Polycystic Ovary Syndrome: Update on the Pros and Cons of Treatment Options

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy among females of reproductive age. In adolescents, PCOS often manifests with irregular menses, hirsutism, and acne. Despite general agreement that the metabolic derangements of PCOS arise during puberty, the condition is diagnosed more often in adults than in adolescents. Treatment is focused on weight loss, menstrual cycle regulation, and amelioration of physical symptoms. Acute symptoms can be managed with combination oral contraceptives and antiandrogens and potentially with insulin-sensitizing drugs. Lifestyle modification, especially in overweight patients, can reduce symptoms and help prevent long-term health consequences. Adolescents with polycystic ovary syndrome (PCOS) are at risk for such complications as dyslipidemia, hypertension, type 2 diabetes, infertility, and (potentially) coronary artery disease. Prompt diagnosis is crucial, as are therapeutic efforts to establish a healthy diet and exercise habits and to prevent potential health risks. This is the second of 2 articles on PCOS. In part 1 (Polycystic Ovary Syndrome: When to Suspect, February 2007, page 98), we focused on diagnosis. Here we concentrate on treatment options and outline management strategies that can reduce associated long-term health risks. MANAGEMENT Patient education and lifestyle modification are crucial in achieving the goals of addressing the acute presenting symptoms and ameliorating the associated long-term health risks. Acute symptoms of PCOS can be managed with combined oral contraceptives (OCs), antiandrogens, and--potentially--insulin-sensitizing drugs. Given the broad range of symptoms in affected patients, a multidisciplinary approach to treatment is generally required. Obesity. Weight reduction is the central component of treatment of overweight patients with PCOS. Weight loss ameliorates many of the associated endocrine derangements, including insulin resistance, depressed sex hormone-binding globulin (SHGB) levels, and hyperandrogenism. A modest weight reduction of 2% to 5% of total body weight has been shown to improve cycle regularity and reduce free testosterone indices.1,2 The most effective approach appears to be a combination of caloric restriction, exercise, and behavior modification. Low-carbohydrate diets do not appear to confer a distinct metabolic benefit over other types of diets.3 Weight loss should be emphasized, regardless of whether medications are incorporated into treatment. Hirsutism and acne. Effective treatment of hirsutism in PCOS requires a multimodal approach, including suppression of androgen production, blockage of androgen effect, and adjuvant dermatologic methods. The medications described here for hirsutism do not eliminate established hair, but rather reduce new hair growth. Thus, up to 6 months may pass before a significant change in hair distribution is noted.1,4 The incorporation of mechanical treatments (such as electrolysis, depilatories, and laser hair removal) with medical therapy can be extremely beneficial. All but one of the medications described below (ie, eflornithine) is FDA-approved for the treatment of hirsutism, but 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 diminish androgen production through several mechanisms. Specifically, OCs reduce ovarian androgen production by suppressing pituitary gonadotropins and stimulating production of SHBG, which binds free testosterone. Both of these actions reduce the amount of testosterone available to stimulate terminal hair growth and cause acne.1,4-6 In addition, OCs reduce androgen production from the adrenal gland by an as yet unspecified mechanism.4 In addition to cosmetic benefits, OCs regulate menstrual bleeding, reduce the likelihood of