What are potential antiandrogen agents used in women with hirsutism beyond spironolactone, and what cautions apply?

• A. Flutamide and others have been used, but hepatotoxicity risk requires careful monitoring; not first-line due to safety and pregnancy risks.
• B. Finasteride is the only alternative with no safety concerns.
• C. Ketoconazole is a standard antiandrogen with no hepatotoxic risk.
• D. Spironolactone is the sole agent; no monitoring needed.

Answer: (A)

Beyond spironolactone, several antiandrogen options have been used to help hirsutism, but safety concerns shape their use. Nonsteroidal antiandrogen drugs like flutamide can reduce androgen effects, yet they carry a real risk of hepatotoxicity. Because of this liver safety issue, they require regular monitoring of liver function and are not favored as first-line therapy. In addition, many antiandrogens carry pregnancy risks, making them unsuitable for women who may become pregnant or are planning pregnancy. This combination of potential liver injury and reproductive safety concerns is why such agents are considered only with caution and typically after weighing risks and benefits and ensuring effective contraception if pregnancy is possible. Other options, such as drugs that reduce DHT formation or suppress androgen synthesis, likewise have safety caveats (including teratogenicity and liver effects), so they are not universally favored as first-line choices either.