A few months ago, we discussed diagnosis of PCOS. To recap, PCOS is very common accounting for 50% of women with irregular periods and 25% of young infertile woman. The most common clinical features include irregular periods and excess hair growth. Polycystic ovaries on ultrasound is not absolutely necessary for the diagnosis. Polycystic ovaries do not cause the syndrome but rather are caused by hormonal abnormalities, in particular elevated testosterone and insulin levels. Most cases of PCOS ,but not all, are associated with insulin resistance and being overweight. Most thin women with increased hair growth and irregular periods also have PCOS. Refer to August 2010 blog for further details.
The treatment for PCOS depends on the patient’s goal of whether or not she wants to conceive. For patients not trying to conceive, we usually recommend birth control pills to regulate their menstrual cycles. If patients display signs of insulin resistance or are overweight, metformin, a common anti-diabetic drug, is added to help reduce insulin levels which in turn help regulate ovulatory cycles. 5-10% weight loss of a patient’s body weight can help normalize insulin and other hormonal abnormalities. Spironolactone, a water pill also used to treat high blood pressure, is also commonly used to reduce testosterone-induced hair growth. Spironolactone blocks the testosterone receptors on the hair follicles.
For women who wish to conceive, Clomid, an infertility drug, acts on the central nervous system to help trick the body into ovulating. This is often used along with metformin in women who show any sign of insulin resistance. Although many women ovulate on Clomid, because it can have negative effects on cervical mucus production and endometrial lining, use for longer than 3-4 months is discouraged. Also, some women with PCOS do not respond to Clomid. For these women, injectable fertility drugs in the form of FSH is necessary. The injectable recombinant FSH need to be monitored closely. The goal with either of these infertiility drugs is to induce 1 to 2 follicles to mature to reduce the chance of multiple pregnancies. With Clomid, there is a 6-8% chance of twins. In women with PCOS, when using recombinant FSH, it can be difficult to get 1 to 2 follicles to mature and therefore, fairly often, PCOS patients treated with recombinant FSH will need to have their cycles cancelled or be converted to IVF and undergo an egg retrieval.