetate acts against ovarian steroidogenesis by inhibiting pituitary LH and FSH production. This in turn reduces the concentration of circulating testosterone and androstenedione, but without affecting adrenal androgens.
These medications tend to work better for PCOS hirsutism than oral contraceptives alone. However, long-term use brings lots of side effects, so this medication is typically only used in women who have very serious hirsutism and only minimal success with other hirsutism medications.

This medication needs to be injected. It is done about once a month, and is quite expensive. It is viewed as a short-term solution only and is not generally used long-term. It may provide a short-term clearing of excess hair that then can be sustained with an oral contraceptive but generally speaking most doctors prefer other choices first.

Anti-Androgens for Hirsutism

One of the most effective treatments for hirsutism is an anti-androgen medication, either by itself or combined with an oral contraceptive. Since PCOS results in androgen excess, treatments aim to reduce the levels of androgens ─ or at least to reduce their effects.

An anti-androgen prevents the body from making as many androgens, or it may limit the activities and effects of androgens. Treatment with anti-androgenic medications can help lower androgen levels, reduce hirsutism, reduce acne, and perhaps even minimize hair loss issues.

While anti-androgens can reduce some PCOS symptoms, they can also cause birth defects and must be taken with an extremely reliable form of birth control, even in women with fertility issues. Occasional spontaneous ovulation does happen even in those struggling with infertility, and the chance of birth defects is high in women who take anti-androgen medications. As a result, anti-androgens are usually taken with oral contraceptives in order to make sure pregnancy is prevented. Sometimes the combination works even better on PCOS than alone, giving it an added bonus.

Anti-androgens are not FDA-approved for the treatment of PCOS. Research reviews note the poor quality of research on these drugs, so the best anti-androgen for treating PCOS symptoms is not yet known, nor is the best combination of anti-androgen and oral contraceptive. Women who want to use any of these drugs should discuss all pros and cons thoroughly with their medical professional.

It is important to note that it takes a long trial of treatment (6-18 months) before it is clear whether a particular anti-androgen drug is impacting your symptoms. Because the hair growth cycle is long, improvement is generally slow and gradual. You must be patient before you decide whether or not an anti-androgen drug is helping.

And remember, the drug's benefits last only as long as you are taking the drug, and the risk of side effects with some drugs is substantial. If the drug's benefits are only modest, some people may feel they are not worth the long-term risk of side effects.

Spironolactone  (brand name: Aldactone)

Spironolactone is the most common anti-androgen drug used for women with PCOS. It is a potassium-sparing diuretic, usually prescribed for treating edema (excess fluid) or high blood pressure. It is also an aldosterone antogonist. Its use for PCOS symptoms is off-label but has been going on for years.

Spironolactone is thought to help in the following way:
Spironolactone inhibits the testosterone secreted by the body, and also competes for hormone receptors in the hair follicles. Receptors are sites on cells which allow hormones or chemical to bind to them, creating a reaction. If another chemical is in the receptor site, androgens cannot bind to them and stimulate the reaction causing hair growth.
Spironolactone has been shown to significantly lessen facial hirsutism in women with PCOS. A recent Cochrane meta-analysis suggests that 100 mg daily is quite effective against hirsutism, although it noted that the quality of this evidence was low and more research is needed. Other OB guidelines have suggested that higher doses may be needed in some women, but that it's best to build dosage up slowly over time.

For many women with significant hirsutism, spironolactone is the medication of choice when used with a form of extremely reliable birth control in women who have even the smallest chance of becoming pregnant. This usually means the Oral Contraceptive Pill. The combination of the Pill and spironolactone can be particularly effective for many women with PCOS. However, not all find it helpful.

Because spironolactone is a diuretic, you will need to be monitored to make sure you don't build up too much potassium in the blood. Frequent urination is the most common side effect. Nausea, fatigue, headache, lightheadedness, indigestion, thirst, electrolyte imbalances, and abnormal bleeding or menstrual disturbances are other potential side effects. Heart arrhythmias can occur if potassium levels spike; this is most common in the elderly or those with kidney disease but can occur in younger patients. Liver enzymes must also be monitored regularly for signs of hepatotoxicity.

The good news is that spironolactone is an extremely affordable drug that is generally quite effective for PCOS hirsutism, especially when used in combination with other drugs. If PCOS-related acne is a problem for you, it often works well for both hirsutism and acne, and possibly for alopecia (hair loss on the head) too. You can read more about the uses, side effects, and cautions for spironolactone here and here


Another medication that works similarly to spironolactone is flutamide. From one website:
Flutamide is a non-steroidal antiandrogen that is devoid of other hormonal activity. It most likely acts after converting to 2-hydroxyflutamide, which is a potent competitive inhibitor of dihydrotestosterone (DHT) binding to the androgen receptor.
A few studies have found that flutamide helps restore regular menstrual cycles and ovulation in women with PCOS, but it is most useful against hirsutism. It is available in the United States, but is usually prescribed for men with prostate cancer, not women with PCOS. As a result, most of the hirsutism research on it is European.

Flutamide can have significant liver toxicity, so some organizations recommend against it use. Flutamide can also result in significant gastrointestinal upset, as well as issues with dry skin. Because of these side effects, flutamide is generally considered unsuitable for the treatment of acne and other skin problems where its benefit is only minimal.

Because it is more effective for hirsutism, the benefit/risk ratio for this is more controversial. A recent Cochrane meta-analysis suggests that flutamide (250 mg, twice daily) is "effective and safe" against hirsutism, although it noted that the quality of this evidence was low. Another recent meta-analysis disagreed, stating:
Due to its risk for hepatotoxicity, flutamide is not considered a first-line therapy. If used, the lowest effective dose should be administered with careful monitoring of liver enzymes.
Some care providers feel that flutamide is relatively safe with careful monitoring of liver function. The chance for birth defects is quite high with Flutamide, so again, a very reliable form of birth control must be used, or it may be prescribed only for women with no childbearing potential.

You can read more about Flutamide here, here, and here.

5 Alpha-Reductase Inhibitors for Hirsutism

Another way to reduce hirsutism is by lessening the effect of androgens on skin cells. 5 alpha-reductase inhibitors are very effective at doing this. [Note: "alpha" may be written out or the greek letter used - "5 α-reductase inhibitor"]

Finasteride  (brand name: Propecia or Proscar)

Finasteride is a 5 alpha-reductase inhibitor. It is FDA-approved for the treatment of baldness and/or Benign Prostatic Hyperplasia (BPH) in men. It has a relatively good safety profile and is well tolerated by most men, but it is quite expensive. It is not approved for use with PCOS or with women.

Finasteride has been shown in some research to be effective against hirsutism, though not for hair loss in women. It works by preventing the androgens from getting into the cells. However, the recent Cochrane meta-analysis notes that the research on finasteride is inconsistent and therefore conclusions cannot be reached. It does not appear to be effective against hair loss in women.

Finasteride can cause headaches and depression. It is associated with a very high risk of birth defects (pregnancy drug category X), so it is not used in women who have even the smallest chance of becoming pregnant. Some doctors consider it an option, however, for women who have no childbearing potential anymore (beyond menopause, tubal ligation, hysterectomy, etc.).

You can read more about finasteride here.

Bicalutamide (brand name: Casodex, Calutide)

A fairly new option for hirsutism is bicalutamide. It is a 5 alpha-reductase inhibitor, like finasteride. It was developed to treat prostate cancer in men. Its mechanism of action is as follows:
Bicalutamide acts as a pure antiandrogen by binding to the androgen receptor and preventing its activation and subsequent upregulation of androgen-responsive genes by androgenic hormones. In addition, bicalutamide accelerates the degradation of the androgen receptor. 
Bicalutamide is considered to be about as effective as finasteride, but with fewer side effects. Although it can impact liver function, bicalutamide is less likely to cause damage than some other anti-androgen drugs, which is a big advantage. Another advantage is its price, as it is a comparatively cheap medication. A generic version is available. 

Like finasteride, it is associated with a high risk of birth defects and is contraindicated in women with any chance of becoming pregnant. However, there is some minimal research on its use in women. A recent study found that an oral contraceptive pill plus bicalutamide was very effective and well-tolerated. 

You can read more about bicalutamide here.

Insulin-Sensitizing Medications for Hirsutism

Another option for treating hirsutism is an insulin-sensitizing medication. Since many women with PCOS have strong insulin resistance and this may result in higher androgen levels, treating the insulin resistance may be helpful in treating mild hirsutism.

Insulin-sensitizing medications may have some anti-androgenic effects and can be somewhat effective against hirsutism or acne. Since they have the distinct advantage of being effective against multiple PCOS symptoms at the same time, some providers will prescribe insulin sensitizers first in women with PCOS. These include TZDs, inositols, and most commonly, metformin.

TZDs like Actos and Avandia may be somewhat effective against hirsutism but because of concerns over their safety, they are not usually used for hirsutism. However, they may be part of an overall PCOS treatment program with some medical professionals. You can read more about TZDs here.

The inositols (myo-inositol and d-chiro-inositol) are insulin-sensitizing supplements that many people with PCOS find more tolerable than metformin or TZDs. They are effective for lessening insulin resistance, but the research on whether they help with symptoms like hirsutism is mixed. More data is needed.

Metformin (brand name Glucophage) is the most commonly used insulin-sensitizing medication in PCOS. It is an old drug that has been in use for a very long time and has an impressive safety record compared to other insulin sensitizers. In diabetics, it has been shown to lower the risk for heart disease and death significantly, a claim few drugs can make. It has also been shown to delay the development of diabetes in those with strong risk factors.

However, metformin is known for its GI side effects in some people. Diarrhea, gas, and bloating are common. Using the extended release formulation can lessen this for many people, but GI side effects can still happen and lead some people to discontinue its use.

Metformin also has been known to impact vitamin B12 levels in some patients so B12 levels should be checked periodically. Rarely, metformin can result in lactic acidosis, a severe complication that can be fatal. To lessen the risk, many doctors recommend temporarily discontinuing metformin during times of significant acute illness or surgery. Liver and kidney labs should be run before starting metformin and periodically during its use. You can read much more about metformin here.

Metformin has been shown in some past research to be as good as or somewhat better than oral contraceptives alone in reducing hirsutism in women with PCOS. A 2009 literature review for the American Academy of Family Physicians notes that past research showed that metformin was as effective for treatment of hirsutism as many oral contraceptives, although later research did not confirm its effectiveness.

Nowadays, metformin alone is not considered to be a first-line drug for use against hirsutism. However, it may increase the effectiveness when used with other hirsutism medications. One recent review said:
Monotherapy with an insulin sensitizer does not significantly improve hirsutism. While insulin sensitizers improve important metabolic and endocrine aberrations in polycystic ovary syndrome, they are not recommended when hirsutism is the sole indication for use. More recent research suggests that metformin modestly increases the effectiveness of other anti-hirsutism medications, particularly oral contraceptives and spironolactone. In other words, while metformin probably shouldn't be prescribed by itself for hirsutism, it may well be prescribed in combination with an anti-androgen medication (probably spironolactone) or an oral contraceptive.
Herbs for Hirsutism

In addition to traditional medicines, there are herbs that are reputed to have anti-androgenic effects.

For example, herbal spearmint tea has long been used as an anti-hirsutism treatment in Middle Eastern cultures. Research suggests that spearmint tea may have mild anti-androgenic effects and may be helpful with hirsutism, but longer studies are needed to evaluate this.

Other possible herbal agents may include red reishi (a mushroom used in Chinese medicine), licorice root, Chinese peony, green tea, black cohosh, and saw palmetto extract. I am not aware of any studies on these herbs for hirsutism; their inclusion is based only on anecdotal evidence from some PCOS sites.

Many women with PCOS use chaste tree/vitex in particular. More information on the (rather sparse) research behind these possibilities can be found here.

Cosmetic Treatments for Hirsutism

There are a number of cosmetic treatments that can help with PCOS symptoms like hirsutism. None are 100% satisfactory, but most women find them preferable to risky drugs, especially during their childbearing years. Over time they develop a routine that works for them, even if it's not as ideal as they'd like.

Mechanical Hair Removal or Disguise

To deal with bothersome facial and body hair, most women employ cosmetic remedies like shaving, plucking, waxing, epilators, and depilatory creams. Bleaching may also help by making the facial hair less noticeable.

If the degree of hirsutism is mild, then shaving is the easiest way to take care of it. Keep in mind that it has to be done often or stubble will show. Shaving does not make the hair grow back darker and thicker; the stubble left over just appears that way. Using an electric shaver may result in less skin irritation than a blade. One woman reports that an electric eyebrow shaver was the best solution for her.
Eyebrow shavers are the best to use for fuzzy face because the blade is much finer and it cuts the hair at an angle that doesn't result in the hair looking darker/thicker as it comes back in.
Lots of people use plucking or tweezing if the hirsutism is mild and just results in a few stray hairs. Waxing is a faster version of plucking. Epilators are small mechanical devices that basically work the same as waxing or tweezing; they pull the hair out by the root. Under ideal conditions this leaves smooth soft skin and lasts several weeks.

However, plucking, tweezing, etc. can permanently damage the hair follicle. Sometimes this is good as the hair follicle might stop producing hair. Sometimes it is bad because the hair follicle may respond by growing a bigger, thicker, and darker hair. You never know which result you are going to get. Also, tweezing, plucking, epilators, and waxing can sometimes lead to major skin irritation and damage. And they hurt!

Bleaching can work well if you are very light-skinned as it reduces the contrast between hair and skin.  However, bleaching can lead to major skin irritation and damage. For many women of color, bleaching is not a good option.

Depilatory (hair removal) creams can be used at times. These creams use very alkaline formulations that weaken the hair shaft so that the hair breaks off below the surface, leading to very smooth skin. One advantage of depilatories is that their results tend to last longer than shaving; however, many women find that depilatory creams cause significant skin irritation and redness. They do fine for a while but eventually many women become too sensitive to use these regularly.

Most women with PCOS use multiple cosmetic measures to deal with visible hirsutism. For example, women may start by waxing off the excess hair, then using an epilator as it grows back. Or they may rotate their approach to lessen the sensitivity of the area.

However, for some women cosmetic measures are not enough. As a result, they may turn to procedures like electrolysis or laser therapy.


In order to destroy the offending hair follicles and hopefully achieve permanent hair loss, electricity is another tool. Basically, it's an epilator with the addition of a small electrical current to destroy the hair root. Here is a description of the procedure:
Electrolysis is defined as the electrochemical destruction of the hair follicle. In electrolytic epilation a fine, disposable wire needle is inserted into the hair follicle. Through this needle, a regulated electric current, either direct or alternating, is transmitted from a highly state-of-the art instrument known as an epilator to destroy the germinative hair bulb. It can be correctly performed only by expert professionals. 
The frequency of the electric current (as regulated by the FDA) is generally 13.56 MHz. The current may be either low power and administered for 3 to 20 seconds, or high power and given for less than a second (the commonly known flash technique).
There are several types of electrolysis available, including galvanic electrolysis, thermolysis, and the blend method. Descriptions of these can be found here and here.

Some people have very good results with electrolysis but it is a long process. Even when seen once a week, treatment for significant PCOS hirsutism may take months or even years. Redness and swelling often result after a session. Infections and scarring may occur. Treatments are expensive and painful and may not result in permanent removal of hair.

Therefore, electrolysis seems most useful for women with small localized patches of hirsutism.

Laser Therapy

Some women with hirsutism choose to try laser therapy:
Laser treatment employs a method called selective photothermolysis in order to destroy the hair follicle selectively. The laser is passed through the skin and specifically targets a chromophore called melanin, a natural pigment present in the hair follicle. Melanin absorbs the laser light at a specific wavelength and converts the laser into heat energy for destroying the hair tissue. Since melanin is located in the hair follicle but not the adjoining dermis, targeting it ensures selective damage of the follicle without harming neighboring tissues. However, melanin is present in the epidermis. Hence, laser methods must ensure that the skin is cooled off to prevent thermal damage of the epidermis.
Laser therapy can be used on larger areas of the body, unlike electrolysis. Treatment does not result in permanent hair loss, but the results do last much longer than other forms of treatment, usually several months. Treatment is often done in threes; one initial dose, another dose when hair regrowth appears several months later, and then a final dose when hair regrowth appears again. A lot depends on the type of laser used; see the article linked above for more specifics.

Laser treatment can be somewhat painful and side effects like swelling and redness are quite common. Less common are more serious side effects like scarring and dyspigmentation. Although longer wave lengths can be used for people of color, laser therapy may cause scarring and damage in people with darker skin.

Other Medications

Besides the anti-androgens listed above, another medication that may help with hirsutism is Vaniqa (Eflornithinepronounced EE-floor-nih-theen). This cream is used to slow growth of unwanted hair, especially on the face. It's not a depilatory cream but rather an enzyme blocker.

The drug works by blocking an enzyme (putrescine) needed for hair to grow. If the patient stops using the cream, the hair will grow back, so a long-term management plan is needed. Eflornithine is FDA-approved for the treatment of facial hirsutism and is considered safe to use during pregnancy.

Like other medications and treatments, it can cause redness and irritation in the area being treated. It must be used for at least 8 weeks to be effective. Discontinuing it for substantial lengths of time would stop its effect.

Although it is known to work successfully in women with facial hirsutism, its specific effectiveness at treating women with PCOS is currently unknown.

To Treat or Not to Treat

Of course, it is also a choice not to treat your cosmetic PCOS symptoms. Just because society says that women should look a certain way doesn't mean that we have to do so. After all, facial hair and thinning hair on the head is accepted in men, so why is it considered so unacceptable in women? It results from sexist double-standards, the idea that it is our main duty as women to be as sexually attractive as possible, and that this sexual attractiveness is measured by extremely narrow standards that very few women actually meet.

Some women struggle for years to deal with cosmetic symptoms, find few treatments that work well for them, and in the end decide to opt out of even trying to treat these cosmetic symptoms. For some women, it can be a tremendously freeing to finally get off the merry-go-round of cosmetic treatments and trying to hide what is happening to them, just to meet some sexist standard of what women "should" look like. There is NO obligation to treat cosmetic symptoms if you don't want to do so.

On the other hand, societal pressure causes most women to want to treat distressing cosmetic symptoms, and that's fine too. Although it is not fair that women are subjected to appearance double-standards, it is a fact of life that social judgment can have significant impacts on self-esteem, dating, and work opportunities. If a woman wants to treat her androgenic symptoms, this is also normal and understandable.

The point is that each woman gets to decide on her own what she will and won't treat. There is no symptom that you have to treat. There is nothing wrong if you want to treat certain symptoms, and there is nothing wrong with opting out of treating those symptoms either. It's your choice.


Hirsutism is one of the more difficult and disheartening PCOS symptoms to deal with. There is no magical cure for it, only ways to manage it, each with its own trade off.

Most women choose a variety of methods to deal with it. They  may use medications to decrease the amount of hirsutism, while also using cosmetic removal methods. A lot depends on the degree of hirsutism and whether the woman is planning on having children anytime soon.

If you are in your childbearing years, sexually active, and have any chance of conceiving, your best choice is probably cosmetic treatments, with the possible addition of metformin. Used carefully, this is pretty effective, especially in those with mild to moderate hirsutism.

If you are not interested in or not ready to conceive and you have moderate to significant hirsutism, one of the most effective treatments is an Oral Contraceptive Pill plus spironolactone. Recent research shows that this is highly effective for many women with PCOS. Another choice is metformin plus an Oral Contraceptive Pill, which can be effective for mild to moderate cases.

For those women who do not have childbearing capacity anymore (due to hysterectomy, tubal ligation, menopause, etc.), treatment can include metformin plus spironolactone, or an alpha-reductase inhibitor for very significant cases of hirsutism.

Most women with mild hirsutism find all they need is cosmetic treatments. Those with significant hirsutism find they have to combine some form of medication with some form of cosmetic treatment in order to get the appearance they want.

Whatever treatment you choose, there's no doubt that dealing with excess facial and body hair is hard. It strikes right at the heart of a woman's perceptions of her own femininity, and it affects how others view her as well.

But you are not alone. There are many PCOS support groups available. These can provide invaluable emotional support when dealing with the emotional angst or social stigma of some of the cosmetic and medical side effects of PCOS.

Remember, your symptoms do not define you.

Cosmetic symptoms are distressing and you have every right to be upset and angry about them, but in the end, they do not define who you are or what kind of life you can have. Only YOU can do that.

Women can have symptomatic PCOS and still have good, happy lives, regardless of what they do about their hirsutism. Half the battle is being determined to have a good life, regardless of whatever challenges you are handed.

This is the only life you get; make the most of it! Don't let PCOS or its symptoms keep you from happiness.


General Information about Hirsutism
Information about Ferriman Gallwey Score
Study Reviews

Am J Clin Dermatol. 2014 Jul;15(3):247-66. doi: 10.1007/s40257-014-0078-4. Hirsutism: an evidence-based treatment update. Somani N, Turvy D. PMID: 24889738
...Four recently published RCTs met criteria for inclusion in our review. In addition, one meta-analysis and one systematic review/treatment guideline were identified in the recent literature. Physical modalities and oral contraceptive pills (OCPs) remain first-line treatments. Evidence supports the use of electrolysis for permanent hair removal in localized areas and lasers (particularly alexandrite and diode lasers) for permanent hair reduction. Topical eflornithine can be used as monotherapy for mild hirsutism and as an adjunct therapy with lasers or pharmacotherapy in more severe cases. Combined OCPs as a class are superior to placebo; however, antiandrogenic and low-dose neutral OCPs may be slightly more efficacious in improving hirsutism compared with other types of OCPs. Antiandrogens are indicated for moderate to severe hirsutism, with spironolactone being the first-line antiandrogen and finasteride and cyproterone acetate being second-line antiandrogens. Due to its risk for hepatotoxicity, flutamide is not considered a first-line therapy. If used, the lowest effective dose should be administered with careful monitoring of liver enzymes. Monotherapy with an insulin sensitizer does not significantly improve hirsutism. While insulin sensitizers improve important metabolic and endocrine aberrations in polycystic ovary syndrome, they are not recommended when hirsutism is the sole indication for use. Lifestyle modification counseling is recommended. Gonadotropin-releasing hormone analogs and glucocorticoids are only recommended in specific circumstances. Additional therapies without sufficient supportive evidence of efficacy are ovarian surgery, statins (HMG-CoA reductase inhibitors), and vitamin D supplementation...CONCLUSIONS: Risks and benefits of treatment must be carefully considered and discussed with the patient. Expectations for efficacy should be appropriately set. A minimum of 6 months is required to see benefit from pharmacotherapy and lifelong treatment is often necessary for sustained benefit.
Cochrane Database Syst Rev. 2015 Apr 28;(4):CD010334. doi: 10.1002/14651858.CD010334.pub2. Interventions for hirsutism (excluding laser and photoepilation therapy alone). van Zuuren EJ, Fedorowicz Z, Carter B, Pandis N. PMID: 25918921
Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective... AUTHORS' CONCLUSIONS: Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision-making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects.Further research should consist of well-designed, rigorously reported, head-to-head trials examining OCPs combined with antiandrogens or 5α-reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α-reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment.
Treatment of Hirsutism

Friday, September 7, 2018

Inositol for PCOS anovulation: 2018 Review

It's September, and that means it's time for PCOS Awareness Month. We have a continuing series on Polycystic Ovarian Syndrome (PCOS) that looks at various PCOS issues from a weight-neutral point of view.

One of the most exciting treatments on the horizon for Polycystic Ovarian Syndrome (PCOS) is inositol, either myo-inositol or d-chiro-inositol, or a combination of both. We've discussed it before, but now there is a recent meta-analysis of the literature.

New Review of Inositol for Fertility

Here is a review of the best research we have so far on inositol for fertility issues in women with PCOS. There are other studies, but these studies met high enough standards for quality to be considered for this analysis.

The good news is that the results so far are quite encouraging. The bad news is that it's clear we still need better-designed trials.

Let's start with the bad news. There was little uniformity in the protocols. Some studies used myo-inositol, some studies used d-chiro-inositol. Some studies compared inositols with metformin, others did not. Trials are also fairly small, which makes it harder to know how reliable the data is. Most importantly, no trials reported on live birth rates, which is the most important outcome.

The good news is that overall, the review was quite positive. The review's authors found that use of inositol improved ovulation rates and regularity of menstrual cycles. 

The review found that inositol was better than placebo (sugar pill), and was also more effective than metformin. In one study, it also increased pregnancy rates (3.3x compared to placebo, 1.5x compared to metformin), but we don't know how many of these ended up as live births. The authors concluded:
Inositol appears to regulate menstrual cycles, improve ovulation and induce metabolic changes in polycystic ovary syndrome; however, evidence is lacking for pregnancy, miscarriage or live birth. A further, well-designed multicentre trial to address this issue to provide robust evidence of benefit is warranted. 
So there are reasons to be cautiously optimistic about inositols, but a lot more research is needed. Come on, researchers, get this work going! Inositol's preliminary results look very promising so far, but we need much more data before it becomes standard of care. In particular, we need to know whether it improves the live birth rate in people with PCOS, which is the ultimate measure of successful treatment.

Still, it's another tool in the toolbox that can be considered for women with PCOS who don't ovulate regularly. And on the whole, that's good news.


BJOG. 2018 Feb;125(3):299-308. doi: 10.1111/1471-0528.14754. Epub 2017 Jul 14. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, Coomarasamy A, Thangaratinam S.  PMID: 28544572
...Systematic review and meta-analysis of randomised controlled trials (RCT) that evaluated the effects of inositol as an ovulation induction agent... We included ten randomised trials. A total of 362 women were on inositol (257 on myo-inositol; 105 on di-chiro-inositol), 179 were on placebo and 60 were on metformin. Inositol was associated with significantly improved ovulation rate (RR 2.3; 95% CI 1.1-4.7; I2 = 75%) and increased frequency of menstrual cycles (RR 6.8; 95% CI 2.8-16.6; I2 = 0%) compared with placebo. One study reported on clinical pregnancy rate with inositol compared with placebo (RR 3.3; 95% CI 0.4-27.1), and one study compared with metformin (RR 1.5; 95% CI 0.7-3.1). No studies evaluated live birth and miscarriage rates. Inositol appears to regulate menstrual cycles, improve ovulation and induce metabolic changes in polycystic ovary syndrome; however, evidence is lacking for pregnancy, miscarriage or live birth. A further, well-designed multicentre trial to address this issue to provide robust evidence of benefit is warranted. 
Tweetable abstract: Inositols improve menstrual cycles, ovulation and metabolic changes in polycystic ovary syndrome.

Friday, August 31, 2018

Keep Children in Rear-Facing Car Seats Longer

Image from Consumer Reports article cited below
As we head into the new school year and the holiday weekend, it is a good time to remind parents and guardians to double-check their car seat usage.

The American Academy of Pediatrics (AAP) has issued new guidelines suggesting that parents keep their young children in rear-facing car seats until they reach the height or weight limits of that seat. 

In other words, don't be so eager to get those children front-facing because children really are safer rear-facing. 

In the past, AAP recommendations were age-based. Generally they recommended that children become front-facing at age two. But there is such a wide variation of size in children, even at the same age, that going only by age doesn't make sense. Also, research shows that rear-facing remains the safest position even for children older than two. Instead, parents should consult the height and weight limits of the car seat they use and use those to guide when to switch to front-facing.

Why Rear-Facing?

It's important to keep children rear-facing as long as possible because it protects the child's head and neck more completely. If a young child is front-facing and an accident occurs, the child's body is restrained but the head is thrown forward, placing tremendous stress on the neck and spine at a time when they are not very strong or developed. If the child is rear-facing in the same scenario, most of the force pushes the child's head and back into the support of the car seat behind them, lessening the stress on the back and limiting extension of the neck.

Research clearly shows that children are safer in rear-facing car seat positions whether the impact is from a head-on collision, a side-impact collision, or a rear-impact collision. This really is a no-brainer.

From the Consumer Reports article on car seat safety:
“Parents and caregivers should never be in a rush to move kids along to the next seat type or orientation,” says Emily Thomas, Ph.D., auto safety engineer at Consumer Reports’ Auto Test Center. “Each move to the next step can actually be a step down in terms of a child’s overall safety. In this case, making the transition to forward-facing too early exposes your child to head and spine injuries during a crash.”
General Car Seat Guidelines

Most parents do a pretty good job these days of using infant car seats correctly when babies are young. However, there is a distinct drop-off of proper use as the child gets older.

Car seat safety doesn't end when the child becomes a toddler or goes to preschool. Research shows that during routine car seat inspections, about one-third of children over 4 years of age were "suboptimally restrained." There's a lot of room for improvement here.

Consumer Reports suggests:
Parents can expect to need a minimum of three seats to best protect their children through the car-seat years: a rear-facing infant seat, a convertible seat (used rear-facing first, then transitioned to forward-facing when appropriate) and a booster seat.
Here are some suggestions for safer car seat use:
  • Start with a rear-facing infant seat or convertible car seat. Always place it in the rear seat. The middle of the back seat is the safest spot in the car for a child
  • Switch from a rear-facing infant seat to a rear-facing convertible seat "no later than your child's first birthday" This is because most babies outgrow their infant seat due to height, not weight, so be sure you pay attention to the height limits as well as weight limits
  • Get the best convertible car seat you can afford, one that goes up to the highest height/weight limits you can find. Children really are safer rear-facing when they are young so find the car seat that will let you keep them rear-facing the longest
  • Children should remain rear-facing until they have reached the height or weight limit for rear-facing children in that seat. At that point, switch to forward-facing in the convertible seat
  • Stay in the forward-facing convertible seat until the height or weight limit is exceeded for the forward-facing position. Only then should you switch to a booster seat
  • Use a booster seat until the child outgrows the height or weight limits of that seat and a lap/shoulder belt fits them properly. Most resources advise that children should be at least 4'9" tall and weigh at least 80 lbs. before they transition out of the booster seat. In some areas, 20% of child injuries under age 8 in car accidents resulted from using adult restraints instead of booster seats
  • Keep children in the back seat until the teenage years (at least 13; in some states it is 14). Air bags in the front are rated for adults and can seriously injure or kill children. Older children may look fairly grown but their skeletal systems are still more vulnerable to force injuries. Restrained children in the front seat are about 40% more likely to sustain an injury than restrained children in the rear seat
There are so many car seats brands and types; each has its own height/weight guidelines. When in doubt, follow the guidelines that came with your car seat.

Always keep the car seat's guidelines with the seat so they are easily found for reference. Tape them to the back or side of the seat. Some experts also recommend writing or attaching an ID tag to the car seat with the child's name, parent names, and pediatrician's name/number. That way if there is a significant accident and a relative is unable to give information or medical contacts, first responders have a lead on who the child is, their medical professional, and a way to find medical history. If your child has special needs, this is particularly important.

Remember that there are many car seat safety inspection clinics available in the community. Please use them. You can be very well-educated and still make mistakes that could be deadly.

Many hospitals host car seat clinics regularly, and many fire departments and police departments sponsor them as well. Many parents go to these inspections when their kids are babies, but do not attend them once the child reaches pre-school or school age, thinking that they now know what to do. Yet frequent errors are found in children between ages four to twelve, and faulty restraint is a major cause of trauma and mortality for children of that age. Don't assume you have it all down; rules change at times and it's easy to overlook a recalled seat or a change in guidelines.

Dealing with Pressure About Restraints

One reason parents don't restrain their children optimally is due to a misunderstanding of the current guidelines. Guidelines do change over time as a result of research, but they represent the best current science on car seat safety that we have. As the research evolves, so do the guidelines.

Unfortunately, many family members and community members aren't familiar with the latest research or minimize its importance. Many parents give in to pressure from family members or peers about car seat rules or simply get lax about them as children grow older.

I know that car seat safety was a continuing source of discord in our family as we raised our children. My husband and I are in agreement on most parenting issues, but not always on safety issues. He and his family felt that many car seat safety guidelines were excessive and unnecessary.

Front-facing vs. rear-facing was one of our biggest ongoing arguments. My husband and his family felt that I was being way too cautious by keeping my children rear-facing, especially once in a convertible seat. They wanted that child front-facing sooner than later. This was probably one of the most contentious parenting battles we had.

It certainly was very tempting to turn the seat forward so I could see the child better when I was driving. I hated not being able to see what was going on with my infant when it was just the baby and me in the car. Also, once they were a little older, the children themselves wanted to be forward-facing so they could feel like Big Kids. It became like a rite of passage emotionally, both to the kids and to other family members. These are understandable reasons why parents ignore the guidelines ─ but the safety of the child should be the top priority. Rear-facing is safer.

The fight over car seat safety didn't end there. My husband and his family also strongly pressured me to switch my children to a booster seat long before they outgrew the height/weight guidelines on the convertible seat. They felt I was being too much of a worrywart and the current safety recommendations were excessive. They also felt the children would be more comfortable in a booster. Still, I didn't give in. I knew the children were safer in a 5-point restraint than using an adult seat belt on a booster.

Then of course, as the children got well into grade school, the family thought it was ridiculous to still have the kids in a booster. They pointed out how much more convenient it would be not to deal with boosters when carpooling or going on field trips. This argument resonated with me because not having boosters would certainly be easier, and I saw many of my children's peers starting to go without boosters. But again, boosters were safer and that's what really mattered. I gritted my teeth and held strong.

The battle continued as the children became pre-teens. They were no longer in boosters, but now they wanted to ride in the front seat instead of the back. My husband was particularly susceptible to this argument. We had to have this discussion multiple times until the law mandated that pre-teens had to be in the back. Then he had no choice but to follow the rules or risk a ticket.

He and his family always had good intentions and they were loving, supportive relatives, but they had a real blind spot about car seat safety. They simply refused to believe the guidelines. However, this was one thing I would not compromise on. 

The safety of my children was always the MOST important thing and I knew the research. So I put my foot down on this battle and would not budge, but let me tell you it wasn't easy sometimes. In the end, it was a battle worth sustaining.

Before you head out to school or on family trips, take a moment now to review the guidelines, review the height/weight limits on your current car seats, write in your children's IDs, and make sure they are properly restrained. Better safe than sorry.


J Trauma Acute Care Surg. 2015 Sep;79(3 Suppl 1):S48-54. doi: 10.1097/TA.0000000000000674. Car seat inspection among children older than 3 years: Using data to drive practice in child passenger safety. Kroeker AM, Teddy AJ, Macy ML. PMID: 26308122
BACKGROUND: Motor vehicle crashes are the leading cause of unintentional death and disability among children 4 years to 12 years of age in the United States. Despite the high risk of injury from motor vehicle crashes in this age group, parental awareness and child passenger safety programs in particular may lack focus on this age group. METHODS: This is a retrospective cross-sectional analysis of child passenger safety seat checklist forms from two Safe Kids coalitions in Michigan (2013) to identify restraint type upon arrival to car seat inspections... Just 10.8% of the total seats inspected were booster seats. Child safety seats for infant and young children were more commonly inspected (rear-facing carrier [40.3%], rear-facing convertible [10.2%], and forward-facing [19.3%] car seats). Few children at inspections used a seat belt only (5.4%) or had no restraint (13.8%). Children 4 years and older were found to be in a suboptimal restraint at least 30% of the time. CONCLUSION: Low proportions of parents use car seat inspections for children in the booster seat age group. The proportion of children departing the inspection in a more protective restraint increased with increasing age. This highlights an area of weakness in child passenger safety programs and signals an opportunity to strengthen efforts on The Booster Age Child.
J Pediatr. 2017 Aug;187:295-302.e3. doi: 10.1016/j.jpeds.2017.04.044. Epub 2017 May 25. Factors Associated with Pediatric Mortality from Motor Vehicle Crashes in the United States: A State-Based Analysis. Wolf LL, Chowdhury R, Tweed J, Vinson L, Losina E, Haider AH, Qureshi FG. PMID: 28552450
...Using the 2010-2014 Fatality Analysis Reporting System, we identified passengers <15 years of age involved in fatal MVCs, defined as crashes on US public roads with ≥1 death (adult or pediatric) within 30 days. We assessed passenger, driver, vehicle, crash, and state policy characteristics as factors potentially associated with MVC-related pediatric mortality. Our outcomes were age-adjusted, MVC-related mortality rate per 100 000 children and percentage of children who died of those in fatal MVCs. Unit of analysis was US state... RESULTS: Of 18 116 children in fatal MVCs, 15.9% died. The age-adjusted, MVC-related mortality rate per 100 000 children varied from 0.25 in Massachusetts to 3.23 in Mississippi (mean national rate of 0.94). Predictors of greater age-adjusted, MVC-related mortality rate per 100 000 children included greater percentage of children who were unrestrained or inappropriately restrained (P < .001) and greater percentage of crashes on rural roads (P = .016)... For 10% absolute improvement in appropriate child restraint use nationally, our risk-adjusted model predicted >1100 pediatric deaths averted over 5 years....