Treatment
Treatment of polycystic ovarian syndrome (PCOS) centers on lifestyle modifications and medication. Surgical procedures to destroy or shrink ovarian cysts are less likely to be performed today given the success of hormonal treatments. Usually, doctors recommend surgical removal typically via laparoscopy if a woman with PCOS doesn't ovulate with conventional treatment (clomiphene and/or metformin) and can't, for whatever reason, proceed to shots or in vitro-fertilization (IVF). Surgery may also be indicated if your doctor is not sure if a cyst is cancerous.
Because the primary cause of PCOS is unknown, treatment is presently directed at the symptoms of the disorder. For some women, the most bothersome symptom is hirsutism (excess facial and/or body hair, often dark and coarse). This symptom, as well as acne and oily skin, stem from the overproduction of androgens. For women with these symptoms, an anti-androgen medication like spironolactone (Aldactone or Spironol) may be prescribed.
Spironolactone is a diuretic that works by blocking the action of testosterone at the hair cell level. It has few major side effects, which may include heartburn and upset stomach, sun sensitivity, and increased urination and feeling weak or faint. At high doses, it can clear oily skin and make unwanted hair finer. Spironolactone contains an FDA "black box" warning because it has caused tumors in laboratory animals, and may also cause birth defects if taken while pregnant. Talk to your health care professional about potential risks.
Electrolysis, and possibly or lasers, can remove any remaining hairs permanently.
Flutamide (Eulexin) is similar to spironolactone, but may have more severe side effects. The FDA has also issued a "black box" warning for flutamide because in rare circumstances it may cause liver failure that could lead to death. The FDA suggests you keep all appointments with your health care professional and immediately report any of the following symptoms when taking flutamide: nausea, vomiting, stomach pain, excessive tiredness, loss of appetite, flu-like symptoms, dark yellow or brown urine, and yellowing of the skin or eyes.
If you are trying to conceive, however, you cannot take an anti-androgen medication because it could cross the placenta and cause defects in a male fetus. Usually, anti-androgen medications are used in combination with birth control pills, which not only prevent unplanned pregnancies, but also improve the success of these medications on excess hair growth.
There has been some speculation that a drug used to treat enlarged prostate and baldness in men--called finasteride (Propecia)--may be useful in women with hyperandrogenism symptoms, including hirsutism. The drug stops the action of an enzyme called 5-alpha reductase, which converts testosterone to the more powerful dihydrotestosterone. Finasteride, however, can also cause birth defects (indeed, pregnant women should not even handle the drug in crushed tablet form).
Bear in mind that it can take up to nine months to see effects on hair growth, and a year or longer to achieve peak effect. The hair will still be there, but will generally grow more slowly and be lighter and finer.
In 2000, the U.S. Food and Drug Administration (FDA) approved Vaniqa (eflornithine hydrochloride), a prescription medication cream that reduces unwanted facial hair. It works well in about half of women using it. The medication is applied to the face twice a day like moisturizer. It works by blocking a key enzyme that makes hair grow. But it must be used regularly or the hair will grow back.
For acne, spironolactone and birth control pills (which decrease ovarian androgen production) are often particularly effective in combination, although other medications may also be prescribed for acne, such as oral or topical antibiotics, isotretinoin (Accutane, which carries an FDA "black box" warning because it can cause birth defects, or peeling medications that such as tretinoin (Retin-A).
A corticosteroid such as dexamethasone (Decadron, Hexadrol) or prednisone (Cortan, Orasone) may be prescribed if the primary source of excess androgens appears to be the adrenal glands. Because these steroids are used at very low doses, they are less likely to cause the usual side effects associated with steroids such as diabetes, weight gain and osteoporosis. However, these steroids could make insulin resistance worse. Overall, today there is limited use for these medications in women with PCOS.
If irregular and/or infrequent menstruation is a problem, birth control pills that typically contain estrogen and progestin can generally regulate your cycles. Restoring regular periods is essential since it insures that the lining of the uterus is shed, protecting against uterine cancer.
If you don't want to take a daily medication, talk to your doctor about a course of progestogen (progesterone-like drugs) several times a year to start your periods. It is important to have at least six to eight periods a year to promote shedding of the endometrial lining; build up can lead to cancer.
Rare side effects of birth control pills include migraines, nausea, and headaches, and, rarely blood clots (especially among smokers and women with persistent high blood pressure), gallbladder disease, and high blood pressure.
Infertility often is a consequence of PCOS. The first line of treatment is an ovulation-stimulating drug called clomiphene (Clomid or Serophene), which is used to treat infertile women with ovulation problems. It works by helping the pituitary gland send hormonal signals to stimulate the development of more eggs in the ovaries.
A combination of injectable gonadotropins, hormones that make the ovaries produce extra egg follicles, and human chorionic gonadotropin (HCG), a hormone that stimulates ovulation, is the next step for women who do not get pregnant using clomiphene.
But this treatment option, while effective, is more challenging to manage and more expensive. Common side effects include bloating and fluid retention, weight gain and a tender stomach. Some women also have some trouble self-administering the injections. Newer versions of these drugs have been developed to help minimize the associated side effects and to make administering the treatment easier, however.
This treatment can also lead to ovarian hyperstimulation syndrome, in which fluid from the bloodstream leaks into the abdominal cavity, causing it to swell and making the blood thicker. This may lead to breathing difficulties, temporary kidney failure, and some blood clots.
Insulin-sensitizing drugs offer a new alternative for treating PCOS symptoms, particularly infertility, and are increasingly prescribed if the initial course of clomiphene does not result in ovulation.
These medications are also used to treat type 2 diabetes. They regulate blood glucose (sugar) levels by reducing the amount of glucose the liver produces, reducing the amount of glucose absorbed from food , and helping the insulin that your body produces to work better to reduce the amount of glucose already in your blood.
They include metformin (Glucophage), pioglitazone (Actos) and rosiglitazone (Avandia). Clinical trials are underway that may ultimately lead to FDA approval for PCOS.
Once you get pregnant, your doctor will want to watch you closely because women with PCOS have a higher risk of miscarriage, although we don't understand why.
Some healthcare professionals prescribe metformin for all women with PCOS, not just those with fertility problems. Some women resume regular menstrual cycles when they are on metformin, and some studies show that high doses of this medication can reduce levels of free testosterone and improve hirsutism.
If you are prescribed an insulin sensitizer, be sure to inform your health care professional of all other medications you are taking, including over-the-counter medicines, to prevent drug interactions.
If you are among the up to ten percent of women with PCOS who already have type 2 diabetes, metformin is also a good therapeutic option.
Another option for women who fail to ovulate with clomiphene or metformin therapy, or who are unwilling/unable to use gonadotropins (or can't afford to use them), is a surgical procedure known as laparoscopic ovarian drilling.
A laser or electrosurgical needle is used to puncture each ovary four to 10 times. This treatment dramatically reduces the amount of male hormones produced by the ovaries within days of surgery. Over a dozen studies have shown that up to 80 percent of women with PCOS benefit temporarily from such treatment.
Additionally, many women who failed to ovulate with clomiphene or metformin therapy are able to ovulate with these medications after ovarian drilling. The success rates for laparoscopic ovarian drilling appear to be better for patients at or near their ideal body weight, as opposed to those who are obese. Interestingly, women in these studies who are smokers rarely improved with the drilling procedure. Side effects are rare, primarily adhesions, although even laparoscopic ovarian surgery requires general anesthesia, which carries its own risks.
Other Approaches
Long-term, non-medical treatment is geared toward modifying your risk factors for health problems often associated with PCOS, including diabetes, uncontrollable weight gain and heart disease. A healthy, low-sugar diet and an exercise program to stabilize your weight can reduce the risk of these conditions.
You can take care of some problems associated with PCOS without medication. Excess hair can be removed by shaving, tweezing, waxing or using depilatory creams, or by electrolysis or laser techniques administered by a trained professional. Since lasers work by attacking a skin pigment, they should be used with caution by darker-skinned women.
If you are overweight and have PCOS, you need to lose weight. Losing weight can lower androgen and insulin levels, reducing your risk of insulin resistance and diabetes. One study found that when obese women with PCOS lost even seven percent of their body weight, their androgen levels dropped significantly and their periods became more regular.
Exercise alone, even without weight loss, is also beneficial since it helps improve insulin sensitivity.
It seems that PCOS symptoms improve as women nears menopause, but it may persist into or beyond menopause, particularly male pattern baldness or thinning hair, which sometimes gets worse after menopause. In cases where PCOS symptoms persist, the best recommendation is to monitor cholesterol, triglycerides and blood pressure, as well as glucose and insulin levels.
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Create Date: 8/17/02
Date Last Updated: 3/15/06
Review Date: 1/16/06
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