Treatment Options
Weight Loss
Women with a BMI of greater than 27 kg/m2 are considered overweight, and they are often insulin resistant. Women with a BMI of > 30 kg/m2 are considered obese and are almost always insulin resistant. Weight loss, even as a little as 5% to 7%, can decrease the amount of circulating androgens and, thus, will induce ovulation. Weight loss is also associated with decreased insulin and testosterone levels and an improved lipoprotein profile. These patients usually do the best when many members of a healthcare team, including a nutritionist, are actively involved in their care.[1,3,8]
Hormonal Treatments
Combination oral contraceptives (OCs) provide many benefits to the PCOS patient and have for a long time been the mainstay of treatment. The progesterone component of the OC provides protection for the endometrium from unopposed estrogen. Also, OCs suppress ovarian, adrenal, and peripheral androgen metabolism, which in turns reduces free testosterone. OCs also suppress LH levels, which then decrease testosterone production by the ovaries. Similarly, OCs inhibit 5 alpha-reductase in the skin, which helps with acne. For those patients not wanting to become pregnant, OCs provide a reliable form of birth control in addition to providing a regular monthly menstrual cycle.
There are no studies that suggest that one OC is better than another for the treatment of PCOS. All OCs, whether they carry an FDA indication, are antiandrogenic. Once a patient has decided that she wants to try and conceive, she should then stop her OCs and promptly begin attempts to conceive. There is no need to wait the traditional 3 months before attempting a pregnancy. This is important because circulating androgens are at their lowest point immediately following OC use, and these patients will more likely ovulate at that time and not require an ovulation induction drug.[1,9,19]
Progestins work well in the patient who is not a candidate for OCs due to smoking, hypertension, or other contraindications. The progestin will protect the endometrium from chronic exposure to estrogen. The progestins, however, will not protect against a pregnancy.[6,9]
Insulin-Sensitizing Agents
Metformin (Glucophage) and troglitazone (Rezulin) are 2 insulin-sensitizing agents that have been shown to be successful in treating anovulation in the infertile PCOS patient. However, because of reports of severe liver toxicity, troglitazone was removed from the market, so metformin is now the insulin-sensitizing agent of choice. The newer agents on the market, rosiglitazone (Avandia) and pioglitazone (Actos), have not been extensively studied.
Insulin-sensitizing agents are indicated in patients with type 2 diabetes mellitus, elevated fasting insulin levels, or elevated 2-hour value on the glucose tolerance test. Metformin 1500-2000 mg per day in 2 to 3 divided doses is prescribed to stimulate resumption of normal menses and ovulation. Generally, it takes about 2 to 4 months for results. Prior to starting metformin, serum creatinine levels should be evaluated. Levels less than 1.4 mg/dL are necessary to reduce the rare complication of lactic acidosis.[1,3,8]
Since few studies report the use of insulin-sensitizing agents in PCOS patients who do not have insulin resistance, their use is not indicated. However, in time, these agents may be used to treat all patients with PCOS.[1,3,8]
Fertility Therapy
Clomiphene (Clomid) may be prescribed for PCOS patients who are anovulatory and desire pregnancy. Once the patient has conceived, clomiphene should be discontinued. If the patient was taking metformin, it should also be discontinued, as it is not FDA approved for use during pregnancy.[1,3,8]
Treatment of Hirsutism
There are many antiandrogenic agents that work well to reduce hirsutism. Oral contraceptives work well because they increase SHBG, which results in lower levels of active androgens. Also, the progestin component in the OCs inhibit 5 alpha reductase in the skin, which helps decrease the amount of hirsutism.
Spironolactone is an aldosterone antagonist that works well to control hirsutism by interfering with androgen synthesis. The recommended dose of spironolactone is 100-200 mg/day in 2 divided doses. There are few side effects associated with this drug. However, because it is a potassium-sparing diuretic, be aware of the potential for hyperkalemia with prolonged use. Flutamide (Eulexin) and finasteride (Proscar) are other antiandrogenic drugs. They are costly and have many side effects, thus making them less appealing options. The length of the hair cycle is long, so the response of these drugs should not be expected for at least 3-6 months. This is an important point to stress to the patient.
Nonpharmacologic treatments for hirsutism may include bleaching, wax stripping, shaving, or the use of hair removal creams or electrolysis. Despite popular beliefs, these approaches do not accelerate the rate of hair growth.[1,9]
Surgical Treatment
Ovarian wedge resectionOvarian drilling
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Case Presentation
Barbara is a 25-year-old morbidly obese African American female, gravida 0, who presented to the gynecology office for evaluation of irregular menses since menarche. The patient stated that on average, she has 1 period every 6 months. When she does have her period, she bleeds very heavily, passing large clots, and has a lot of cramping. She also complained about excessive facial hair, which requires her to shave at least once every several days, and a lot of hair on her abdomen and arms. Barbara stated that her mother also has a lot of facial hair but doesn't think that she does anything about it.
She denied any change in her voice or increase in the size of her muscles. She has been morbidly obese since she was a young teenager. She denied any headaches, blurred vision, or discharge from her nipples. She also denied any hyper/hypothyroid symptoms. She has never had any surgery and has never conceived, despite several years of trying. Barbara is not currently taking any medication and has never used any form of contraception.
On examination, she was clearly hirsute (Ferriman-Gallowey score of 10), especially in the chin and midabdominal regions. Her BMI was 32. Her pelvic exam was unremarkable, including no evidence for clitoromegaly, but her uterus and adnexa were very difficult to assess secondary to the patient's morbid obesity. The rest of her physical exam was unremarkable. Because she had been amenorrheic for 6 months, an endometrial aspiration was performed. The uterus sounded to 8 cm and there was a good amount of tissue on return.
A uterine ultrasound was performed, which revealed a normal appearing uterus, with an endometrial stripe of 6 mm and bilateral normal ovaries. Specifically, there was no evidence for polycystic ovaries.
Laboratory studies were undertaken to further evaluate her problem. Her FSH was normal, but her LH was elevated. Her TSH, prolactin, chemistry panel, cholesterol, triglycerides, HDL, and low-density lipoprotein (LDL) were all within normal limits. Her fasting insulin level was elevated at 36 UU/mL; fasting blood sugar was 130 mg/dL, and the 2-hour value on glucose tolerance test was 233 mg/dL. Her total testosterone was 78 ng/dL, and her free testosterone was 30 pg/mL (normal range, 1-21 pg/mL.) Her 17OH-progesterone was normal at 92 ng/dL, as was the DHEAS at 131 ug/dL. The endometrial aspirate showed proliferative endometrium without hyperplasia or neoplasia.
The clinical and laboratory results were consistent with PCOS. Because she desired a pregnancy, she was a candidate for metformin not only for control of her blood sugar but also to help regulate her menstrual cycles. She also required clomiphene to induce ovulation. After being started on a diet, an exercise program for weight loss, and metformin, her blood sugars responded well. After 6 months of blood glucose control, menstrual regularity, and increasing doses of clomiphene, she became pregnant. Today, Barbara is doing well in our high-risk OB practice.
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Conclusion
PCOSPCOS patients
Disclosure
1
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Topics in Advanced Practice Nursing eJournal. 2002;2(3) © 2002 Medscape
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Clinical Articles MEDLINE Abstracts: Polycystic Ovary Syndrome
Conference Coverage 4th Annual Conference of the National Association of Nurse Practitioners in Women's Health
11th Annual Meeting and Clinical Congress of the American Association of Clinical Endocrinologists
Topics in Advanced Practice Nursing eJournal. 2002;2(3) © 2002 Medscape
Cite this: Polycystic Ovary Syndrome: An Overview - Medscape - Jul 31, 2002.
