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Treatment

PCOS cannot be cured, but there are many medications that can be used to control the symptoms. Very occasionally, surgery may also be a useful way to reduce androgen levels and relieve symptoms. Which method of treatment is right for you depends on your symptoms and concerns, and whether or not you are trying to get pregnant.

Therapy options to relieve the symptoms of PCOS include:

Hormone Therapies | Insulin-sensitizing drugs | Fertility Medications | Surgery

Hormone Therapies

Oral Contraceptives
Oral contraceptives, also known as the birth control pill or simply “the Pill,” regulate the menstrual cycle and reduce acne and excess hair growth. Controlled doses of estrogen inhibit the production of ovarian steroids, including androgens, and suppress the secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH). The effect depends on the estrogen dose in the contraceptive. Oral contraceptives may also reduce the risk of endometrial cancer. However, the use of birth control pills is contraindicated in older women who smoke, and is associated with other rare but serious risks, including heart attack, stroke and blood clots.

If you take oral contraceptives, or are considering starting, talk to your physician about the most effective prescription and dose for you.

Progestin
A progestin is a medication that mimics the action of the female hormone progesterone. Women who do not wish to take oral contraceptives can take a progestin to induce menstrual bleeding and prevent the abnormal build-up of the uterine lining. While progestins may be used to regulate the menstrual cycle and reduce blood levels of LH, they appear to be of little use in reducing hair growth.

Anti-Androgens
Anti-androgens block the effects of androgens, and can help improve PCOS symptoms, such as excess facial and body hair and acne. Examples of these medications include spironolactone, flutamide, cyproterone acetate and finasteride. Note that some may have potentially serious side effects, including depression and loss of libido. Do not use anti-androgens if you are trying to get pregnant.

Insulin-Sensitizing Drugs

If a woman with PCOS is above ideal weight, most physicians will first recommend diet changes, exercise and possibly weight loss. However, insulin-sensitizing or insulin-lowering medications may be used in certain situations as well. Reducing insulin resistance with these medications can help improve ovulation and reduce the levels of androgens in many women with PCOS. The effects of these medications on hair growth and weight are generally small.

There are very few studies showing the results of these medications in women with PCOS.

Before you're placed on an insulin-lowering drug, ask your doctor about how diet and exercise can help your body use insulin more efficiently. Insulin-sensitizing drugs have not been proven safe for pregnant women, so if you are trying to get pregnant, you should also discuss these issues with your doctor.

Metformin
One such drug being used by some women with PCOS is Metformin. Traditionally a drug for people with diabetes, it is also used to lower the levels of insulin of women with PCOS. Metformin has been used in combination with fertility drugs to restore ovulation for women who were previously resistant to those fertility agents. It has been shown to reduce insulin resistance and levels of male hormones in women with PCOS. In individuals with impaired glucose tolerance (“borderline diabetes”), Metformin has been shown to prevent or delay the onset of diabetes. It may have a similar benefit for women with PCOS and impaired glucose tolerance.

Metformin may cause gastrointestinal upset and loose stools or more frequent bowel movements. This is likely the reason for the modest weight loss sometimes associated with Metformin. Lactic acidosis, a rare but potentially fatal condition, has been associated with Metformin use. Talk to your doctor if you are considering taking this medication.

Fertility Medications

Some women with PCOS have trouble getting pregnant because the normal mechanism of ovulation may be disturbed, causing infertility. Fertility drugs are commonly used in an attempt to temporarily override the problem and facilitate ovulation. If these medications fail, women and their partners may wish to consider other technologies, like in vitro fertilization, if they still wish to conceive.

Doctors may recommend several treatments for women with PCOS who are having problems conceiving.

Clomiphene Citrate (Clomid)
The fertility drug clomiphene citrate (clomid) may be prescribed. If a woman has not had her period for an extended length of time (amenorrhea), the doctor may recommend a progesterone supplement to induce menstruation before taking clomiphene.

It is estimated that up to 50 percent of women with PCOS who take the medication will eventually have a baby. Clomiphene increases a woman’s chance of conceiving multiples (e.g. twins or more).

Gonadotropins
If you do not ovulate after taking clomiphene, a hormone called human chorionic gonadotropin (hCG) may be prescribed prior to the luteal phase of your menstrual cycle.

If this regimen fails, injections of gonadotropin therapy (a treatment that includes combinations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) preparations) may be recommended. Although this treatment is more successful than clomiphene, it is less commonly used because it is more expensive and more likely to cause a woman to conceive multiples (twins or more). While 70 to 80 percent of women with PCOS will ovulate with gonadotropin therapy, only 20 to 40 percent will become pregnant.

Surgery

Surgical treatments for PCOS are intended to reduce a woman’s level of androgens and restore her menstrual cycle. Although these surgeries remove or destroy a portion of the ovaries, they generally do not impair a woman’s fertility. Surgery is often performed to help restore a woman’s fertility; however, a woman’s fertility can be impaired if the operation causes scarring.

Two surgeries are used to treat PCOS: ovarian wedge resection and ovarian drilling. Both surgeries reduce levels of androgens and restore the menstrual cycle, but the wedge resection is rarely used today. Wedge resection, a major abdominal surgery that removes a portion of the ovary, may be more successful than ovarian drilling, but the drilling is a less invasive procedure with less risk of scarring.

Ovarian drilling is done using laparoscopic surgery, on an outpatient basis. A small needle is used to make 4 to 20 punctures in the ovary. An electric current is passed through the needle and a small portion of the ovary is destroyed. Often a small amount of cyst fluid can be seen escaping as the puncture is made. Alternatively, lasers have been used for the same effect, with the disadvantage of potentially injuring a larger surface area and leading to the formation of scar tissue.

There is no data available about the percentage of women who have had live births after ovarian drilling but it is estimated to be less than 50 percent.

Surgical therapy for PCOS should not be considered as a first step in treatment in part because it is unclear what the long-term effects might be.

 

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