Polycystic ovary syndrome medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
The first step in the management of PCOS is weight loss if the patient is [[obese]], and treatment of [[type 2 diabetes]] with [[metformin]]. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating [[Anovulatory cycle|anovulatory]] | The first step in the management of PCOS is weight loss if the patient is [[obese]], and treatment of [[type 2 diabetes]] with [[metformin]]. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating [[Anovulatory cycle|anovulatory]] cycles, either by stimulating [[ovulation]] or suppressing [[androgenic]] and [[ovarian]] activity. The selection of treatment depends on whether the pregnancy is desired or not. All anti-androgen treatments will take at least 3 months to affect [[hirsutism]]. The drug regimen for PCOS depends upon the desire for the [[fertility]] of the patient. | ||
==Pharmacotherapy== | ==Pharmacotherapy== | ||
The first step in the management of PCOS is weight loss if the patient is [[obese]], and treatment of [[type 2 diabetes]] with [[metformin]]. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating [[annovulation|anovulatory cycling]], either by stimulating ovulation or suppressing [[androgenic]] and [[ovarian]] activity. The selection of treatment depends on whether the pregnancy is desired. All anti-androgen treatments will take at least 3 months to affect [[hirsutism]]. | The first step in the management of PCOS is weight loss if the patient is [[obese]], and treatment of [[type 2 diabetes]] with [[metformin]]. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating [[annovulation|anovulatory cycling]], either by stimulating ovulation or suppressing [[androgenic]] and [[ovarian]] activity. The selection of treatment depends on whether the pregnancy is desired or not. All anti-androgen treatments will take at least 3 months to affect [[hirsutism]]. | ||
The goals of treatment are:<ref name="pmid15931331">{{cite journal |vauthors=Sheehan MT |title=Polycystic ovarian syndrome: diagnosis and management |journal=Clin Med Res |volume=2 |issue=1 |pages=13–27 |year=2004 |pmid=15931331 |pmc=1069067 |doi= |url=}}</ref><ref name="pmid20186113">{{cite journal |vauthors=Artini PG, Di Berardino OM, Simi G, Papini F, Ruggiero M, Monteleone P, Cela V |title=Best methods for identification and treatment of PCOS |journal=Minerva Ginecol |volume=62 |issue=1 |pages=33–48 |year=2010 |pmid=20186113 |doi= |url=}}</ref><ref name="pmid17081931">{{cite journal |vauthors=King J |title=Polycystic ovary syndrome |journal=J Midwifery Womens Health |volume=51 |issue=6 |pages=415–22 |year=2006 |pmid=17081931 |doi=10.1016/j.jmwh.2006.01.008 |url=}}</ref><ref name="pmid21339935">{{cite journal |vauthors=Badawy A, Elnashar A |title=Treatment options for polycystic ovary syndrome |journal=Int J Womens Health |volume=3 |issue= |pages=25–35 |year=2011 |pmid=21339935 |pmc=3039006 |doi=10.2147/IJWH.S11304 |url=}}</ref><ref name="pmid28885578">{{cite journal |vauthors=Kataoka J, Tassone EC, Misso M, Joham AE, Stener-Victorin E, Teede H, Moran LJ |title=Weight Management Interventions in Women with and without PCOS: A Systematic Review |journal=Nutrients |volume=9 |issue=9 |pages= |year=2017 |pmid=28885578 |pmc=5622756 |doi=10.3390/nu9090996 |url=}}</ref><ref name="pmid26060208">{{cite journal |vauthors=Naderpoor N, Shorakae S, de Courten B, Misso ML, Moran LJ, Teede HJ |title=Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis |journal=Hum. Reprod. Update |volume=21 |issue=5 |pages=560–74 |year=2015 |pmid=26060208 |doi=10.1093/humupd/dmv025 |url=}}</ref><ref name="pmid21328294">{{cite journal |vauthors=Moran LJ, Hutchison SK, Norman RJ, Teede HJ |title=Lifestyle changes in women with polycystic ovary syndrome |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD007506 |year=2011 |pmid=21328294 |doi=10.1002/14651858.CD007506.pub2 |url=}}</ref><ref name="pmid24627300">{{cite journal |vauthors=Martin A, Saunders DH, Shenkin SD, Sproule J |title=Lifestyle intervention for improving school achievement in overweight or obese children and adolescents |journal=Cochrane Database Syst Rev |volume= |issue=3 |pages=CD009728 |year=2014 |pmid=24627300 |doi=10.1002/14651858.CD009728.pub2 |url=}}</ref> | The goals of treatment are:<ref name="pmid15931331">{{cite journal |vauthors=Sheehan MT |title=Polycystic ovarian syndrome: diagnosis and management |journal=Clin Med Res |volume=2 |issue=1 |pages=13–27 |year=2004 |pmid=15931331 |pmc=1069067 |doi= |url=}}</ref><ref name="pmid20186113">{{cite journal |vauthors=Artini PG, Di Berardino OM, Simi G, Papini F, Ruggiero M, Monteleone P, Cela V |title=Best methods for identification and treatment of PCOS |journal=Minerva Ginecol |volume=62 |issue=1 |pages=33–48 |year=2010 |pmid=20186113 |doi= |url=}}</ref><ref name="pmid17081931">{{cite journal |vauthors=King J |title=Polycystic ovary syndrome |journal=J Midwifery Womens Health |volume=51 |issue=6 |pages=415–22 |year=2006 |pmid=17081931 |doi=10.1016/j.jmwh.2006.01.008 |url=}}</ref><ref name="pmid21339935">{{cite journal |vauthors=Badawy A, Elnashar A |title=Treatment options for polycystic ovary syndrome |journal=Int J Womens Health |volume=3 |issue= |pages=25–35 |year=2011 |pmid=21339935 |pmc=3039006 |doi=10.2147/IJWH.S11304 |url=}}</ref><ref name="pmid28885578">{{cite journal |vauthors=Kataoka J, Tassone EC, Misso M, Joham AE, Stener-Victorin E, Teede H, Moran LJ |title=Weight Management Interventions in Women with and without PCOS: A Systematic Review |journal=Nutrients |volume=9 |issue=9 |pages= |year=2017 |pmid=28885578 |pmc=5622756 |doi=10.3390/nu9090996 |url=}}</ref><ref name="pmid26060208">{{cite journal |vauthors=Naderpoor N, Shorakae S, de Courten B, Misso ML, Moran LJ, Teede HJ |title=Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis |journal=Hum. Reprod. Update |volume=21 |issue=5 |pages=560–74 |year=2015 |pmid=26060208 |doi=10.1093/humupd/dmv025 |url=}}</ref><ref name="pmid21328294">{{cite journal |vauthors=Moran LJ, Hutchison SK, Norman RJ, Teede HJ |title=Lifestyle changes in women with polycystic ovary syndrome |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD007506 |year=2011 |pmid=21328294 |doi=10.1002/14651858.CD007506.pub2 |url=}}</ref><ref name="pmid24627300">{{cite journal |vauthors=Martin A, Saunders DH, Shenkin SD, Sproule J |title=Lifestyle intervention for improving school achievement in overweight or obese children and adolescents |journal=Cochrane Database Syst Rev |volume= |issue=3 |pages=CD009728 |year=2014 |pmid=24627300 |doi=10.1002/14651858.CD009728.pub2 |url=}}</ref> | ||
*Exclude [[androgen]]-secreting [[tumors]], [[Endometrial cancer|endometrial tumors]], and [[endometrial hyperplasia]] | *Exclude [[androgen]]-secreting [[tumors]], [[Endometrial cancer|endometrial tumors]], and [[endometrial hyperplasia]] | ||
*Reduce [[ovarian]] androgen secretion and/or antagonist activity at target tissues | *Reduce [[ovarian]] androgen secretion and/or [[antagonist]] activity at target tissues | ||
*Interrupt the self-sustaining abnormal [[hormonal]] cycle | *Interrupt the self-sustaining abnormal [[hormonal]] cycle | ||
*Normalize the [[endometrium]] | *Normalize the [[endometrium]] | ||
*Restore fertility by correcting [[anovulation]] | *Restore fertility by correcting [[anovulation]] (if desired) | ||
*Reduce [[insulin resistance]] | *Reduce [[insulin resistance]] | ||
==If Pregnancy is not desired== | ==If Pregnancy is not desired== | ||
*Preferred regimen (1): Combined [[Oral contraceptive| | *Preferred regimen (1): Combined [[Oral contraceptive|oral contraceptive pills]] (OCP) one tablet of formulations containing 30 to 35 μg [[estrogen]] orally daily for 21 days. | ||
*Preferred regimen (2): [[Progesterone]]-only contraceptive pills (eg, [[norethindrone]], [[norgestrel]] ) are the treatment of choice if combined [[ | *Preferred regimen (2): [[Progesterone]]-only contraceptive pills (eg, [[norethindrone]], [[norgestrel]] ) are the treatment of choice if combined [[Oral contraceptive|oral contraceptive pills]] are contraindicated. | ||
*Alternative regimen(1): [[Medroxyprogesterone]] may be used, although it is not approved by the U.S. Food and Drug Administration (FDA) for this indication | *Alternative regimen (1): [[Medroxyprogesterone]] may be used, although it is not approved by the U.S. Food and Drug Administration (FDA) for this indication. | ||
*Alternative regimen(2): [[Glucocorticoids]] (eg, [[hydrocortisone]], [[cortisone]], [[dexamethasone]] ) may be used to suppress [[adrenal]] [[androgen]] production, although they are not approved by the [[FDA]] for this indication | *Alternative regimen (2): [[Glucocorticoids]] (eg, [[hydrocortisone]], [[cortisone]], [[dexamethasone]] ) may be used to suppress [[adrenal]] [[androgen]] production, although they are not approved by the [[FDA]] for this indication. | ||
*Alternative regimen(3): [[Spironolactone]] and [[flutamide]] are [[androgen]] receptor antagonists that may be added to the [[oral contraceptive pill]], but they are not approved by the [[FDA]] for this indication; [[flutamide]] is not usually recommended because of its unproven efficacy and associated risk of [[hepatic]] impairment | *Alternative regimen (3): [[Spironolactone]] and [[flutamide]] are [[androgen]] receptor antagonists that may be added to the [[oral contraceptive pill]], but they are not approved by the [[FDA]] for this indication; [[flutamide]] is not usually recommended because of its unproven efficacy and associated risk of [[hepatic]] impairment. | ||
==If Pregnancy is desired== | ==If Pregnancy is desired== | ||
*Preferred regimen (1): [[Clomiphene]], alone or in combination with [[glucocorticoids]], is the first-choice treatment | *Preferred regimen (1): [[Clomiphene]], alone or in combination with [[glucocorticoids]], is the first-choice treatment. | ||
*Preferred regimen (2): [[FSH|Follicle-stimulating hormone]] may be administered in conjunction with timed [[HCG|human chorionic gonadotropin]] for [[ovulation]] induction | *Preferred regimen (2): [[FSH|Follicle-stimulating hormone]] may be administered in conjunction with timed [[HCG|human chorionic gonadotropin]] for [[ovulation]] induction. | ||
*Preferred regimen (3): [[Metformin]] | *Preferred regimen (3): [[Metformin]] | ||
==Symptomatic Medical Therapy== | ==Symptomatic Medical Therapy== | ||
====Treatment of Hirsutism and Acne==== | ====Treatment of Hirsutism and Acne==== | ||
*[[Cyproterone acetate]] is an anti-[[androgen]], which blocks the action of male hormones that are believed to contribute to acne and the growth of unwanted facial and body hair. | *[[Cyproterone acetate]] is an anti-[[androgen]], which blocks the action of male hormones that are believed to contribute to [[Acne vulgaris|acne]] and the growth of unwanted facial and body hair. | ||
* [[Cyproterone acetate]] is also contained in the contraceptive pill Dianette®. | * [[Cyproterone acetate]] is also contained in the contraceptive pill Dianette®. | ||
* [[Spironolactone]] also has some benefits, again through anti-androgen activity, and metformin can also help. | * [[Spironolactone]] also has some benefits, again through anti-androgen activity, and [[metformin]] can also help. | ||
* [[Eflornithine]] is a drug which is applied to the skin in cream form (Vaniqa®), and acts directly on the hair follicles to inhibit hair growth. | * [[Eflornithine]] is a drug which is applied to the skin in cream form (Vaniqa®), and acts directly on the hair follicles to inhibit hair growth. | ||
* The average reduction in hair growth is generally in the region of 25%, which may not be enough to eliminate the social embarrassment of [[hirsutism]] or the inconvenience of plucking/shaving. | * The average reduction in hair growth is generally in the region of 25%, which may not be enough to eliminate the social embarrassment of [[hirsutism]] or the inconvenience of plucking/shaving. | ||
* Individuals may vary in their response to different therapies, and it is | * Individuals may vary in their response to different therapies, and it is recommended to try other medications if one is not effective although, drug treatments is not effective for all individuals. | ||
* Alternatives include [[electrolysis]] and various forms of laser therapy. | * Alternatives include [[electrolysis]] and various forms of laser therapy. | ||
====Treatment of Menstrual Irregularity and Prevention of Endometrial Hyperplasia/Cancer==== | ====Treatment of Menstrual Irregularity and Prevention of Endometrial Hyperplasia/Cancer==== | ||
* [[Menstruation]] can be regulated with a contraceptive pill. | * [[Menstruation]] can be regulated with a contraceptive pill. | ||
* Most brands of contraceptive pill result in a withdrawal | * Most brands of contraceptive pill result in a withdrawal menstrual bleeding every 28 days. | ||
* Dianette® (a contraceptive pill containing [[cyproterone acetate]]) is also beneficial for hirsutism and is therefore often prescribed in PCOS. | * Dianette® (a contraceptive pill containing [[cyproterone acetate]]) is also beneficial for hirsutism and is therefore often prescribed in PCOS. | ||
* If a regular menstrual cycle is not desired, then a standard contraceptive pill is not appropriate. | * If a regular menstrual cycle is not desired, then a standard contraceptive pill is not appropriate. | ||
Latest revision as of 14:19, 2 November 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
The first step in the management of PCOS is weight loss if the patient is obese, and treatment of type 2 diabetes with metformin. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating anovulatory cycles, either by stimulating ovulation or suppressing androgenic and ovarian activity. The selection of treatment depends on whether the pregnancy is desired or not. All anti-androgen treatments will take at least 3 months to affect hirsutism. The drug regimen for PCOS depends upon the desire for the fertility of the patient.
Pharmacotherapy
The first step in the management of PCOS is weight loss if the patient is obese, and treatment of type 2 diabetes with metformin. In significantly overweight patients, weight loss alone usually effects a cure and should always be vigorously attempted. Diet and exercise are recommended in all women with PCOS. The next step is the initiation of treatment to break the self-perpetuating anovulatory cycling, either by stimulating ovulation or suppressing androgenic and ovarian activity. The selection of treatment depends on whether the pregnancy is desired or not. All anti-androgen treatments will take at least 3 months to affect hirsutism. The goals of treatment are:[1][2][3][4][5][6][7][8]
- Exclude androgen-secreting tumors, endometrial tumors, and endometrial hyperplasia
- Reduce ovarian androgen secretion and/or antagonist activity at target tissues
- Interrupt the self-sustaining abnormal hormonal cycle
- Normalize the endometrium
- Restore fertility by correcting anovulation (if desired)
- Reduce insulin resistance
If Pregnancy is not desired
- Preferred regimen (1): Combined oral contraceptive pills (OCP) one tablet of formulations containing 30 to 35 μg estrogen orally daily for 21 days.
- Preferred regimen (2): Progesterone-only contraceptive pills (eg, norethindrone, norgestrel ) are the treatment of choice if combined oral contraceptive pills are contraindicated.
- Alternative regimen (1): Medroxyprogesterone may be used, although it is not approved by the U.S. Food and Drug Administration (FDA) for this indication.
- Alternative regimen (2): Glucocorticoids (eg, hydrocortisone, cortisone, dexamethasone ) may be used to suppress adrenal androgen production, although they are not approved by the FDA for this indication.
- Alternative regimen (3): Spironolactone and flutamide are androgen receptor antagonists that may be added to the oral contraceptive pill, but they are not approved by the FDA for this indication; flutamide is not usually recommended because of its unproven efficacy and associated risk of hepatic impairment.
If Pregnancy is desired
- Preferred regimen (1): Clomiphene, alone or in combination with glucocorticoids, is the first-choice treatment.
- Preferred regimen (2): Follicle-stimulating hormone may be administered in conjunction with timed human chorionic gonadotropin for ovulation induction.
- Preferred regimen (3): Metformin
Symptomatic Medical Therapy
Treatment of Hirsutism and Acne
- Cyproterone acetate is an anti-androgen, which blocks the action of male hormones that are believed to contribute to acne and the growth of unwanted facial and body hair.
- Cyproterone acetate is also contained in the contraceptive pill Dianette®.
- Spironolactone also has some benefits, again through anti-androgen activity, and metformin can also help.
- Eflornithine is a drug which is applied to the skin in cream form (Vaniqa®), and acts directly on the hair follicles to inhibit hair growth.
- The average reduction in hair growth is generally in the region of 25%, which may not be enough to eliminate the social embarrassment of hirsutism or the inconvenience of plucking/shaving.
- Individuals may vary in their response to different therapies, and it is recommended to try other medications if one is not effective although, drug treatments is not effective for all individuals.
- Alternatives include electrolysis and various forms of laser therapy.
Treatment of Menstrual Irregularity and Prevention of Endometrial Hyperplasia/Cancer
- Menstruation can be regulated with a contraceptive pill.
- Most brands of contraceptive pill result in a withdrawal menstrual bleeding every 28 days.
- Dianette® (a contraceptive pill containing cyproterone acetate) is also beneficial for hirsutism and is therefore often prescribed in PCOS.
- If a regular menstrual cycle is not desired, then a standard contraceptive pill is not appropriate.
- Women who are having irregular menses do not necessarily require any therapy; most experts consider that if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.
- If menstruation occurs less often or not at all, some form of progesterone replacement is recommended. Some women prefer a uterine progesterone implant such as the Mirena® coil, which provides simultaneous contraception and endometrial protection for years, though often with unpredictable minor bleeding.
- An alternative is an oral progesterone taken at intervals (e.g. every three months) to induce a predictable menstrual bleed.
References
- ↑ Sheehan MT (2004). "Polycystic ovarian syndrome: diagnosis and management". Clin Med Res. 2 (1): 13–27. PMC 1069067. PMID 15931331.
- ↑ Artini PG, Di Berardino OM, Simi G, Papini F, Ruggiero M, Monteleone P, Cela V (2010). "Best methods for identification and treatment of PCOS". Minerva Ginecol. 62 (1): 33–48. PMID 20186113.
- ↑ King J (2006). "Polycystic ovary syndrome". J Midwifery Womens Health. 51 (6): 415–22. doi:10.1016/j.jmwh.2006.01.008. PMID 17081931.
- ↑ Badawy A, Elnashar A (2011). "Treatment options for polycystic ovary syndrome". Int J Womens Health. 3: 25–35. doi:10.2147/IJWH.S11304. PMC 3039006. PMID 21339935.
- ↑ Kataoka J, Tassone EC, Misso M, Joham AE, Stener-Victorin E, Teede H, Moran LJ (2017). "Weight Management Interventions in Women with and without PCOS: A Systematic Review". Nutrients. 9 (9). doi:10.3390/nu9090996. PMC 5622756. PMID 28885578.
- ↑ Naderpoor N, Shorakae S, de Courten B, Misso ML, Moran LJ, Teede HJ (2015). "Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis". Hum. Reprod. Update. 21 (5): 560–74. doi:10.1093/humupd/dmv025. PMID 26060208.
- ↑ Moran LJ, Hutchison SK, Norman RJ, Teede HJ (2011). "Lifestyle changes in women with polycystic ovary syndrome". Cochrane Database Syst Rev (2): CD007506. doi:10.1002/14651858.CD007506.pub2. PMID 21328294.
- ↑ Martin A, Saunders DH, Shenkin SD, Sproule J (2014). "Lifestyle intervention for improving school achievement in overweight or obese children and adolescents". Cochrane Database Syst Rev (3): CD009728. doi:10.1002/14651858.CD009728.pub2. PMID 24627300.