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. 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 (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