Treatment of polycystic ovary syndrome in adults
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- David A Ehrmann, MD
David A Ehrmann, MD
- Professor of Medicine
- University of Chicago
The polycystic ovary syndrome (PCOS) is an important cause of both menstrual irregularity and androgen excess in women. When fully expressed, the manifestations include irregular menstrual cycles, hirsutism, obesity, insulin resistance, and anovulatory infertility.
The treatment of PCOS will be reviewed here. The epidemiology and pathogenesis, diagnostic criteria, and clinical manifestations of PCOS are described in detail separately. (See "Epidemiology and pathogenesis of the polycystic ovary syndrome in adults" and "Diagnosis of polycystic ovary syndrome in adults" and "Clinical manifestations of polycystic ovary syndrome in adults".)
OVERVIEW OF APPROACH
Women with polycystic ovary syndrome (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. Our overall approach is similar to that described by the 2013 Endocrine Society Clinical Guidelines .
Goals — The overall goals of therapy of women with PCOS include:
●Amelioration of hyperandrogenic symptoms (hirsutism, acne, scalp hair loss)
- Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2013; 98:4565.
- Moran LJ, Hutchison SK, Norman RJ, Teede HJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2011; :CD007506.
- Dumesic DA, Lobo RA. Cancer risk and PCOS. Steroids 2013; 78:782.
- Moghetti P, Castello R, Negri C, et al. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin Endocrinol Metab 2000; 85:139.
- Unlühizarci K, Keleştimur F, Bayram F, et al. The effects of metformin on insulin resistance and ovarian steroidogenesis in women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 1999; 51:231.
- Legro RS, Zaino RJ, Demers LM, et al. The effects of metformin and rosiglitazone, alone and in combination, on the ovary and endometrium in polycystic ovary syndrome. Am J Obstet Gynecol 2007; 196:402.e1.
- Tang T, Lord JM, Norman RJ, et al. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev 2012; :CD003053.
- Martin KA, Chang RJ, Ehrmann DA, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008; 93:1105.
- Pasquali R, Gambineri A, Cavazza C, et al. Heterogeneity in the responsiveness to long-term lifestyle intervention and predictability in obese women with polycystic ovary syndrome. Eur J Endocrinol 2011; 164:53.
- Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F, et al. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. J Clin Endocrinol Metab 2005; 90:6364.
- Harrison CL, Lombard CB, Moran LJ, Teede HJ. Exercise therapy in polycystic ovary syndrome: a systematic review. Hum Reprod Update 2011; 17:171.
- Pasquali R, Antenucci D, Casimirri F, et al. Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol Metab 1989; 68:173.
- Kiddy DS, Hamilton-Fairley D, Bush A, et al. Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 1992; 36:105.
- Huber-Buchholz MM, Carey DG, Norman RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab 1999; 84:1470.
- Crosignani PG, Colombo M, Vegetti W, et al. Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and fertility rate induced by diet. Hum Reprod 2003; 18:1928.
- Tang T, Glanville J, Hayden CJ, et al. Combined lifestyle modification and metformin in obese patients with polycystic ovary syndrome. A randomized, placebo-controlled, double-blind multicentre study. Hum Reprod 2006; 21:80.
- Moran LJ, Noakes M, Clifton PM, et al. Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003; 88:812.
- Dunaif A, Scott D, Finegood D, et al. The insulin-sensitizing agent troglitazone improves metabolic and reproductive abnormalities in the polycystic ovary syndrome. J Clin Endocrinol Metab 1996; 81:3299.
- Ehrmann DA, Schneider DJ, Sobel BE, et al. Troglitazone improves defects in insulin action, insulin secretion, ovarian steroidogenesis, and fibrinolysis in women with polycystic ovary syndrome. J Clin Endocrinol Metab 1997; 82:2108.
- Nestler JE, Jakubowicz DJ, Reamer P, et al. Ovulatory and metabolic effects of D-chiro-inositol in the polycystic ovary syndrome. N Engl J Med 1999; 340:1314.
- Sepilian V, Nagamani M. Effects of rosiglitazone in obese women with polycystic ovary syndrome and severe insulin resistance. J Clin Endocrinol Metab 2005; 90:60.
- Brettenthaler N, De Geyter C, Huber PR, Keller U. Effect of the insulin sensitizer pioglitazone on insulin resistance, hyperandrogenism, and ovulatory dysfunction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2004; 89:3835.
- Ortega-González C, Luna S, Hernández L, et al. Responses of serum androgen and insulin resistance to metformin and pioglitazone in obese, insulin-resistant women with polycystic ovary syndrome. J Clin Endocrinol Metab 2005; 90:1360.
- Rautio K, Tapanainen JS, Ruokonen A, Morin-Papunen LC. Endocrine and metabolic effects of rosiglitazone in overweight women with PCOS: a randomized placebo-controlled study. Hum Reprod 2006; 21:1400.
- Godsland IF, Walton C, Felton C, et al. Insulin resistance, secretion, and metabolism in users of oral contraceptives. J Clin Endocrinol Metab 1992; 74:64.
- Pasquali R, Gambineri A, Anconetani B, et al. The natural history of the metabolic syndrome in young women with the polycystic ovary syndrome and the effect of long-term oestrogen-progestagen treatment. Clin Endocrinol (Oxf) 1999; 50:517.
- Korytkowski MT, Mokan M, Horwitz MJ, Berga SL. Metabolic effects of oral contraceptives in women with polycystic ovary syndrome. J Clin Endocrinol Metab 1995; 80:3327.
- Cibula D, Sindelka G, Hill M, et al. Insulin sensitivity in non-obese women with polycystic ovary syndrome during treatment with oral contraceptives containing low-androgenic progestin. Hum Reprod 2002; 17:76.
- Costello MF, Shrestha B, Eden J, et al. Metformin versus oral contraceptive pill in polycystic ovary syndrome: a Cochrane review. Hum Reprod 2007; 22:1200.
- Raval AD, Hunter T, Stuckey B, Hart RJ. Statins for women with polycystic ovary syndrome not actively trying to conceive. Cochrane Database Syst Rev 2011; :CD008565.
- Tasali E, Chapotot F, Leproult R, et al. Treatment of obstructive sleep apnea improves cardiometabolic function in young obese women with polycystic ovary syndrome. J Clin Endocrinol Metab 2011; 96:365.
- Gangale MF, Miele L, Lanzone A, et al. Long-term metformin treatment is able to reduce the prevalence of metabolic syndrome and its hepatic involvement in young hyperinsulinaemic overweight patients with polycystic ovarian syndrome. Clin Endocrinol (Oxf) 2011; 75:520.
- Brown AJ, Tendler DA, McMurray RG, Setji TL. Polycystic ovary syndrome and severe nonalcoholic steatohepatitis: beneficial effect of modest weight loss and exercise on liver biopsy findings. Endocr Pract 2005; 11:319.
- Zhuang J, Wang X, Xu L, et al. Antidepressants for polycystic ovary syndrome. Cochrane Database Syst Rev 2013; :CD008575.
- Domecq JP, Prutsky G, Mullan RJ, et al. Adverse effects of the common treatments for polycystic ovary syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab 2013; 98:4646.
- Bates GW, Whitworth NS. Effect of body weight reduction on plasma androgens in obese, infertile women. Fertil Steril 1982; 38:406.
- Guzick DS, Wing R, Smith D, et al. Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil Steril 1994; 61:598.
- Legro RS, Dodson WC, Kunselman AR, et al. Benefit of Delayed Fertility Therapy With Preconception Weight Loss Over Immediate Therapy in Obese Women With PCOS. J Clin Endocrinol Metab 2016; 101:2658.
- Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril 2008; 89:505.
- Kelly AC, Jewelewicz R. Alternate regimens for ovulation induction in polycystic ovarian disease. Fertil Steril 1990; 54:195.
- White DM, Polson DW, Kiddy D, et al. Induction of ovulation with low-dose gonadotropins in polycystic ovary syndrome: an analysis of 109 pregnancies in 225 women. J Clin Endocrinol Metab 1996; 81:3821.
- Ghazeeri G, Kutteh WH, Bryer-Ash M, et al. Effect of rosiglitazone on spontaneous and clomiphene citrate-induced ovulation in women with polycystic ovary syndrome. Fertil Steril 2003; 79:562.
- Yilmaz M, Karakoç A, Törüner FB, et al. The effects of rosiglitazone and metformin on menstrual cyclicity and hirsutism in polycystic ovary syndrome. Gynecol Endocrinol 2005; 21:154.
- Baillargeon JP, Jakubowicz DJ, Iuorno MJ, et al. Effects of metformin and rosiglitazone, alone and in combination, in nonobese women with polycystic ovary syndrome and normal indices of insulin sensitivity. Fertil Steril 2004; 82:893.
- Gill S, Taylor AE, Martin KA, et al. Specific factors predict the response to pulsatile gonadotropin-releasing hormone therapy in polycystic ovarian syndrome. J Clin Endocrinol Metab 2001; 86:2428.
- OVERVIEW OF APPROACH
- Lifestyle changes
- Oral contraceptives and risk assessment
- WOMEN NOT PURSUING PREGNANCY
- Menstrual dysfunction
- - Endometrial protection
- Androgen excess
- - Hirsutism
- - Choice of oral contraceptive
- - Antiandrogens
- - Other
- - Acne and androgenetic alopecia
- Metabolic abnormalities
- - Obesity
- Weight reduction
- - Bariatric surgery
- Insulin resistance/type 2 diabetes
- Metabolic effects of OCs in PCOS
- - Dyslipidemia
- - Obstructive sleep apnea
- - Nonalcoholic steatohepatitis
- WOMEN PURSUING PREGNANCY
- Weight loss
- Laparoscopic surgery
- In vitro fertilization
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS