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Polycystic Ovarian Syndrome (PCOS) Treatment

Treatment of polycystic ovarian syndrome (PCOS) centers on lifestyle modifications and medication. Surgical procedures — cauterization of ovarian cysts or wedge resection to reduce the size of cysts — are less likely to be performed today, due to recent successes with ovulation-inducing medications. Usually, a health care professional will recommend surgical removal only if a cyst is thought to be potentially 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, stems from overproduction of androgens. For women with such symptoms, spironolactone (Aldactone or Spironol) may be prescribed. The drug, a diuretic, has few side effects, and at high doses can clear oily skin and make unwanted hair finer (electrolysis or laser processes can remove hair permanently). It works by blocking the action of testosterone at the hair cell level. Flutamide (Eulexin) is similar to spironolactone, but has potentially severe side effects. If you are trying to conceive, however, an anti-androgen medication cannot be used because it can cross the placenta and cause defects in a male fetus.

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Bear in mind that it can take up to nine months to see effects on hair growth, and a year to achieve peak effect. The hair will still be there, but will generally grow more slowly and will be lighter and finer. Electrolysis or repeated laser treatments are the only ways to get rid of the already present hair for extended periods or permanently.

Recently, the U.S. Food and Drug Administration (FDA) approved Vaniqa (eflornithine hydrochloride), a prescription medication cream that reduces unwanted facial hair. The medication is applied to the face twice per day in the same manner as moisturizer and works by blocking a key enzyme that makes hair grow. It must be used regularly or else hair growth will resume.

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, Accutane (which can cause birth defects) or peeling medications such as Retin-A.

A steroid such as dexamethasone or prednisone may be prescribed if the primary source of excess androgens appears to be the adrenal glands (as evidenced by high levels of DHEA-S). Because these steroids are used at very low doses, they do not cause the usual side effects associated with steroids.

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 an enzyme called 5-alpha reductase, which converts testosterone to the more powerful dihydrotestosterone. Finasteride, however, can cause birth defects (indeed, pregnant women should not even handle crushed tablets).

If irregular and/or infrequent menstruation is a problem, birth control pills (typically incorporating estrogen and progestin) can probably get you on schedule again. During menstruation, the lining of the uterus is shed, providing protection against uterine cancer, so restoring regular periods (at least four per year) is essential. Some women may not want to take a daily medication, so a course of progestogen may be prescribed several times a year for women who are amenorrheic (absence of menstruation) to induce periods. Side effects of oral contraceptives include migraines, blood clots (especially among smokers), gallbladder disease and high blood pressure.

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Infertility often is a consequence of PCOS. The first line of treatment if you have the syndrome and cannot conceive is usually an ovulation-stimulating drug called clomiphene citrate, which is sold under the brand name Clomid.

Until recently, a combination of injectable chorionic gonadotropin and gonadotropin was the next step for women who did not get pregnant using clomiphene. But this gonadotropin, in addition to being inconvenient and expensive, can lead to ovarian hyperstimulation syndrome, more common in women with PCOS, enlarged ovaries, escape of fluid into the abdomen, low blood volume and stroke.

Insulin-sensitizing drugs offer a new alternative for treating PCOS symptoms, particularly infertility, and are increasingly being prescribed if an initial course of clomiphene doesn’t result in pregnancy. These products were designed to treat Type II diabetes and are approved by the FDA for that. The class includes metformin (sold under the name Glucophage), pioglitazone (Actos) and rosiglitazone (Avandia). Clinical trials are under way that may ultimately lead to the FDA’s sanctioning them specifically for PCOS.

Some physicians prescribe metformin for women with PCOS, not just those with fertility problems. Some women resume regular menstrual cycles on metformin, but so far only one long-term study has been done, and it showed that the male-hormone symptoms didn’t get better (someone with severe male hormone problems would need an anti-androgen as well). Health care professionals are undecided on the issue of using insulin-sensitizers in PCOS patients not attempting conception.

If prescribed an insulin sensitizer, be sure to inform your health care professional of all other medications you take, including over-the-counter medicines, to prevent drug interactions.

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If you are among the 7 to 8 percent of women with PCOS who already have type II diabetes, metformin is a good therapeutic option.

Another available 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. The technique employs a laser fiber or electrosurgical needle to puncture each ovary four to 20 times. This treatment results in a dramatic lowering of male hormones within days. Over a dozen studies have shown that up to 80 percent of women with PCOS will benefit from such treatment. Many who failed to ovulate with clomiphene or metformin therapy will respond when re-challenged 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 with obesity. Interestingly, women in these studies who are smokers rarely responded to the drilling procedure. Side effects are rare, but may result in adhesion formation or the general complications of any surgical procedure.

PCOS is associated with insulin resistance and diabetes, but not all women who have PCOS are insulin-resistant or diabetic. If you have PCOS, you should also be evaluated for diabetes with both a fasting glucose test and a glucose challenge test with insulin levels. The fasting glucose test is the standard, but that test alone misses about half the women with concomitant elevated insulin levels with PCOS who have diabetes or insulin resistance.

Long-term non-medical treatment is geared toward modifying your risk factors for health problems that often are associated with PCOS, including diabetes, uncontrollable weight gain and heart disease. A healthy low-sugar diet and an exercise program to stabilize body weight can reduce the risk.

You can take care of some problems associated with PCOS without medications. 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, weight loss is recommended. Losing weight can lower levels of androgens and insulin, thereby reducing your risk of developing insulin resistance and diabetes. One study found that when obese women lose even seven percent of body weight, they cut androgen levels significantly and improve menstrual regularity.

Copyright 2003

National Women's Health Resource Center Inc. (NWHRC).

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