The treatment for polycystic ovarian syndrome (PCOS) is aimed at the symptoms. There are treatments for the anovulatory bleeding pattern, for the abnormal hair growth (hirsutism), and for the obesity. None of the treatments cures the problems but they help to alleviate the symptoms.
The treatment for anovulatory or irregular bleeding depends on the fertility desires of the individual woman with PCOS. In a woman that does not wish to be pregnant, hormonal contraceptive agents are the mainstay of treatment. Birth control pills, the birth control patch, and the birth control ring are are equivalent. These agents all have similar medications, they just deliver the medication to the body in different ways. These hormaonal contraceptive agents will make the periods regular and light and protect the endometrium from developing uterine cancer. They can also slow the abnormal hair growth that is often a problem in PCOS. The Mirena IUD, the contraceptive patch, and the contraceptive injection will also help stabalize the abnormal bleeding but will not give the benefit of reducing abnormal hair growth.
In women who do not desire to be pregnant but do not want birth control cycling Provera can be used. Provera is a progesterone, one of the two hormones that are found in birth control pills. Taking Provera for 10 days will bring on a period sometime after the 10 days of medication. I advise my patients that are using this strategy to use the provera if they go 2 months without a menses. The idea being that as long as the woman has a period at least every 3 months the endometrium is protected from cancer and the bleeding is typically not too heavy. For women that desire a menses every month the Provera can be taken each month. This will solve the bleeding issues but it will not help abnormal hair growth.
Women that desire to become pregnant need a different approach. Provera is typically given to start a menstrual cycle. Clomid (clomiphene citrate) is then given once daily on cycle days 5-9. This will trigger an ovulation so that the patient can get pregnant. Clomid is safe and inexpensive. The biggest risk of Clomid id the risk of twins. A woman has about a 7% chance of having twins if she conceives using Clomid, this is about twice the normal risk. The risk of having triplets and higher order multiples is minimal. Clomid can also cause some pms like symptoms during the days the woman is taking it. For women who do not ovulate with Clomid, about 80% will ovulate if the dabetes medication mtformin is added.
Hirsutism (abnormal hair growth) can be slowed with hormonal contraceptives. Spiranolactone is a medication that can also decrease hair growth. Spiranolactone is safe with few side effects but it can cause significant birth defects so it is very important that a woman is on reliable birth control if she is using spiranolactone. Other methods for controlling hair growth are plucking, shaving, and waxing. These are temporary methods and need to be repeated often. Electrolysis can also be used for hair growth, this is not permanent and continuing treatment will be needed. Laser hair removal can be permanent and is the best solution for hirsutism, unfortunately this is expensive and not covered by insurance. There is a cream called Finesteride that is effective for the treatment of abnormal hair growth. This cream is very expensive and the hair comes back when the cream is discontinued. In my opinion, if a woman is going to spend the money on the cream, she is better off using laser hair removal.
Obesity is difficult to treat in PCOS. The diabetic drug, metformin (Glucaphage), is sometimes used to treat the insulin resistance in some women with PCOS. It may also help with obesity. Metformin can have a lot of side effects especially diarrhea and nausea. The theory is that it decrease the insulin resistance and therefore breaks the metabolic cycle that causes obesity. Although this makes some sense logically, the studies have not shown metformin to be very helpful for most women. Women with polcystic ovarian syndrome do have a higher chance of becoming diabetic. Clearly this medication is indicated if diabetes and probably pre-diabetes is present. The studies have not shown metformin to be very helpful in other populations of women with PCOS. Because of this and the fact that metformin has side effects, I do not recommend using metformin unless there is significant insulin resistance or glucose abnormalities. Treatment for obesity remains mainly behavioral modification through exercise and diet.