Byline: SAMANTHA BUTTS, MD and DEBORAH A. DRISCOLL, MD
ABSTRACT: The symptoms of polycystic ovary syndrome (PCOS) can be managed with combination oral contraceptives (OCs), progestins, antiandrogens, insulin sensitizers, agents for ovulation induction, and weight reduction in overweight patients. Combination OCs are first-line therapy for acne and hirsutism; they are also a highly effective means of achieving menstrual cycle regularity. If possible, select an OC with a minimally androgenic progestin. All women with PCOS need to be screened with blood pressure measurement, a lipid panel, and both fasting glucose and 2-hour oral glucose tolerance tests. Maintain a high index of suspicion for endometrial hyperplasia and carcinoma in women with PCOS who have amenorrhea or abnormal bleeding in the third or fourth decade of life.
Key words: polycystic ovary syndrome, endocrinopathy, insulin resistance, obesity
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 our previous article on page 745, we focused on the evaluation of the syndrome.
MANAGEMENT
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...