What is the optimal anti androgen dose of spironolactone when treating female hirsutism?

My experience with this issue has primarily been in treating women with PCOS who have hirsutism and so these comments are limited to that condition. First, it is important to establish normal renal function and electrolytes before starting. It is also important to know if the patient is on an ACE-I or ARB for hypertension. I would not use spironolactone with either of those classes of drugs. Most importantly, it is necessary to make sure the patient is using reliable contraception. I then start with 50 mg a day to make sure the patient doesn’t have side effects such as dizziness or breast tenderness. I warn about possible menstrual spotting. If she is tolerating the drug, then I increase it to 100 mg a day. Though a recent international guideline-recommended dosing spironolactone bid (Teede et al., PMID 37580314), I have not found that added benefit, and patients often complain that they miss the evening dose. Generally, 100 mg is the dose that I use. On occasion, I have tried 150mg or even 200 mg a day, but rarely and with caution. If the patient is not getting adequate response, I discuss using dutasteride [off-label! See: Barbieri, UpToDate 2024, Patient education: Hirsutism (excess hair growth in females) (Beyond the Basics)] or laser.