Weight loss and Diet
If overweight or obese weight loss must be the starting point as it helps to reduce the insulin levels and improve the overall hormone imbalance. Ideally the body mass index (BMI) should be 20-25 (BMI = W/H2, W is weight in Kg and H is height in metres). Symptoms will improve significantly and may even disappear with weight loss. In some cases this may be the only treatment needed to restore ovulation and regular periods.
The most appropriate diet for women with PCOS is one that promotes more stable levels of blood sugar and lower levels of insulin. The standard low fat, high carbohydrate weight loss diet is not ideal. High intakes of carbohydrates, especially refined carbohydrates - like sweets, white bread, white rice, etc. - will quickly turn to sugar and cause elevated levels of insulin. A low glycaemic index diet which will not cause a rapid rise in blood sugar is better for women with PCOS.
Carbohydrates should be spaced throughout the day to avoid peaks in blood sugar and insulin production. Importantly, carbohydrates should be combined with proteins and/or fat rather than be eaten alone. It is also best to avoid carbohydrates that trigger more hunger or cravings.
Drugs may be used to aid weight loss. These act by either reducing gastro-intestinal absorption of fats (Orlistat) or by suppressing appetite in the brain (Sibutramine). In severe cases of obesity, the gastric bypass and other similar approaches should be considered.
The combined oral contraceptive pill (COC) is given to regulate the menstrual cycle and to reduce the risk of endometrial cancer (cancer of the lining of the womb). The COC pill causes elevated circulating levels of sex hormone binding globulin (SHBG) in the blood which works 'mopping' up the androgens, resulting in improvements in the symptoms of acne and unwanted excessive hair.
Dianette is a hormone preparation containing the anti-androgen cyproterone acetate (CPA). Dianette is not licensed as a contraceptive but solely for treatment of acne and/or hirsutism. There is a small risk of deep venous thrombosis (DVT) and it is advisable to consider changing treatment 6 months after symptoms have improved. An individual risk assessment needs to be made taking into account all the important factors. Some women may choose to take Dianette long term if other options are not suitable. CPA may take 6-12 months to improve symptoms. In some severe cases, additional CPA can be added on day 5-15 of the menstrual cycle.
Yasmin is another hormonal contraception that contains ethinylestradiol (synthetic form of oestrogen) and drospirenone (synthetic form of progesterone). This preparation is taken exactly the same as the pill.
Metformin is a type of drug known as insulin-sensitising agent which increases the sensitivity of the tissues to insulin, reduces insulin levels in the blood stream and indirectly reduces excess androgen levels. It may therefore restore ovulation, regular menstruation and improve symptoms such as acne and hirsutism in some cases. Metformin should only be prescribed to women with a BMI less than 30 kg/m2. A small number of patients taking Metformin, will discontinue treatment complaining of abdominal cramps, nausea and other gastrointestinal side effects. To avoid this it is recommended to take Metformin always at the time of the main meals.
Other anti-androgen treatments
The diuretic drug Spironolactone has anti-androgen properties. It is useful in women unable to take the COC or Metformin but it should not be taken if trying to conceive. Side effects may include gastro-intestinal disturbance and frequent periods. Finesteride is a powerful anti-androgen usually used to treat male-pattern baldness and overgrowth of the prostate in men. Although the manufacturer does not license it for use in PCOS, it is used in specialist clinics. It is particularly useful in resistant cases with good results and has few side effects. Finesteride should not be taken if trying to conceive.
Eflornithine HCl Cream (Vaniqa®) is an effective non-hormonal approach to helping women with increased facial hair. It works directly to slow hair growth by inhibiting the enzyme ornithine decarboxylase (ODC). When this enzyme is blocked metabolic activity in the hair follicle decreases and hair growth is slowed down. Vaniqa® does not remove hair therefore it needs to be used in combination with a removal method. The studies so far have looked at facial and neck hair only, so Vaniqa® is not indicated for body use.
Cosmetic treatment can be used in addition to or as an alternative to medical drug treatments for excessive hair growth. Alternatives include plucking, shaving, waxing, electrolysis and laser treatments. All improve symptoms.
Lack of ovulation is treated initially with up to six cycles of clomiphene citrate (Clomid®). This acts by blocking the oestrogen receptors, which in turn increases the levels of follicle stimulating hormone (FSH). FSH promotes follicle recruitment and development within the ovary. The first cycle of treatment with clomiphene should be monitored with ultrasound scan to confirm follicular response to treatment and to reduce the risk of multiple pregnancy (10%). If there is an over response to the treatment and more than 2 follicles are produced the treatment cycle should be abandoned. Clomiphene should not normally be used for more than 9-12 cycles because of the very limited benefits which have to be balanced against the small risk of ovarian cancer with prolonged exposure. Clomiphene should also not be used in women who have normal regular ovulatory periods as it does improve outcomes.
Some women with PCOS are resistant to treatment with clomiphene. In these cases alternatives include: ovarian drilling which involves making four small holes in the ovary using a needle that carries electricity (diathermy) performed at the time of laparoscopy (keyhole surgery), gonadotrophins (FSH/LH) injections alone or in an assisted conception programme (intrauterine insemination -- IUI or in vitro fertilisation -- IVF).
Ovulation induction with gonadotrophins should be carried out in a specialist fertility centre. Investigations on behalf of both partners to exclude other co-existing causes of infertility should be considered before starting treatment.