Before we go into PCOS Treatment strategies, let’s understand about this condition briefly.
PCOS is the commonest hormonal disorder in women of reproductive age and affect millions of women world-wide. Women can have a varied set of symptoms like menstrual irregularities, infertility, hirsutism and acne. Treatment of PCOS currently depends on primary concern of the patient and is symptom-based.
What is PCOS?
PCOS is the commonest endocrinopathy (hormonal disorder) in reproductive-age women and is the most common cause of WHO Type II anovulation. In addition, PCOS has long-term consequences with increased risk of developing Type 2 diabetes, metabolic syndrome, cardiovascular disease and endometrial cancer. It is, hence imperative to manage these women keeping in mind their present symptomology, future reproductive goals and long-term health.
Management of PCOS
Treatment of PCOS is aimed at relieving the primary symptom of the patient. Various PCOS treatment modalities available are as follows.
Lifestyle modification and PCOS
Lifestyle modification remains the first-line treatment strategy for women with PCOS, especially those who are obese. Weight-loss of even 5% has been known to restore ovulation and improve metabolic derangements including blood sugars, insulin resistance and lipid profile. Since insulin resistance is increasingly being recognised as the primary metabolic abnormality in PCOS, including in those with the lean-phenotype, regular exercise can be recommended to all women with PCOS.
TREATMENT OPTIONS FOR PCOS MENSTRUAL IRREGULARITIES
Combined Oral Contraceptive pills
The COC’s usually contain low-dose estrogen along with a progestogen. These are usually prescribed cyclically to be started from anytime in the first five days of the menstrual cycle and are taken for 21 days. Cyclic OCP’s ensure regular menstrual bleeding with reduced chances of heavy menstrual bleeding and can also correct hyperandrogenism depending on the progestogen component. They also reduce the risk of development of endometrial hyperplasia and carcinoma.
TREATMENT OPTIONS FOR PCOS WOMEN WITH INFERTILITY ISSUES
Women with PCOS face difficulty in conceiving on account of anovulation. PCOS is the most common cause of anovulatory infertility in women. PCOS Treatment options for women include:
- Clomifene citrate: is an estrogen receptor modulator with anti-estrogenic effect on the hypothalamic-pituitary axis, leading to ovulation due to rise in FSH. While ovulation rates with CC are high, these do not translate into a correspondingly high pregnancy rate, presumably due to its anti-estrogenic effect on the endometrium. 75% of the pregnancies in patients using clomiphene are conceived in the first 3 months of treatment.
- Letrozole: this drug is increasingly being recommended as a first-line drug for management of anovulatory infertility in PCOS women. It is an aromatase inhibitor that leads to fall in peripheral conversion to estrogen which in turn gives rise to the FSH. Advantages of using Letrozole over CC are the potential for mono-follicular development and lack of effect on the endometrium. Letrozole has been found to have comparable pregnancy rates as CC and recent reports have failed to show any increase in birth defects with its use.
- Metformin: is an insulin sensitizer that has been shown to be effective in anovulatory women. In women who fail to ovulate CC alone, addition of metformin has been shown to improve rates of ovulation. In addition, metformin has shown to reduce the incidence of moderate OHSS in patients undergoing IVF.
- Gonadotropins: these are usually second-line drugs for women who fail to ovulate or achieve pregnancy with oral drugs alone. While rates of ovulation with these drugs are quite high, they are increased risks of multiple pregnancy due to multi-follicular development. If used, a low-dose step-up protocol is the treatment of choice. If IVF is done, the antagonist protocol is recommended with agonist trigger to eliminate risk of OHSS.
- Laparoscopic ovarian drilling: it is also a second-line treatment strategy for women who fail to ovulate with first-line ovulation induction. It involves drilling multiple holes into the ovarian stroma which has been shown to improve the hormonal profile and resumption of spontaneous ovulation. This leads to an increase in the chances of natural conception with reduction in the rates of multiple pregnancy which is frequent side-effect of OI. Its principal drawbacks are the risk of surgery and anaesthesia, temporary effects and risk of reduction in ovarian reserve as a consequence of drilling.
Adjuvants like Inositol are also frequently prescribed for treating women with PCOS though their effectiveness in subfetile women with PCOS is questioned.
TREATMENT OPTIONS FOR VISIBLE PCOS SYMPTOMS HIRSUTISM AND ACNE
Pharmacological treatment for dermatological features of PCOS is aimed at reducing the levels of circulating androgens. Drug treatments for treating PCOS symptoms can include:
- Combined oral contraceptives containing cyproterone acetate eg. Krimson 35
- Spironolactone is a potassium-sparing diuretic which affects the synthesis of testosterone reducing its levels
- Flutamide is an antiandrogen that blocks the action of both endogenous and exogenous testosterone by binding to the androgen receptor
- Finastride is a drug that blocks the conversion of testosterone to the potent dihydrotestosterone(DHT) which is responsible for the majority of the androgenic features like hirsutism, acne and hair loss.
- Local treatments include the eflorithine cream which acts at the level of the hair follicle. It can take upto 12 weeks for the action to occur as its acts on the hair that will grow.
- Permanent hair removal by laser remains a good option for those who wish for a long-term solution.
TREATMENT PCOS WOMEN DURING PREGNANCY
Women with PCOS who conceive are at an increased risk of miscarriage, increased risk of development of hypertension during pregnancy, both essential and gestational, gestational diabetes leading to corresponding increases in rates of caesarean section and neonatal morbidity. Use of metformin during pregnancy can improve the metabolic profile and it is generally considered safe during pregnancy.
Women with PCOS face a host of issues ranging from menstrual irregularities to metabolic syndrome. PCOS treatment and Management is patient preference-based and can depend on whether the woman has one concern or multiple. Though no cure is available, with increased awareness and adhering to PCOS treatment, women with PCOS can be affectively managed.
To know more about PCOS watch this video by Dr Sneha Tickoo:
- The pathogenesis and treatment of polycystic ovary syndrome: What’s new? Sylwia BednarskaA–D, Agnieszka SiejkaB–Fces. Adv Clin Exp Med. 2017;26(2):359–367
- Medical and Surgical Treatment of Reproductive Outcomes in Polycystic Ovary Syndrome: An Overview of Systematic Reviews. Gadalla et al. Int J Fertil Steril 2020 Jan-Mar; 13(4): 257–270
- Inositol for subfertile women with polycystic ovary syndrome. Cochrana Database Syst Rev. 2018 Dec; 2018(12): CD012378.