Polycystic ovary syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

The first step in the management of PCOS is weight loss if the patient is obese, and treatment of type 2 diabetes with metformin. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating anovulatory cycles, either by stimulating ovulation or suppressing androgenic and ovarian activity. The selection of treatment depends on whether the pregnancy is desired or not. All anti-androgen treatments will take at least 3 months to affect hirsutism. The drug regimen for PCOS depends upon the desire for the fertility of the patient.

Pharmacotherapy

The first step in the management of PCOS is weight loss if the patient is obese, and treatment of type 2 diabetes with metformin. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating anovulatory cycling, either by stimulating ovulation or suppressing androgenic and ovarian activity. The selection of treatment depends on whether the pregnancy is desired or not. All anti-androgen treatments will take at least 3 months to affect hirsutism. The goals of treatment are:[1][2][3][4][5][6][7][8]

If Pregnancy is not desired

If Pregnancy is desired

Symptomatic Medical Therapy

Treatment of Hirsutism and Acne

  • Cyproterone acetate is an anti-androgen, which blocks the action of male hormones that are believed to contribute to acne and the growth of unwanted facial and body hair.
  • Cyproterone acetate is also contained in the contraceptive pill Dianette®.
  • Spironolactone also has some benefits, again through anti-androgen activity, and metformin can also help.
  • Eflornithine is a drug which is applied to the skin in cream form (Vaniqa®), and acts directly on the hair follicles to inhibit hair growth.
  • The average reduction in hair growth is generally in the region of 25%, which may not be enough to eliminate the social embarrassment of hirsutism or the inconvenience of plucking/shaving.
  • Individuals may vary in their response to different therapies, and it is recommended to try other medications if one is not effective although, drug treatments is not effective for all individuals.
  • Alternatives include electrolysis and various forms of laser therapy.

Treatment of Menstrual Irregularity and Prevention of Endometrial Hyperplasia/Cancer

  • Menstruation can be regulated with a contraceptive pill.
  • Most brands of contraceptive pill result in a withdrawal menstrual bleeding every 28 days.
  • Dianette® (a contraceptive pill containing cyproterone acetate) is also beneficial for hirsutism and is therefore often prescribed in PCOS.
  • If a regular menstrual cycle is not desired, then a standard contraceptive pill is not appropriate.
  • Women who are having irregular menses do not necessarily require any therapy; most experts consider that if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.
  • If menstruation occurs less often or not at all, some form of progesterone replacement is recommended. Some women prefer a uterine progesterone implant such as the Mirena® coil, which provides simultaneous contraception and endometrial protection for years, though often with unpredictable minor bleeding.
  • An alternative is an oral progesterone taken at intervals (e.g. every three months) to induce a predictable menstrual bleed.

References

  1. Sheehan MT (2004). "Polycystic ovarian syndrome: diagnosis and management". Clin Med Res. 2 (1): 13–27. PMC 1069067. PMID 15931331.
  2. Artini PG, Di Berardino OM, Simi G, Papini F, Ruggiero M, Monteleone P, Cela V (2010). "Best methods for identification and treatment of PCOS". Minerva Ginecol. 62 (1): 33–48. PMID 20186113.
  3. King J (2006). "Polycystic ovary syndrome". J Midwifery Womens Health. 51 (6): 415–22. doi:10.1016/j.jmwh.2006.01.008. PMID 17081931.
  4. Badawy A, Elnashar A (2011). "Treatment options for polycystic ovary syndrome". Int J Womens Health. 3: 25–35. doi:10.2147/IJWH.S11304. PMC 3039006. PMID 21339935.
  5. Kataoka J, Tassone EC, Misso M, Joham AE, Stener-Victorin E, Teede H, Moran LJ (2017). "Weight Management Interventions in Women with and without PCOS: A Systematic Review". Nutrients. 9 (9). doi:10.3390/nu9090996. PMC 5622756. PMID 28885578.
  6. Naderpoor N, Shorakae S, de Courten B, Misso ML, Moran LJ, Teede HJ (2015). "Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis". Hum. Reprod. Update. 21 (5): 560–74. doi:10.1093/humupd/dmv025. PMID 26060208.
  7. Moran LJ, Hutchison SK, Norman RJ, Teede HJ (2011). "Lifestyle changes in women with polycystic ovary syndrome". Cochrane Database Syst Rev (2): CD007506. doi:10.1002/14651858.CD007506.pub2. PMID 21328294.
  8. Martin A, Saunders DH, Shenkin SD, Sproule J (2014). "Lifestyle intervention for improving school achievement in overweight or obese children and adolescents". Cochrane Database Syst Rev (3): CD009728. doi:10.1002/14651858.CD009728.pub2. PMID 24627300.


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