PCOS (Polycystic Ovary Syndrome) - Women's Health
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Treatments for PCOS
Although the exact cause for PCOS is unknown, significant aspects of the mechanism of the condition are known, and therefore treatments can be directed at modifying these. In other words there is no known treatment for the underlying condition, but much can be done to alleviate the symptoms. In this regard treatment needs to be individualized to the patient’s presenting symptoms, as detailed below.
(i) Menstrual disturbance
The birth control pill is an effective treatment for the menstrual disturbance seen in women with PCOS, providing regular menstruation, alleviating heavy menses and providing contraception – it is well to remember that NOT ALL WOMEN WITH PCOS ARE SUBFERTILE!. When given to teenagers, who might have menstrual disturbance not necessarily due to PCOS, the diagnosis of PCOS may often be delayed until after the pill is discontinued. There are types of the combined oral contraceptive pill that particularly suit women with PCOS, as they not only control the menstrual disturbance, but they also address the problems of acne and hirsutism. An example of such a pill in the UK is Dianette. It is taken in exactly the same way as any other combined oral contraceptive pill.
(ii) Subfertility
The good news is that the majority of women with PCOS who do not ovulate spontaneously readily respond to ovulation stimulation with simple drugs such as clomid (clomiphene citrate). Some women are resistant to clomid, and other oral medications such as a group of drugs called aromatase inhibitors may be more effective – an example of such drugs is one called Letrozole. These medications have minimal side-effects, and are highly effective. For those who fail to respond will require more powerful ovulation induction drugs. It is rare for a PCOS woman to fail to respond altogether. Some who require powerful ovulation induction medication may also require in-vitro fertilization (test-tube baby treatment) as it is not uncommon that other causes of subfertility may also be present. Surgery in women with PCOS: In women who fail to respond to medication in attempts to induce ovulation, “ovarian drilling” is often an effective surgical treatment performed via key-hole surgery. Laser or diathermy is used to puncture tiny holes into the substance of the ovary. It is not fully understood how this works, but reduction in volume of the tissue substance of the ovaries may reduce androgen levels, leading to ovulation. All treatments for inducing ovulation, even the simple ones with clomid, should be monitored by a specialist. Ultrasound is required, and sometimes hormonal measurements too are necessary. The important point to remember is that fertility prospects in women with PCOS are good!
(iii) Changes in hair growth (hirsutism and hair loss)
Excess body hair can become the bain of many a woman with PCOS, especially the young who tend to be very self-conscious, and lose self-confidence. There are many treatment options, but unfortunately no permanent cure. As indicated above, the oral contraceptive pill Dianette and similar preparations kill several birds with one stone – regulating the menses, addressing the acne as well as reducing excess body hair. With regard to the hirsutism, it is important to recognize that it can take 3-4 months before any benefits become apparent, and the effects may not be as dramatic as some may wish. There is a wide range of other treatment options including waxing, electrolysis, shaving, and special creams (such as Vaniqua cream) that attack the hair follicles. Different treatments may suit different women, and it may be a matter of trial and error to find the treatment that suits a particular individual. GP’s, dermatologists,gynaecologists, skin and hair clinics etc are all sources of advice and treatment.
(iv) Skin problems
Acne is a particular problem for a teenager with PCOS, although it also well to remember that not every teenager with acne has PCOS. There are again a variety of effective treatments. Dianette can have dramatic results on facial acne, as well as spots on the back and front of the chest. It has the other advantages of acting on other symptoms already referred to above. Low dose antibiotics are also often used as low-grade infections may worsen the appearance of the acne, and nowadays some of preparations containing these antibiotics can be purchased over the counter (ie do not require a doctor’s prescription). Skin tags can be readily excised under local anaesthetic in outpatients – dermatologists usually offer this service.
(v) Obesity
Weight loss can be very challenging for women with PCOS, yet if successful it has a profound and positive impact on many aspects of the symptoms of PCOS. Unfortunately there is no one-shot, sure fire answer: success comes from a combination of strict calorie reduction, exercise and sometimes the addition of the diabetes drug metformin, as part of a supervised programme.
Importance of weight loss in women with PCOS:
Approximately 50-60% of women with PCOS are obese based n their BMI. Being obese worsens the symptoms of PCOS (including irregular menses and subfertility), increases the risk of diabetes, increases cholesterol levels and the risks of heart disease. Obese women with PCOS are seven times more likely to develop diabetes or heart disease because of insulin resistance. This means that their body does not respond to normal levels of the hormone insulin, a hormone critical for normal bodily functions, and whose absence causes what is known as type 1 diabetes. In type 2 diabetes (usually seen in adults) the levels of insulin are normal or even higher than normally, but the cells of the body have become insensitive (hence the need for higher levels of insulin!). The insulin resistance in women with PCOS causes the levels of cholesterol to rise, while the insulin resistance itself pre-disposes to diabetes. To compound matters, the insulin resistance contributes to weight gain and makes losing weight difficult, thus creating a vicious cycle.
Impact of weight loss in PCOS women:
Weight loss results in more regular menses, more regular ovulation, reduction in hirsutism and skin problems, more stable hormone levels and a reduction in the risks of both diabetes and heart disease. Thus weight loss is a topic of major importance in women with PCOS. Current approaches include a healthy diet, regular exercise and when necessary the addition of metformin.
It is very encouraging to note that a woman with PCOS trying to lose weight will often notice a significant improvement in PCOS symptoms with as little as 5-10% loss. Of course the goal should be to aim for weight to be within the normal range for height, but this should be seen as a life-long goal.
Approaches to losing weight in women with PCOS:
Diet: Women with PCOS are usually recommended low glycaemic index diets ie foods that do not cause high and sustained levels of insulin. Low carbohydrate diest are therefore the norm, although extreme diets that cut out all carbohydrate are unwise as they tend to cntain too much saturated fats, which may increase the risk of heart disease. The key is to have diets containing the right kind of carbohydrates, rather than trying to cut out carbohydrates altogether eg whole grain carbohydrates, which contain more fibre and take longer for the body to turn into sugar have a low glycaemic index when compared to starchy, processed carbohydrates, which stimulate high insulin secretion. Often many women will need some guidance from a nutritionist to understand the correct balance of carbohydrate intake relative to other food stuffs, but a simple rule of thumb is that reducing daily carbohydrate intake to 40% of the diet often achieves the desired results. A monitoring of the impact of reducing the carbohydrate (such as a change in PCOS symptoms) will indicate if the diet is achieving the desired effect. Calorie intake also needs to be reduced, since excessive calories, whatever their source, will cause weight gain!
• Exercise
A prudent diet works hand-in-glove with exercise to achieve and sustain weight loss. Joining a gym and engaging in aerobic exercises helps burn calories and contribute to weight loss. Trying to exercise alone at home is often futile, and a gym or exercise group affords much needed psychological support as one often finds that there are other women facing even greater challenges, and the camaraderie that comes from shared endeavors also helps weight loss.
• Metformin
This is a drug usually used to lower blood sugar in people with type II diabetes. It works by sensitizing the body to insulin, and because women with PCOS often have insulin insensitivity, metformin, in combination with a prudent diet and regular exercise, will help many women to lose weight. However, this is a drug which can have side-effects, and for safety it should be supervised by a doctor, who will explain risks and benefits.
Alternative therapies for PCOS
A variety of alternative therapies have been advocated for the treatment of PCOS, but there are often no adequate research data to substantiate the claims of success often made by enthusiasts. Many centre around dietary maneuvers – and of course prudent diets are bound to work for the reasons already explained above. Other approaches include the use of acupuncture, and many women report benefits. The important point to make regarding alternative therapies is to avoid those that could potentially cause harm. To this end it seems that a variety of diets and /or acupuncture are likely not to cause any harm.
Prognosis in women with PCOS
It is now widely recognized that PCOS has significant long-term implications for sufferers because of the insulin resistance found in 75% of obese PCOS women and at least 30% of non-obese PCOS sufferers. This puts these women at risk of developing type II diabetes, and linked to these are a whole range of potential complications of diabetes; and an increased risk of heart disease. Such women also have an increased risk of developing diabetes during pregnancy (referred to in medical terminology as “gestational diabetes or GDM). Weight loss is a major and effective tool in combating the risks associated with insulin resistance.
• Role of insulin and insulin resistance
Insulin is a hormone released from the pancreas after a meal and regulates how the body handles carbohydrates. When carbohydrates are eaten, the body digests them and breaks them down into glucose, a sugar that readily provides energy to the body. In response to rising glucose levels, the pancreas secretes insulin, which works to move the glucose around to different parts of the body. In women with PCOS the cells of the body appear to be “insensitive” to insulin, so that the pancreas has to secrete more insulin to compensate. The resultant excessively high levels of insulin can cause further health problems, as well as directing affecting the ovaries by preventing ovulation and causing the high levels of androgens described above, and causing the some of the symptoms already described. The long-term risks of PCOS are related to both the high insulin levels and the high androgen levels. In addition to diabetes and heart disease, women with PCOS are also at increased risk of developing cancer of the womb (endometrial carcinoma). This is, in part, due to high levels of the hormone oestrogen, which over-stimulates the lining of the womb in the absence of progesterone.
• Minimising the long-term risks of PCOS
Studies suggest that the use of Metformin may be beneficial. This drug “sensitizes” the body to insulin, therey reducing the insulin levels and the consequences of high insulin levels. Androgen levels are thus reduced, leading to fewer hormone-related PCOS symptoms (including increasing fertility and inducing regular menses) and reducing the risks of heart disease.
If you have any queries regarding the topics raised within this article please do not hesistate to contact the Women's Health Clinic via the email form at the bottom of the page or by calling our London clinic on 020 8947 9877.
