Polycystic Ovary Syndrome:
Polycystic Ovary Syndrome:
The treatment of polycystic ovary syndrome (PCOS) is based on the patient's presenting symptoms and any significant abnormal findings. Symptoms can be managed with combined oral contraceptives (OCs), insulin-sensitizing agents, antiandrogens, and medications used to induce ovulation.
Here we detail the various treatment options. We also discuss screening for and monitoring of the long-term health risks associated with PCOS. In Polycystic Ovary Syndrome:
When to Suspect, we focused on the evaluation of the syndrome.
Hirsutism and acne. Effective management of hirsutism in PCOS requires a multimodality approach, including androgen suppression, blockage of androgen production, and adjuvant dermatologic methods. The medications described in this section do not eliminate established hair, but rather reduce new hair growth. Thus, 6 months may pass before a significant change in hair distribution is noted.1,2 The incorporation of mechanical treatments (such as electrolysis, depilatories, and laser hair removal) with medical therapy can be extremely beneficial. Although all the medications described, except for eflornithine, are not FDA-approved for the treatment of hirsutism, all have demonstrated efficacy. The absence of pregnancy must be confirmed before initiation of any medical treatments.
Androgen suppression. Combination OCs are first-line therapy for acne and hirsutism because they safely suppress ovarian androgen production and stimulate production of hepatic sex hormone-binding globulin (SHBG), which binds free testosterone. Both of these actions reduce the amount of testosterone available to stimulate terminal hair growth and cause acne.1-4 In addition to cosmetic benefits, OCs regulate menstrual bleeding, reduce the odds of endometrial hyperplasia, and are highly effective contraception for sexually active women. The potential for worsened insulin resistance in women with PCOS who use OCs has been suggested. However, to date, a substantial clinical risk has not been confirmed, and the clear benefits of OCs overshadow this possibility.3,5
The ideal OC for treatment contains a minimally androgenic progestin, such as norgestimate or desogestrel. Drospirenone, an analog of spironolactone, is now available in combination OCs and may prove to be of particular benefit in patients with PCOS.3
When OCs are contraindicated or declined by the patient, medroxyprogesterone acetate may be used as an alternative to reduce androgen levels. The medication can be administered intramuscularly (depot medroxyprogesterone acetate, 150 mg every 3 months) or orally (10 to 20 mg each day). The efficacy of medroxyprogesterone acetate compared with that of OCs may be limited because it produces a less dramatic reduction in testosterone levels and is associated with diminished SHBG levels.1,6
Androgen blockade. Medications that block or reduce the action of androgens on terminal hair production are used in combination with OCs to prevent fetal exposure and the risk of ambiguous genitalia in a male fetus.1,7 Spironolactone is first-line among this class of drugs and has multiple antiandrogenic effects that make it an effective treatment. Most important, spironolactone is an androgen receptor blocker and is believed to have synergistic treatment effects when used in combination with OCs.1-4 Because spironolactone is also a potassium-sparing diuretic, patients who take this agent may be at risk for hyperkalemia, especially if they have underlying renal dysfunction. Before initiation of treatment, make sure that serum potassium and creatinine levels are normal. Although some patients benefit from a daily dose of 100 mg, the optimal dosage appears to be 200 mg/d (divided 100 mg bid).1,2,4
Flutamide is a powerful antiandrogen that is FDA-approved for adjuvant treatment of prostate cancer and may also be used to treat hirsutism. It is not as widely used as other modalities because of concerns about rare but potentially fatal hepatic toxicity.6
Finasteride blocks the conversion of testosterone to the more powerful androgen dihydrotestosterone, the hormone primarily responsible for influencing hair growth. Although finasteride may be less effective than flutamide and spironolactone, it has the best side effect profile of the 3 drugs.6,7
Adjuvant dermatologic methods. Eflornithine, a topical ornithine decarboxylase inhibitor that prevents hair growth, is the only FDA-approved medication for excess facial hair. In clinical trials, the drug has been highly effective; however, its benefits appear to be short-lived after discontinuation. Side effects are limited. Its effect on excess nonfacial hair has not been investigated. In addition, the long-term safety of this drug remains to be determined.2,6,7
Mechanical treatments of hirsutism have been used as monotherapy and as adjuncts to hormonal therapies. Common approaches include shaving, hair bleaching, and chemical depilation. It has been suggested that waxing or plucking of hairs in areas of androgenized skin increases the risk of folliculitis, ingrown hairs, and skin damage.2 The objective of electrolysis and laser hair removal is to permanently destroy follicles that produce unwanted hair.2,8 The best results are achieved when initiated after at least 6 months of medical inhibition of new hair growth.1,2,8
Electrolysis produces electrocoagulation of the base of the hair follicle. Laser hair removal causes selective thermal damage of the follicle while sparing adjacent tissues.2,8 Patients with the best results from laser therapy are those with lighter skin and dark hairs.1,2,8 Although both electrolysis and laser therapy aim to permanently destroy hair follicles, repeated treatments are required and complete hair removal is not always achieved. Thus, a description of these methods as "permanently reducing" rather than "permanently removing" unwanted hairs has been suggested.8
Laser hair removal appears to be a promising adjunct to the medical treatment of hirsutism; more outcomes research is required. Most of the data on this method are from small, uncontrolled, and unblinded studies. To date, no studies comparing laser removal and electrolysis have been performed.1,8
Abnormal bleeding. If no contraindications exist and pregnancy is not desired, OCs are a highly effective means of achieving menstrual cycle regularity in patients with PCOS. Another approach is to use oral medroxyprogesterone acetate, 5 to 10 mg daily, for the first 10 days of each month. Although this regimen does not provide contraception, it can prevent endometrial hyperplasia and dysfunctional uterine bleeding. Alternatively, depot medroxyprogesterone acetate may be used in patients who desire long-term contraception and in those who cannot take or refuse to take OCs.1,4
Infertility. The main barriers to conception in women who have PCOS are oligoovulation and anovulation. Weight loss, insulin sensitizers, and ovulation induction medications (such as clomiphene citrate) have all been shown to increase ovulatory frequency in PCOS.1,9 Appropriate referral to a reproductive endocrinologist for complete evaluation and treatment is warranted in most cases.