Polycystic Ovary Syndrome

Women's Corner - Syndromes
Polycystic Ovary Syndrome

By: Abdel-Maguid Ismail Ramzy, M.D.
Ass. Prof. Of Obstetrics and Gynaecology, Cairo University.
Consultant R

Hormonal therapy

Although doomed with myths, hormonal therapy remains the mainstay for the treatment of hormonal disturbances. In PCOS, the key issue is to cut down the high levels of LH. This will decrease the secretion of androgens from the ovary. Together with loosing some of the body fat will eventually decrease the estrogen production and relief the FSH from the high negative feed back. This will break the cycle and ovulation will soon ensue.
However as any other medications, hormonal medication should be exercised with utmost caution and after excluding contraindications for its use. The physician should be experienced in the treatment with such hormones whether used simply or in combinations. He should always update himself with the most recent products. He should also be aware of its complications, side effects and draw backs. The patient should be properly oriented with these side effect and properly counseled on what to expect as signs of improvement or failure of treatment.
The question now is which hormone to use for which patient?
A young girl with menstrual irregularities and hirsutism may be best treated with low dose, low androgenic combined oral contraceptive pills (OC). This will suppress the LH production from the pituitary. The patient will resume cyclicity and will soon notice gradual improvement of hirsutism. A word of caution here is that the hair cycle is around 3 months. So to expect break through improvement before this time is unlikely. She will first feel improvement in hair colour and texture. Later on the rate of hair production will eventually decrease.
In the treatment of PCOS in a patient not seeking fertility and in which hirsutism is not a prominent feature of the disease, gestagen (synthetic progesterones) may have a stand. This may be used 3 weeks out of every month. Gestagens will help maintain cyclic bleeds and will not arrest ovulation. Side effects include weight gain, bloating and mood changes (depression). They will oppose the effect of estrogen on the endometrium and will prevent endometrial over activity and the chance of developing endometrial carcinoma.
Ciproterone acetate is not a hormone, it is considered an anti-hormone. It acts as an anti-androgen at the receptor level. It helps improve hirsutism. It should not be used in patients seeking fertility as they are teratogenic if continued through a missed early pregnancy.
Spironolactone is a diuretic that antagonises the effect of androgens at the receptor level. It has been used and proved effective in some of PCOS cases with evident hirsutism
Ketoconazole is an anti-fungal medication that has been found to be a enzyme blocking agent preventing the synthesis of dihydro-testosterone. This is the final effective product that sustains significant hair formation.
Insulin Sensitising Medications such as Metformin and relate compound are used since a long time as oral hypoglycaemic medicaments. It was not until recently that their positive effect as insulin sensitisers at the ovarian level have been discovered. Based on the fact that PCOS may be initiated by a condition of insulin resistance augmented by obesity, metformin has been suggested as a treatment option in oloigohypomenorrhoeic, hyperandrogenic obese patients with PCOS. Metformin is best used together with calorie limiting diets. The medical literature repeatedly reported success with such regimens in achieving pregnancy in PCOS patients. Some authors even stressed on continuing such regimen well into pregnancy to decrease the otherwise higher abortion rates.
Corticosteroids may be used but only to a limited extent. Clinically the candidates are those PCOS who show evident signs of hyperandrogenism (baldness, hirsutism, ..etc.). Corticosteroids suppresses androgens secreted from the suprarenal glands. The precursor of adrenal androgens is dihydroepiandrosterone sulphate (DHEA-S). The physician should first assess the DHEA-S levels in blood before the initiation of corticosteroid therapy. Corticosteroids (dexamethasone) are prescribed as a single bed time dose (0.5-0.75 mg) whenever DHEA-S levels are found to be elevated. Controversy in the medical literature exists on the use of corticosteroids in cases of PCOS.

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