What are your best tips for management of pcos patients with hirsutism despite spironolactone, ocps and vaniqa?

DHEAS. If the dheas levels are elevated then adding Dexamethasone each night may be very helpful also.
weight loss. I have had several patients lose significant weight, usually through gastric banding procedures report significant improvement in hirsutism and acne. Most likely due to improved Insulin function and thereby reducing androgen production from the ovaries and increasing shbg production in the liver. (anecdotal).
Laser. Medical management of pcos related hirsutism can help reduce new hair growth or slow down the hair growth but it is exceedingly difficult to get rid of follicles once they have started to grow. Laser hair removal or electrolysis is usually necessary. Medication will help to reduce the frequency of these treatments though.
Metformin. Losing weight with a balance of diet, aerobic and muscle retaining exercise. (ha ha ha, just kidding, while effective in theory only 10% or less of patients can do that!) Metformin and/or OCP's are most common therapies. http://www.ncbi.nlm.nih.gov/pubmed/24720592 http://www.ncbi.nlm.nih.gov/pubmed/24790517 check vitamin D http://www.ncbi.nlm.nih.gov/pubmed/24770121.