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How is polycystic ovary syndrome (PCOS) treated?

Kevin W. Windom, MD
OBGYN (Obstetrics & Gynecology)

When I have a patient with polycystic ovarian syndrome, my first question is "are you trying to get pregnant or not".  If they are not planning on getting pregnant, I will treat these patients with oral contraception.  During the diagnostic process of deciding how severe their "PCOS" is, I will a do a significant amount of blood tests on the 3rd day of their menstrual cycle.  If they in fact have high levels of insulin and high glucose levels, I will consider putting them on a medication called Metformin that will help make their body more sensitive to insulin, and it can sometimes help reverse the changes of PCOS.  If patients are considering pregnancy, these patients most commonly will need medication to help them ovulate such as Clomid or Letrozole and possibly also need Metformin.

 

Mark Perloe, MD
Reproductive Endocrinology
PCOS is often associated with obesity, abnormal male hormones, cholesterol anomalies and high blood pressure. The best treatment approach combines a low glycemic diet, 20-30 minutes exercise along with metformin. Studies have shown that such an approach may restore normal menstural cycles in up to 85% of those with PCOS by six months.

The generic metformin seems to work better than the extended release version. The overwhelming majority of studies showing a benefit have used the generic form. A recent large multicentre trial showed limited usefulness of the extended release form, and unfortunately, there have been no side by side trials.

For women who do not need to lose weight, your physician may consider an alternative insulin sensitizer from the thiazolidinedione class of medications, ie Actos, to address your symptoms.

Many women have gastrointestinal upset or diarrhea when initially, but a gradual start increasing doses over a few weeks along with the low glycemic diet may reduce the risk of this unpleasant side effect.

Some women with PCOS and obesity have sleep apnea. If you snore while sleeping or are frequently fatigued, check with your physician to see if a sleep study may be in order. Sleep apnea can result in a hormonal picture similar to PCOS, and treatment with CPAP, may be beneficial for some women.

The easiest way to monitor therapy for those who desire pregnancy is to monitor the BBT charts. Initially, they will be all over the place, but once a more normal metabolic balance is achieved, BBT charts may demonstrate the resumption of normal ovulation.

I prefer to normalize the metabolic abnormalities associated with PCOS prior to initiating ovulation medications, as miscarriage rates appear lower, and ovulation medications may not be necessary. If one achieves normal metabolic parameters at three months of diet, exercise and insulin sensitizer and ovulation is not seen on the BBT charts, then a treatment with medications such as letrozole or clomiphene may be advisable.
Jennifer Ashton, MD
OBGYN (Obstetrics & Gynecology)
Good news is that there are a variety of treatments for PCOS.  These include nutrition/lifestyle modifications, low-dose birth control pills to suppress the over-activity of the ovaries, a drug called metformin (often used in treating diabetes) which is successful in restoring ovulation in approximately 25% of teens and adult women, and no treatment at all (provided there are no bothersome symptoms of PCOS).  which treatment you choose is based on your age, your symptoms and whether or not you are trying to become pregnant.  Treatment may vary at different points in your life.  Probably the most important goals of treatment are to reduce the chances of abnormal build-up in the uterine lining, called endometrial hyperplasia, that can occur if periods are too infrequent, and the 5-7fold increased risk of developing Type 2 diabetes over your lifetime.  By being proactive in addressing both of these possible concerns, PCOS doesn't have to have a negative effect on your health.  I usually recommend yearly fasting bloodwork to check cholesterol and glucose and insulin levels, as well as nutritional counseling to learn how best to eat well to avoid situations of insulin resistance that can be seen in women with PCOS.  The key to management is  to strive for preventative health and wellness and to minimize symptoms with PCOS.  As with everything: knowledge is power.
Dr. Michael Roizen, MD
Internal Medicine
PCOS treatment depends on what symptoms you have. Birth control pills may be prescribed because they regulate hormone levels and help stabilize menstrual periods. What’s more, they prevent acne, overgrowth of the uterine lining--a potential risk factor for uterine cancer later in life--and the continued overproduction of testosterone. Other hormonal methods, such as the patch or the NuvaRing, may also regulate periods.

For girls with hirsutism (excessive unwanted hair), waxing, bleaching, depilatories, electrolysis, and laser treatment can help. Some girls choose to use spironolactone (Aldactone), a prescription medicine that works at the skin level to decrease hair growth and make the offending hair grow in slightly lighter and more fine. Girls with PCOS-derived insulin resistance should stick to complex carbohydrates rather than sugary items, get plenty of exercise, eat lots of fruits and vegetables, and drink plenty of water. A medicine called metformin (used to manage type 2 diabetes) can help the overweight person with PCOS drop 5 to 10 pounds. It works best in conjunction with the birth control pill.
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Because there is no cure for polycystic ovarian syndrome (PCOS), it needs to be managed to prevent further problems. There are many medications to control the symptoms of PCOS. Doctors most commonly prescribe birth control pills for this purpose. Birth control pills regulate menstruation, reduce androgen levels, and help to clear acne. Your doctor will talk to you about whether a birth control pill is right for you and which kind to take. Other drugs can help with cosmetic problems. There also are drugs available to control blood pressure and cholesterol. Progestins and insulin-sensitizing medications can be taken to induce a menstrual period and restore normal cycles. Eating a balanced diet low in carbohydrates and maintaining a healthy weight can help lessen the symptoms of PCOS. Regular exercise helps weight loss and also aids the body in reducing blood glucose levels and using insulin more efficiently.

Although it is not recommended as the first course of treatment, surgery called ovarian drilling is available to treat PCOS. A very small incision is made above or below the navel, and a small instrument called a laparoscope that acts like a telescope is inserted into the abdomen. During laparoscopy, the doctor then can make punctures in the ovary with a small needle carrying an electric current to destroy a small portion of the ovary. The surgery can produce an improvement in hormone levels and ovulation, although the improvement may only last a matter of months.
Many physicians have found that one of the most effective treatment options for polycystic ovary syndrome (PCOS), especially for those trying to become pregnant, is the use of medications to trigger ovulation and if need be to control abnormal insulin production and sugar metabolism. Insulin sensitizers used alone or with other fertility medications such as clomiphene citrate or injectables often restore ovulation and maintain regular menstrual cycles allowing many women with PCOS to become pregnant.
The most common cause of irregular menstrual cycles is polycystic ovary syndrome (PCOS). This is the most common endocrine disorder affecting reproductive-aged women and is often associated with irregular cycles, polycystic-appearing ovaries on ultrasound, and frequently signs or symptoms of excessive male hormone, testosterone.

The good news is that polycystic ovary syndrome (PCOS) is a recognized cause of infertility and can be adequately treated with diet and exercise, although medications are often helpful as well.
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Although genetic factors are believed to make certain women more susceptible to polycystic ovary syndrome (PCOS), Susan Davis, M.D., a UCLA endocrinologist, notes that lifestyle, including diet and exercise, plays an important role in its severity. In particular, excess weight exacerbates both the reproductive problems and the insulin resistance that is linked to diabetes. "Thus, weight loss through diet and exercise is one of the most important strategies to combat the effects of PCOS."

Beyond that, treatment is individualized, depending on whether the focus is to correct the irregular uterine bleeding; restore fertility; correct excessive hair growth, acne and hair loss from excess male hormone production; or prevent diabetes and cardiovascular disease.
Daniel A. Dumesic, MD
Reproductive Endocrinology
Clomiphene citrate is an anti-estrogen that is commonly used as a first-line therapy for ovulation induction in polycystic ovary syndrome (PCOS). Metformin is a medicine called an insulin sensitizer, which lowers insulin levels in circulation and, to some degree, lowers androgen levels as well. Metformin does not differ from clomiphene regarding ovulation induction, pregnancy, live birth or miscarriage rates, so doctors have some alternatives on which agent to use.

Clomiphene citrate acts rapidly to block steroid negative feedback, but by blocking steroid negative feedback, the follicle-stimulating hormone (FSH) goes up excessively to drive the follicle, and sometimes more than one follicle could grow. As a result, clomiphene citrate is associated with approximately a 5% to 10% multiple-birth rate, while metformin gradually reduces insulin levels and tends to be associated with a lower multiple-birth rate.

The ability to block aromatase, which makes estrogen, is a clever way to introduce ovulation protocols for women with PCOS by elevating FSH without disrupting normal feedback actions. Medicines that do this are called letrozole or aromatase inhibitors.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.