Polycystic Ovarian Syndrome Medication

  • Author: Richard Scott Lucidi, MD; Chief Editor: Richard Scott Lucidi, MD   more...
 
Updated: Apr 11, 2012
 

Medication Summary

Drugs used in the treatment of polycystic ovarian syndrome (PCOS) include metformin (off-label use), spironolactone, eflornithine (topical cream to treat hirsutism), and oral contraceptives. Oral contraceptives containing a combination of estrogen and progestin increase SHBG levels and thereby reduce the free testosterone level. LH and FSH levels are also suppressed. This restores cyclic exposure of the endometrium to estrogen-progestin, with the resumption of menstrual periods and decreased hirsutism. However, the use of oral contraceptives may be associated with an increased risk of thrombosis and metabolic abnormalities.

An oral contraceptive containing ethinyl estradiol and a progestin with minimal androgenic activity, such as norgestimate, norethindrone, or desogestrel, should be selected. Ethinyl estradiol combined with drospirenone (Yasmin) has a progestin that acts as an antiandrogen and thus may add antiandrogenic effects.

Withdrawal bleeding can be induced with medroxyprogesterone (Provera) given for 5-10 days before the start of oral contraceptive therapy. Pregnancy must be ruled out before oral contraceptive therapy is started.

The indications, contraindications, and adverse effects of metformin therapy should be carefully reviewed with the patient before such therapy is begun. In addition, women starting metformin therapy should be informed that such treatment may result in ovulatory menstrual cycles and increase the probability of pregnancy.

Women taking spironolactone require reliable contraception. An oral contraceptive is preferable, but if that form of contraception is contraindicated, another type of contraception should be used.

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Hypoglycemic Agents

Class Summary

These agents reduce blood glucose levels.

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Metformin (Glucophage, Glumetza, Riomet, Fortamet)

 

Metformin reduces insulin resistance; it is an insulin sensitizer. Hepatic glucose output is decreased and peripheral, insulin-stimulated uptake is increased.

Insulin (Humulin, Novolin)

 

Insulin is effective when metformin cannot control hyperglycemia. Several short-acting and long-acting dosage forms are available. Insulin must be initiated in conjunction with dietary assessment and nutritional management by a registered clinical dietitian as part of an overall weight-management system. Insulin is seldom indicated as a first-line agent for polycystic ovarian syndrome (PCOS).

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Antiandrogens

Class Summary

Spironolactone has been used to treat hirsutism.

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Spironolactone (Aldactone)

 

Spironolactone is an antiandrogen that is a nonspecific androgen-receptor blocker. It may be used in conjunction with oral contraceptive pills to treat hirsutism by reducing hair diameter. Begin oral contraceptive pills first to avoid worsening of menstrual irregularities and to prevent pregnancy, because spironolactone may have feminizing effects on the male fetus. Periodically assess adverse effects (eg, fluid and electrolyte abnormalities). Spironolactone is also used as a potassium-sparing diuretic.

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Leuprolide (Lupron, Eligard)

 

Leuprolide suppresses ovarian and testicular steroidogenesis by decreasing LH and FSH levels. GnRH analogs with oral contraceptive pills are an option to consider for women with hirsutism who fail to respond to combined therapy with spironolactone and oral contraceptive pills. Anatomic effects of androgens (eg, clitoromegaly and deepening of the voice) are not responsive to GnRH analogs.

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Finasteride (Proscar, Propecia)

 

Finasteride is a 5-alpha-reductase inhibitor that is approved for use in benign prostatic hypertrophy and in male-patterned alopecia. It blocks conversion of testosterone to its more active metabolite, dihydrotestosterone. Finasteride is more effective when used in combination with oral contraceptive pills.

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Topical Hair-Removal Agents

Class Summary

Eflornithine cream can be used to treat androgen excess.

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Eflornithine (Vaniqua)

 

Eflornithine is indicated for the reduction of unwanted facial hair in women. It interferes with ornithine decarboxylase (needed for hair growth) in skin hair follicles. Eflornithine does not have a depilatory action; instead, it appears to retard hair growth and improve appearance where applied. Improvement may be seen in as little time as 4-8 weeks, although 6 months may be required. In clinical studies, hair returned to its previous condition 8 weeks after discontinuation of eflornithine.

The drug's use has been studied only on the face and adjacent involved areas under the chin of individuals with hypertrichosis; therefore, limit eflornithine's use to these areas. Patients will likely need other hair-removal methods in conjunction with eflornithine therapy.

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Oral Contraceptives

Class Summary

These agents reduce the secretion of LH and FSH from the pituitary by decreasing the amount of GnRH. All oral contraceptives decrease ovarian androgen production. By inhibiting gonadotropin secretion and, therefore, tertiary follicle development, ovarian secretion of testosterone and androstenedione is decreased. All oral contraceptives increase SHBG and, therefore, reduce free testosterone. Evidence indicates that high doses of contraceptive progestins may inhibit 5-alpha reductase. Oral contraceptives also decrease the production of adrenal androgens, particularly DHEA-S.

Different contraceptive preparations have different effects on ovarian androgen production and SHBG. However, they all reduce levels of free testosterone equally (by approximately 50%). Free testosterone levels achieved with oral contraceptive preparations are unrelated to the increased levels of SHBG. Preparations that have high SHBG are associated with high total testosterone levels.

Restoration of regular menstrual cycles prevents endometrial hyperplasia associated with anovulation. Oral contraceptives also improve acne and hirsutism.

Ethinyl estradiol

 

Ethinyl estradiol reduces the secretion of LH and FSH from the pituitary by decreasing the amount of GnRH. Use ethinyl estradiol 30-35 mg combined with any form of progesterone. Restoration of the regular menstrual cycles prevents endometrial hyperplasia associated with anovulation. Improvements of hyperandrogenic effects are seen in 60-100% of women but usually require a least 6-12 months of use. Perform a pregnancy test before therapy. If the patient has had no menstrual period for 3 months, induce withdrawal bleeding with medroxyprogesterone acetate (Provera) 5-10 mg/day for 10 days, then begin therapy with oral contraceptives.

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Medroxyprogesterone ( Depo-Provera, Provera)

 

Medroxyprogesterone has no effect on androgen production. Progestins stop the proliferation of endometrial cells, allowing organized sloughing of cells after withdrawal.

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Contributor Information and Disclosures
Author

Richard Scott Lucidi, MD  Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Robert J Ferry Jr, MD  Le Bonheur Chair of Excellence in Endocrinology, Professor and Chief, Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, University of Tennessee Health Science Center

Robert J Ferry Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, American Medical Association, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research, and Texas Pediatric Society

Disclosure: Eli Lilly & Co Grant/research funds Investigator; MacroGenics, Inc Grant/research funds Investigator; Ipsen, SA (formerly Tercica, Inc) Grant/research funds Investigator; NovoNordisk SA Grant/research funds Investigator; Diamyd Grant/research funds Investigator; Bristol-Myers-Squibb Grant/research funds Other; Amylin Other; Pfizer Grant/research funds Other; Takeda Grant/research funds Other

Lynne Lipton Levitsky, MD  Chief, Pediatric Endocrine Unit, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School

Lynne Lipton Levitsky, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Diabetes Association, American Pediatric Society, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Pfizer Grant/research funds P.I.; Tercica Grant/research funds Other; Eli Lily Grant/research funds PI; NovoNordisk Grant/research funds PI; NovoNordisk Consulting fee Consulting; Onyx Heart Valve Consulting fee Consulting

Phyllis W Speiser, MD  Chief, Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Professor of Pediatrics, Hofstra-North Shore LIJ School of Medicine at Hofstra University

Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Jordan G Pritzker, MD, MBA, FACOG  Assistant Professor of Obstetrics/Gynecology and Women's Health, Women's Comprehensive Health Center, Hofstra University School of Medicine; Attending Physician, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Stephen Kemp, MD, PhD  Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD  Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Kathy Silverman, DO, and Elizabeth Alderman, MD, to the development and writing of a source article.

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Longitudinal transabdominal ultrasonogram of an ovary. This image reveals multiple peripheral follicles.
 
 
 
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