TREATMENTS

Oral contraceptives — Oral contraceptives (OCs) are the most commonly used treatment for regulating menstrual periods in women with PCOS. OCs protect the woman from endometrial (uterine) cancer or overgrowth by inducing a monthly menstrual period. OCs are also effective for treating hirsutism and acne.

Women with PCOS occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although an OC allows for bleeding once per month, this does not mean that the PCOS is "cured"; irregular cycles generally return when the OC is stopped.

Oral contraceptives decrease the body's production of androgens, and anti-androgen drugs (such as spironolactone) decrease the effect of androgens. These treatments can be used in combination to reduce and slow hair growth. Oral contraceptives and anti-androgens can also reduce acne. Other prescription skin treatments (eg, medicated lotions) or oral antibiotics may be recommended in some cases.

Before prescribing an oral contraceptive, a clinician will perform an examination or a blood test to be certain that a woman is not pregnant. If a woman has not had a period for six weeks or longer, the clinician may first prescribe a hormone (eg, Provera®) to induce a menstrual period.

• Side effects — Some women who take birth control pills (not just those with PCOS) stop having monthly bleeding or develop irregular spotting and bleeding. Irregular bleeding usually resolves after a few menstrual cycles.

Many women worry that they will gain weight on the pill. This is not a concern with the currently available low-dose pills. Some women develop nausea, breast tenderness, and bloating after beginning the pill, but these symptoms usually resolve after two or three months.

The pill is safe and effective, although it slightly increases the risk of blood clots in the legs or lungs; this is a rare complication in young, healthy women who do not smoke. The risk is higher in women older than 35 years and in smokers.

Progestin — Another method to treat menstrual irregularity is to take a hormone called progestin (eg, Provera®) for 10 to 14 days every one to three months. This will induce a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hirsutism and acne) and does not prevent pregnancy. It does reduce the risk of uterine cancer.

Hair treatments — Excess hair growth can be removed by shaving or use of depilatories, electrolysis, or laser therapy. Many women worry that these treatments cause hair to grow faster, although this is not true.

Hair loss can be treated with medications in some situations, although medications are not usually as effective in women as they are in men. Other options include hair replacement and wigs.

Weight loss — Weight loss is one of the simplest, yet most effective, approaches for managing insulin abnormalities, menstrual irregularities, and other symptoms of PCOS. For example, many overweight women with PCOS who lose 5 to 10 percent of their body weight notice that their periods become more regular. Weight loss can often be achieved with a program of diet and exercise.

There are a number of options available to treat obesity. These options are identical to those recommended for women without PCOS, and include diet and exercise, weight loss medications, and weight loss surgery.

Weight loss surgery may be an option for severely obese women with PCOS. Significant amounts of weight can be lost after surgery, which can restore normal menstrual cycles, reduce high androgen levels and hirsutism, and reduce the risk of type 2 diabetes.

Metformin — Metformin (Glucophage®) is medication that improves the effectiveness of insulin produced by the body. It was developed as a treatment for type 2 diabetes, but may be recommended for women with PCOS in selected situations.

• If a woman does not have regular menstrual cycles, the first-line treatment is a hormonal method of birth control, such as birth control pills. If the woman cannot take birth control pills, one alternative is to take metformin; a progestin is usually recommended, in addition to metformin, for six months or until menstrual cycles are regular. (See "Progestin" above).

• Metformin may help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added. If metformin is used, it is essential that diet and exercise are also part of the recommended regimen because the weight that is lost in the early phase of metformin treatment may be regained over time.

Metformin is not usually recommended for women with PCOS who have difficulty becoming pregnant. (See "Treatment of infertility" below).

An expert group does not recommend metformin for women with PCOS who have excessive hair growth (hirsutism). Birth control pills alone, or in combination with an anti-androgen medication, are a better option.

Treatment of infertility — If tests determine that lack of ovulation is the cause of infertility, several treatment options are available. These treatments work best in women who are not obese. A summary of treatment options is shown in table 1 (show table 1).

The primary treatment for women who are unable to become pregnant and who have PCOS is weight loss. Even a modest amount of weight loss may allow the woman to begin ovulating normally. In addition, weight loss can improve the effectiveness of other infertility treatments.

Clomiphene is a medication that stimulates the ovaries to release one or more eggs. It triggers ovulation in about 80 percent of women with PCOS, and about 50 percent of these women will become pregnant.

A few studies have shown that taking metformin in addition to clomiphene increases the rate of ovulation; other studies have shown no benefit [1]. In addition, it is not clear if metformin is safe during pregnancy; women who take metformin before pregnancy are usually advised to stop it once pregnancy is achieved.

If a woman does not ovulate or is unable to conceive with clomiphene, gonadotropin therapy may be recommended. Gonadotropins are hormones (LH and FSH) that are given as a daily injection. Ovulation occurs in almost all women with PCOS who use gonadotropin therapy; approximately 60 percent of these women become pregnant.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.