gynecology and obstetrics
Polycystic Ovary Syndrome (PCOS)
Treatment of PCOS
Usually estrogen/progestin contraceptives or progestins Sometimesmetforminor otherinsulinsensitizers Management of hirsutism and, in adult women, long-term risks of hormonal abnormalities Infertility treatments in women who desire pregnancy Treatment of polycystic ovary syndrome aims to Manage hormonal and metabolic abnormalities and thus reduce risks ofestrogenexcess (eg, endometrial hyperplasia) and androgen excess (eg, diabetes, cardiovascular disorders) Relieve symptoms Treat infertility Hormonal medications are used to cause regular shedding of the endometrium and reduce the risk of endometrial hyperplasia and cancer. Women are usually given an intermittent progestin (eg,medroxyprogesterone5 to 10 mg orally once a day for 10 to 14 days every 1 to 2 months) or combination oral contraceptives to. These treatments also reduce circulating androgens and usually help make menstrual cycles more regular. Hormonal contraceptives are first-line therapy for menstrual abnormalities, hirsutism, and acne in women who have PCOS and who do not desire pregnancy. Lifestyle changes and pharmacologic approaches are used to manageinsulininsensitivity. sensitivity, and reduce acanthosis nigricans and hirsutism. Weight loss may also help improve fertility. Bariatric surgery may be an option for some women with PCOS ( Treatment references ). However, weight loss is unlikely to benefit normal-weight women with PCOS. Metformin500 to 1000 mg twice a day is used to help increaseinsulinsensitivity in women with PCOS, irregular menses, and diabetes orinsulinresistance if lifestyle modifications are ineffective or if they cannot take or cannot tolerate hormonal contraceptives.Metformincan also reduce freetestosteronelevels. Whenmetforminis used, serum glucose should be measured, and kidney and liver function tests should be done periodically. Becausemetforminmay induce ovulation, contraception is needed if pregnancy is not desired.Metforminhelps correct metabolic and glycemic abnormalities and makes menstrual cycles more regular, but it has little or no beneficial effect on hirsutism, acne, or infertility. are being studied ( Treatment references ). Other studies are evaluating the role of microbiota treatments for PCOS ( Many patients with PCOS have infertility, and those who desire pregnancy should be referred to infertility specialists. Treatment (eg, Ifclomipheneand other medications are unsuccessful or if there are other indications for laparoscopy, laparoscopic ovarian drilling may be considered; however possible long-term complications of drilling (eg, adhesions, ovarian insufficiency) must be considered. Ovarian drilling involves using electrocautery or a laser to drill holes in small areas of the ovaries that produce androgens. Ovarian wedge resection is not recommended. Because women with PCOS-associated obesity have a higher risk of pregnancy complications (including gestational diabetes, preterm delivery, and preeclampsia), preconception assessment of body mass index, blood pressure, and oral glucose tolerance is recommended. Treatment None In adult women who do not desire pregnancy, hormone therapy that decreases androgen levels orspironolactonecan be tried.Spironolactone50 to 100 mg twice a day is effective, but because this medication may have teratogenic effects, effective contraception is needed. Cyproterone, an antiandrogen (not available in the US), reduces the amount of unwanted body hair in 50 to 75% of affected women. Weight reduction decreases androgen production in women with obesity and thus may slow hair growth. GnRH agonists and antagonists are being studied as treatment for unwanted body hair. Both types of medications inhibit the production of sex hormones by the ovaries. But both can cause bone loss and lead to osteoporosis. Treatment None Because risk of depression and anxiety is increased in PCOS, women and adolescents with PCOS should be screened for these problems based on history, and if a problem is identified, they should be referred to a mental health care practitioner and/or treated as needed. Adolescents and women who have PCOS and overweight or obesity should be screened for symptoms of Diagnosis using polysomnography and treated as needed. Because PCOS can increase the risk of cardiovascular disorders, referral to a cardiovascular specialist for prevention of cardiovascular disorders is necessary if women with PCOS have any of the following: A family history of early-onset cardiovascular disorders Cigarette smoking Diabetes mellitus Hypertension Dyslipidemia Sleep apnea Abdominal obesity (as for Diagnosis ) Clinicians should evaluate cardiovascular risk by determining body mass index (BMI), measuring fasting lipid and lipoprotein levels, and identifying risk factors for metabolic syndrome. Adult women with PCOS are evaluated for Metabolic Syndrome by measuring blood pressure and usually serum glucose and lipids (lipid profile). Tests for coronary artery calcification and thickened carotid intima media should be done to check for subclinical atherosclerosis. Women with abnormal vaginal bleeding should be screened for endometrial hyperplasia or carcinoma using endometrial biopsy and/or transvaginal ultrasonography or office hysteroscopy. 1.Yue W, Huang X, Zhang W, et al: Metabolic surgery on patients with polycystic ovary syndrome: A systematic review and meta-analysis.Front Endocrinol (Lausanne)13:848947, 2022. doi: 10.3389/fendo.2022.848947 2.Xing C, Li C, He B:Insulinsensitizers for improving the endocrine and metabolic profile in overweight women with PCOS.J Clin Endocrinol Metab10 5(9):2950–2963, 2020. 3.Batra M, Bhatnager R, Kumar A, et al: Interplay between PCOS and microbiome: The road less travelled.Am J Reprod Immunol 88 (2):e13580, 2022. doi: 10.1111/aji.13580 Epub 2022 May 29. 4.Martin KA, Chang RJ, Ehrmann,DA, et al: Evaluation and treatment of hirsutism in premenopausal women: An Endocrine Society Clinical Practice Guideline.J Clin Endocrinol Metab93 (4):1105–1120, 2008. doi: 10.1210/jc.2007-2437 Epub 2008 Feb 5. 