{"id":697,"date":"2020-02-17T20:57:01","date_gmt":"2020-02-17T15:27:01","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=697"},"modified":"2020-02-17T20:57:01","modified_gmt":"2020-02-17T15:27:01","slug":"polycystic-ovary-syndrome-pcos","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/polycystic-ovary-syndrome-pcos\/","title":{"rendered":"Polycystic ovary syndrome (PCOS)"},"content":{"rendered":"\n<p><strong>Polycystic ovary syndrome (PCOS)<\/strong><\/p>\n\n\n\n<ul><li>most common cause of infertility in women<\/li><li>PCOS encompasses a spectrum of variably associated clinical features that are not otherwise explained:<\/li><\/ul>\n\n\n\n<p>\u25cfCutaneous signs of hyperandrogenism (eg, hirsutism, moderate-severe acne)<\/p>\n\n\n\n<p>\u25cfMenstrual irregularity (eg, oligo- or amenorrhea, or irregular bleeding)<\/p>\n\n\n\n<p>\u25cfPolycystic ovaries (one or both)<\/p>\n\n\n\n<p>\u25cfObesity and insulin resistance<\/p>\n\n\n\n<ul><li>originally was described by Stein and Leventhal as the association of amenorrhea with polycystic ovaries<\/li><li>diagnostic criteria &#8211; Rotterdam consensus criteria&nbsp;<ul><li>hyperandrogenism, anovulation, and a polycystic ovary<\/li><\/ul><\/li><li>Hirsutism- graded according to the Ferriman-Gallwey system<\/li><\/ul>\n\n\n\n<p>Women with PCOS have multiple abnormalities that require attention, including oligomenorrhea, hyperandrogenism, anovulatory infertility, and metabolic risk factors such as obesity, insulin resistance, dyslipidemia, and impaired glucose tolerance. Weight loss, which can restore ovulatory cycles and improve metabolic risk, is the first-line intervention for most women.<\/p>\n\n\n\n<p>Our overall approach \u00e0 Endocrine Society Clinical Guidelines<\/p>\n\n\n\n<p><strong>Goals<\/strong>&nbsp;\u2014&nbsp;The overall goals of therapy of women with PCOS include:<\/p>\n\n\n\n<p>\u25cfAmelioration of <strong>hyperandrogenic features<\/strong> (hirsutism, acne, scalp hair loss)<\/p>\n\n\n\n<p>\u25cfManagement of <strong>underlying metabolic abnormalities<\/strong> and <strong>reduction of risk factors for type 2 diabetes and cardiovascular disease<\/strong><\/p>\n\n\n\n<p>\u25cf<strong>Prevention of endometrial hyperplasia<\/strong> <strong>and carcinoma,<\/strong> which may occur as a result of chronic anovulation<\/p>\n\n\n\n<p>\u25cf<strong>Contraception for those not pursuing pregnancy<\/strong>, as women with oligomenorrhea ovulate intermittently and unwanted pregnancy may occur<\/p>\n\n\n\n<p>\u25cf<strong>Ovulation induction for those pursuing pregnancy<\/strong><\/p>\n\n\n\n<p><strong>Lifestyle changes<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>diet and exercise for weight reduction as the first step for overweight and obese women with PCOS.<\/li><\/ul>\n\n\n\n<p><strong>Women not pursuing pregnancy<\/strong><\/p>\n\n\n\n<p><strong>Menstrual dysfunction<\/strong><\/p>\n\n\n\n<p><strong>Endometrial protection<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>The chronic anovulation seen in PCOS is associated with an increased risk of endometrial hyperplasia and possibly endometrial cancer<\/p>\n\n\n\n<ul><li>combined estrogen-progestin oral contraceptives (COCs) as first-line therapy for menstrual dysfunction and endometrial protection<\/li><li>COCs provide a number of benefits in women with PCOS, including:<\/li><\/ul>\n\n\n\n<p>\u25cfDaily exposure to progestin, which antagonizes the endometrial proliferative effect of estrogen<\/p>\n\n\n\n<p>\u25cfContraception in those not pursuing pregnancy, as women with oligomenorrhea ovulate intermittently and unwanted pregnancy may occur<\/p>\n\n\n\n<p>\u25cfCutaneous benefits for hyperandrogenic manifestations<\/p>\n\n\n\n<p><strong>Choice of oral contraceptive<\/strong>&nbsp;\u2014&nbsp;COC containing 20 mcg of ethinyl estradiol combined with a progestin such as&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/norethindrone-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">norethindrone<\/a>&nbsp;or norethindrone acetate, progestins that have lower androgenicity, but similar VTE risk compared with levonorgestrel-containing COCs<\/p>\n\n\n\n<ul><li>COCs affect insulin sensitivity, carbohydrate metabolism, and lipid metabolism; the effects depend upon the estrogen dose and androgenicity of the progestin.<\/li><li>Absence of pregnancy should be documented before COCs are begun.<\/li><li>COCs are associated with an <strong>increased risk of venous thromboembolism (VTE)<\/strong> in all users but particularly in obese women.<\/li><li>Alternatives to COCs \u00e0 cyclic progestin therapy, continuous progestin therapy (progestin-only pills [the &#8220;mini-pill&#8221;]), or a progestin-releasing intrauterine device (IUD).<\/li><li>Alternative \u00e0 <a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/medroxyprogesterone-acetate-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">medroxyprogesterone acetate<\/a>&nbsp;(5 to 10 mg) for 10 to 14 days every one to two months.<\/li><li>Both continuous progestin therapy (eg, a progestin-only pill such as&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/norethindrone-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">norethindrone<\/a>&nbsp;0.35&nbsp;mg\/day)and the progestin-releasing IUD provide contraception and reduce the risk of endometrial hyperplasia.<\/li><\/ul>\n\n\n\n<ul><li><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/metformin-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">Metformin<\/a>&nbsp;is a potential alternative to restore menstrual cyclicity as it restores ovulatory menses in approximately 30 to 50 percent of women with PCOS<\/li><\/ul>\n\n\n\n<ul><li>Its ability to provide endometrial protection is less well established, and we therefore consider it to be second-line therapy<\/li><\/ul>\n\n\n\n<p><strong>Androgen excess<\/strong><\/p>\n\n\n\n<p><strong>Hirsutism<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>COC as first-line pharmacologic therapy for most women<\/li><li>An antiandrogen is then added after six months if the cosmetic response is suboptimal<\/li><li>COCs and an antiandrogen may sometimes be started simultaneously at the outset, particularly when the cutaneous manifestations are bothersome to the patient.<\/li><li>Progestins with lower androgenicity include desogestrel,&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/cyproterone-united-states-not-available-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">cyproterone acetate<\/a>, and drospirenone, but all have been associated with a possible higher risk of venous thromboembolism (VTE).<\/li><li>Norgestimate is a progestin with low androgenicity and similar VTE risk to&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/norethindrone-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">norethindrone<\/a>&nbsp;and&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/levonorgestrel-systemic-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">levonorgestrel<\/a>. However, there are currently no COCs containing 20 mcg of ethinyl estradiol with norgestimate.<\/li><\/ul>\n\n\n\n<p><strong>Antiandrogens<\/strong>&nbsp;\u2014&nbsp;After six months, if the patient is not satisfied with the clinical response to COC monotherapy (for hyperandrogenic symptoms), we typically add&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/spironolactone-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">spironolactone<\/a>&nbsp;50 to 100 mg twice daily<\/p>\n\n\n\n<p>Other \u00e0<\/p>\n\n\n\n<ul><li><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/finasteride-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">finasteride<\/a>, which inhibits 5-alpha-reductase type 2, the enzyme that converts testosterone to dihydrotestosterone (DHT), and&nbsp;<\/li><li><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/dutasteride-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">dutasteride<\/a>, an inhibitor of both 5-alpha-reductase types 1 and 2. No clinical trial data are available for dutasteride use in hirsute women.<\/li><li><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/cyproterone-united-states-not-available-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">Cyproterone acetate<\/a>&nbsp;<\/li><li>Gonadotropin-releasing hormone (GnRH) agonists are also sometimes used \u00e0 &#8220;add-back&#8221; estrogen-progestin therapy is necessary to avoid bone loss and estrogen deficiency symptoms.<\/li><li>Although some clinicians use&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/metformin-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\"><strong>metformin<\/strong><\/a>&nbsp;to treat hirsutism, the Endocrine Society Clinical Practice <strong>Guidelines suggest against its routine use<\/strong> as it is associated with <strong>minimal or no benefit<\/strong> and is less effective than treatment with COCs&nbsp;and\/or&nbsp;antiandrogens<\/li><\/ul>\n\n\n\n<ul><li>Hirsutism can also be treated by removal of hair by mechanical means such as shaving, waxing, depilatories, electrolysis, or laser treatment.<\/li><li>In addition,&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/eflornithine-united-states-availability-of-intravenous-preparation-limited-to-cdc-and-who-distribution-programs-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">eflornithine<\/a>&nbsp;hydrochloride cream (13.9%) is a topical drug that inhibits hair growth. It is not a depilatory and must be used indefinitely to prevent regrowth.<\/li><\/ul>\n\n\n\n<p><strong>Acne and androgenetic alopecia<\/strong>&nbsp;\u2014&nbsp;management of acne and scalp hair loss (androgenetic alopecia) in women with PCOS<\/p>\n\n\n\n<p><strong>Metabolic abnormalities<\/strong><\/p>\n\n\n\n<p><strong>Obesity<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>Weight loss, which can restore ovulatory cycles and improve metabolic risk, is the first-line intervention for most women.<\/li><li>approach \u00e0starting with lifestyle changes (diet and exercise) \u00e0 followed by pharmacotherapy, and, when necessary, bariatric surgery<\/li><\/ul>\n\n\n\n<p>Even modest weight loss (5 to 10 percent reduction in body weight) in women with PCOS may result in restoration of normal ovulatory cycles and improved pregnancy rates<\/p>\n\n\n\n<p><strong>Bariatric surgery<\/strong>&nbsp;\u2014&nbsp;Bariatric surgery is another strategy for weight loss in women with PCOS.<\/p>\n\n\n\n<p><strong>Insulin resistance\/type 2 diabetes<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>Several drugs, including biguanides (<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/metformin-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">metformin<\/a>) and thiazolidinediones (<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/pioglitazone-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">pioglitazone<\/a>,&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/rosiglitazone-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">rosiglitazone<\/a>), can reduce insulin levels in women with PCOS.<\/p>\n\n\n\n<p>These drugs may also reduce ovarian androgen production (and serum free testosterone concentrations) and restore normal menstrual cyclicity<\/p>\n\n\n\n<p>Though not specifically approved for PCOS,&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/liraglutide-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">liraglutide<\/a>&nbsp;is approved for individuals with a BMI of 30&nbsp;kg\/m<sup>2<\/sup>&nbsp;or greater. Limited data in women with PCOS suggest that liraglutide results in greater weight loss than placebo<\/p>\n\n\n\n<p><strong>Dyslipidemia<\/strong>&nbsp;\u2014&nbsp;The approach to treatment of dyslipidemia in women with PCOS is the same as for other patients with dyslipidemia. Exercise and weight loss are the first-line approach, followed by pharmacotherapy, if needed.<\/p>\n\n\n\n<p><strong>Statins<\/strong>&nbsp;\u2014&nbsp;Statins are effective for dyslipidemia in women with PCOS but do not appear to have other clinically important metabolic or endocrine effects.<\/p>\n\n\n\n<p><strong>Obstructive sleep apnea<\/strong>&nbsp;\u2014&nbsp;Sleep apnea, a common disorder in women with PCOS, is an important determinant of insulin resistance, glucose intolerance, and type 2 diabetes<\/p>\n\n\n\n<p><strong>treatment with continuous positive airway pressure (CPAP)<\/strong> improved insulin sensitivity and reduced diastolic blood pressure<\/p>\n\n\n\n<p><strong>Nonalcoholic steatohepatitis<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>The prevalence of nonalcoholic steatohepatitis (NASH) appears to be increased in women with PCOS. Both weight loss <strong>and&nbsp;<\/strong><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/metformin-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\"><strong>metformin<\/strong><\/a>&nbsp;use appear to improve metabolic and hepatic function in these women<\/p>\n\n\n\n<p><strong>Women pursuing pregnancy<\/strong><\/p>\n\n\n\n<p><strong>Weight loss<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>For anovulatory women with PCOS who are overweight or obese, we suggest weight loss prior to initiating ovulation induction therapy.<\/p>\n\n\n\n<p><strong>Ovulation induction medications<\/strong><\/p>\n\n\n\n<p>\u25cfFor oligoovulatory women with PCOS undergoing ovulation induction,<\/p>\n\n\n\n<p><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/letrozole-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\"><strong>letrozole<\/strong><\/a><strong>&nbsp;as first-line therapy over&nbsp;<\/strong><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/clomiphene-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\"><strong>clomiphene<\/strong><\/a><strong>&nbsp;citrate, regardless of the patient&#8217;s BMI.<\/strong><\/p>\n\n\n\n<p>Before starting letrozole, the clinician&nbsp;<strong>must<\/strong>&nbsp;discuss that this use of the <strong>drug is not approved by the US Food and Drug Administration (FDA) for this purpose and that there is an available alternative (clomiphene citrate).<\/strong><\/p>\n\n\n\n<p>\u25cf<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/clomiphene-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\"><strong>Clomiphene<\/strong><\/a><strong>&nbsp;citrate had been the first-line drug for this population for many years, with&nbsp;<\/strong><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/metformin-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\"><strong>metformin<\/strong><\/a><strong>&nbsp;used as an alternative.<\/strong><\/p>\n\n\n\n<p>However, both clomiphene and metformin appear to be less effective for live birth rates than&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/letrozole-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">letrozole<\/a>&nbsp;<\/p>\n\n\n\n<p>\u25cf<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/metformin-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">Metformin<\/a>&nbsp;\u2013<\/p>\n\n\n\n<p>has been used to promote ovulation either alone or in combination with&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/clomiphene-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">clomiphene<\/a>,<\/p>\n\n\n\n<p>clomiphene or&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/letrozole-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">letrozole<\/a>&nbsp;monotherapy appears to be superior to metformin monotherapy on live birth rates.<\/p>\n\n\n\n<p>Current guidelines recommend against the routine use of&nbsp;<a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/metformin-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\">metformin<\/a>&nbsp;in obese women with PCOS (including ovulation induction), except in women with glucose intolerance who have failed lifestyle interventions<\/p>\n\n\n\n<p>\u25cf<strong>Gonadotropin therapy<\/strong>&nbsp;\u2013<\/p>\n\n\n\n<p>Another method to induce ovulation is administration of exogenous gonadotropins<\/p>\n\n\n\n<p>pulsatile GnRH may be a reasonable option, particularly for lean women with PCOS.<\/p>\n\n\n\n<p>Women with PCOS and anovulatory infertility treated with gonadotropins are at <strong>high risk for ovarian hyperstimulation syndrome (OHSS).<\/strong><\/p>\n\n\n\n<p><strong>Laparoscopic surgery<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<p>In the past, wedge resection of the ovaries was a standard treatment for infertility in women with PCOS. However, this approach has been <strong>abandoned, both because of the efficacy of&nbsp;<\/strong><a href=\"http:\/\/www.uptodate.com.kem.remotexs.in\/contents\/clomiphene-drug-information?search=polycystic+ovarian+syndrome&amp;topicRef=7421&amp;source=see_link\"><strong>clomiphene<\/strong><\/a><strong>&nbsp;and because of the high incidence of pelvic adhesions seen with wedge resection<\/strong>.<\/p>\n\n\n\n<p><strong>In vitro fertilization<\/strong>&nbsp;\u2014&nbsp;If weight loss, ovulation induction with medications,&nbsp;and\/or&nbsp;laparoscopic ovarian laser electrocautery are unsuccessful, the next step is in vitro fertilization<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Polycystic ovary syndrome (PCOS) most common cause of infertility in women PCOS encompasses a spectrum of variably associated clinical features that are not otherwise explained: \u25cfCutaneous signs of hyperandrogenism (eg, hirsutism, moderate-severe acne) \u25cfMenstrual irregularity (eg, oligo- or amenorrhea, or irregular bleeding) \u25cfPolycystic ovaries (one or both) \u25cfObesity and insulin resistance originally was described by[&#8230;]\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/697"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=697"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/697\/revisions"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=697"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=697"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=697"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}