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Polycystic Ovary Syndrome: Treatment Option Pros and Cons

Polycystic Ovary Syndrome: Treatment Option Pros and Cons

Adolescents with polycystic ovary syndrome (PCOS) are at risk for such complications as dyslipidemia, hypertension, type 2 diabetes mellitus (DM), and potentially coronary artery disease (CAD). Prompt diagnosis is crucial, as are therapeutic efforts to establish healthy diet and exercise habits. This is the second of 2 articles on PCOS in adolescents and is an update to a previous report on this subject. In part 1 we focused on PCOS diagnosis. Here we concentrate on treatment options and outline management strategies that can reduce symptoms and associated long-term health risks. Among the most important clinical updates in the management of adolescent PCOS is the growing recognition that the levonorgestrel intrauterine device (LNG-IUD) is a suitable treatment for dysfunctional uterine bleeding associated with the syndrome.

MANAGEMENT
Patient education and lifestyle modification are crucial to addressing the acute presenting symptoms and ameliorating the associated long-term health risks. Acute symptoms of PCOS can be managed primarily with combined oral contraceptives (OCs) and antiandrogens. In addition to OCs, multiple delivery systems (transdermal contraceptive patch and vaginal contraceptive ring) of combined hormonal contraceptives achieve similar treatment results in adolescents. Insulin sensitizing drugs are best incorporated into the treatment of adolescents with DM and could contribute to the management of impaired glucose tolerance. Given the broad range of symptoms in affected patients, a multidisciplinary approach to treatment is generally required.

Obesity. Weight reduction is the central component of treatment of overweight patients with PCOS.1 Weight loss ameliorates many of the associated endocrine derangements, including insulin resistance, depressed sex hormone–binding globulin (SHGB) levels, and hyperandrogenism. Modest weight reduction of 2% to 5% of total body weight has been shown to improve cycle regularity and reduce free testosterone indices.2,3 The most effective approach appears to be a combination of caloric restriction, exercise, and behavior modification. Low-carbohydrate diets do not appear to confer a distinct metabolic benefit over other types of diets.4 Weight loss should be emphasized, regardless of whether medications are incorporated into treatment.

Hirsutism and acne. Effective treatment of hirsutism in PCOS requires a multimodal approach, including reduction of androgen synthesis, blocking androgen action, and mechanical removal of excess hair. The medications described here for hirsutism do not eliminate established hair, but rather reduce new hair growth. Thus, when only medical management is used, up to 6 months may pass before a significant change in hair distribution is noted.2,5 The incorporation of mechanical treatments (eg, electrolysis, depilatories, and laser hair removal) with medical therapy can be extremely beneficial. Only one of the medications described below (eflornithine) is FDA-approved for the treatment of hirsutism but all have demonstrated efficacy. The absence of pregnancy must be confirmed before initiation of any medical treatments and a reliable contraceptive method must be used in combination with these drugs.

Androgen suppression. Combination OCs are first-line therapy for acne and hirsutism because they safely diminish androgen production through several mechanisms. Transdermal and vaginal contraceptives reduce androgen levels through identical mechanisms. Specifically, OCs diminish ovarian androgen production by suppressing pituitary gonadotropins and by up-regulation of SHBG, which binds bioactive free testosterone. Both of these actions reduce the amount of testosterone available to stimulate terminal hair growth and cause acne.1,2,5,6 In addition, OCs reduce androgen production from the adrenal gland by an as yet unspecified mechanism.5

In addition to cosmetic benefits, OCs regulate menstrual bleeding, reduce the likelihood of endometrial hyperplasia, and are effective contraception for sexually active teenagers.1,2

The potential deterioration of insulin sensitivity in adolescents with PCOS using OCs has been suggested. However, to date, a substantial clinical risk has not been confirmed, and the clear benefits of OCs overshadow this possibility.6,7 An OC containing a minimally androgenic progestin, such as norgestimate or desogestrel is a preferred initial treatment option. Of note, etonogestrel, the progestin in the contraceptive vaginal ring is the active metabolite of desogestrel; norelgestromin the progestin in the contraceptive path is the active metabolite of norgestimate. Drospirenone, an analogue of spironolactone, is available in combination OCs (Yasmin) and may prove to be of particular benefit in patients with PCOS.6 When OCs are contraindicated or declined by the patient, medroxyprogesterone acetate may be used as an alternative to reduce androgen levels. We recommend the intramuscular route of administration (depot medroxyprogesterone acetate, 150 mg IM every 3 months), which also provides excellent contraception. Compared with OCs, the relative efficacy of medroxyprogesterone acetate to control excess hair growth may be limited by a less dramatic impact on SHBG and free testosterone levels.2,8

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