Conventional treatments of PCOS tended to only treat one aspect of the syndrome at a time, such as fertility, acne or hirsuitism. However in the past decade research has come to light on how to treat the most common underlying cause of PCOS, Insulin Resistance. Treatment of Insulin Resistance can be combined with other treatments or used by itself to help all aspects of PCOS.
The best way to manage insulin resistance is lifestyle. Even a small 3-5% weight loss can reduce insulin resistance by 40-60%. If inadequate or unsuccessful, medications may help.
Prior to 1990s PCOS was treated by separating out the symptoms and treating each individual one. Research has led to scientists focusing on what may be the underlying cause of PCOS, insulin resistance. Treatment of the underlying cause therefore benefits all aspects of PCOS rather than the specific targeting on each symptom.
Medications that lower insulin levels in the blood may be effective in restoring menstruation and reducing some of the health risks associated with PCOS. It can also lead to the reduction of testosterone, thus diminishing many of the symptoms associated with excess testosterone: hair growth on body, alopecia (hair loss on head), acne, obesity and cardiovascular risk.
In Australia, a drug called metformin is now being used to treat some women with PCOS, and research about its effectiveness is being conducted in a number of states. Metformin improves both glucose tolerance and insulin sensitivity. It is approved by the Australian federal drug authority as a treatment for diabetes, however is not registered as a treatment for PCOS. Even though it is not listed as a treatment for PCOS, many doctors are comfortable with and supportive of its use in PCOS give international research and documented effects of the drug. It is hoped in the next few years after more studies are conducted that metformin will be a registered treatment for PCOS.
Metformin is prescribed under many different brand names and, it is available in 500mg, 850mg & 1000mg tablets. The therapeutic dose for PCOS has been found to be around 1500mg. Metformin is available as a normal or extended release preparation.
Approximately 30% of patients started on metformin will experience gastrointestinal symptoms (diarrhoea, nausea, vomiting, abdominal bloating, flatulence, and loss of appetite). These symptoms are usually temporary (1-4 weeks) and will disappear during continued therapy. It is advisable for new patients to initiate therapy slowly to minimize the gastrointestinal side effects. For example half a 500mg tablet for 2 weeks, 500mg for 2 weeks, 1g for 2 weeks then 1500mg.
There are 3 main treatments for women suffering from acne due to PCOS, the pill, Spironolactone (Aldactone) and Roaccutane. Oral contraceptive pills help reduce the testosterone and therefore helps control acne and hirsutism of PCOS. If not found to be adequate to control the acne it can be prescribed by itself or other drugs can be used such as Roaccutane or Spironolactone. Spironolactone works as an anti androgen, it can be used to treat acne and hirsutism caused by high testosterone. Keep in mind that the pill takes up to 6-12 months to redress excess hair so wait before adding other treatments. Aldactone should ideally only be used with the pill or other contraception or it can cause irregular menstrual cycles and can harm your baby if you are on it when you are pregnant.
Roaccutane is used for severe cases of acne. It cannot be used by women who are trying to conceive as it can cause defects to fetuses. It is usually taken for 4-7 months and then stopped once the acne is under control. Roaccutane works by reducing sebum production and shrinking the sebaceous glands. Treated skin is dry, inhibiting the growth of bacteria.
It can cause a number of side effects that can be unpleasant (extremely dry skin, eczema, increased susceptibility to sunburn, hair loss, fragile skin etc).
Hirsuitism is excess body hair, such as on chins, chest and necks. This hair is different from the hair that some women have on their upper lip, chin, breasts, stomach or the fine "baby" hair all over their body, tending to be longer and more coarse.
Hirsuitism is caused by hair follicles that are overly sensitive to male hormones (called androgens), or when there are abnormally high levels of these hormones as is the case with PCOS. Treatment is usually various types of antiandrogens which reduce the testosterone levels which cause the male like hair growth.
Cosmetic Treatments (first line)
- Laser – effective but can be costly and may cause hyperpigmentation. Most suited to pale skinned, dark haired women.
- Electrolysis - can cause scarring.
- Diet - exercise to keep weight off, and low carbohydrate diets mean less excess insulin is produced thus reducing the amount of androgens in the body.
Doctors can prescribe medicine to decrease excess hair growth. However, depending on the medicine, it will usually takes six to twelve months to work and may only decrease the amount of new hair growth. Existing hairs may have to be removed by electrolysis or laser.
Oral contraceptives inhibit ovarian steroid production with consequent effectively reduced hair growth. In higher dose pills, they contain a small amount of the anti-androgen Cyproterone Acetate in combination with the normal pill hormones. The use of higher dose pills to treat the cosmetic consequences of PCOS is questioned in research as oral contraceptives can cause weight gain, which could aggravate the PCO at a later stage; they have the potential to increase the number of ovarian cysts; and there are concerns that oral contraceptives may result in a deterioration in glucose tolerance. However increasing evidence suggests lower dose (20ug) pills are equally effective but have less side effects.
- Metformin increases the effectiveness of insulin at the peripheral cell level, reduces hyperinsulinemia, and reduces hyperandrogenemia in turn, thus correcting this biochemical domino effect by correcting it at the source. Evidence shows metformin doesn’t decrease weight generally although it may help individual women, however overall it does help prevent weight gain though, and may lose the extra body hair (caused by high testosterone).
- Spironolactone (Aldactone) is a powerful anti-androgen reducing body hair growth over time and is also used to treat alopeocia. It can only be used by women who aren't trying to conceive a baby as it can cause defects in a developing foetus and should be used with the pill or contraception.
- Cyproterone is another anti-androgen available, considered as effective as spironalactone. It can cause weight gain and may cause depression.