eMedicine Specialties > Pediatrics: General Medicine > Endocrinology

Polycystic Ovarian Syndrome: Treatment & Medication

Author: Robert J Ferry Jr, MD,, Chief, Division of Pediatric Endocrinology and Metabolism, Le Bonheur Children's Medical Center, University of Tennessee Health Science Center at Memphis, and St. Jude Children's Research Hospital; Brigade Surgeon, 36th Sustainment Brigade, 13th Expeditionary Sustainment Command, U.S. Army
Contributor Information and Disclosures

Updated: Oct 21, 2009

Treatment

Medical Care

Medical therapy in patients with polycystic ovarian syndrome (PCOS) is used to treat menstrual dysfunction, manifestations of hyperandrogenism, infertility,6 and insulin resistance. The Endocrine Society published its clinical practice guideline in April 2008.7

  • First-line medical therapy usually consists of an oral contraceptive to suppress ovarian androgen production and induce regular menses. If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added (see Medications).
  • Recently, metformin has been successfully used in clinical trials;8 however, data are insufficient as yet to recommend this agent to all women with polycystic ovarian syndrome. A recent study concluded that the use of metformin throughout pregnancy was associated with a 9-fold decrease in gestational diabetes in women with polycystic ovarian syndrome.9
  • If the patient has concomitant adrenal hyperandrogenism, treatment with low dose prednisone or dexamethasone may be considered.
  • Depot leuprolide acetate (Lupron) is effective in suppressing ovarian hormone production, which effectively induces menopause; therefore, this drug must be accompanied by hormone replacement therapy. This treatment approach has not gained widespread favor.
  • Several medications, including benzoyl peroxide, Retin-A, and topical and oral antibiotics, are effective for acne treatment.
  • If the patient develops type 2 diabetes mellitus, consider treatment with oral antihyperglycemic drugs, such as metformin. Clinical trials have recently shown that metformin can effectively reduce androgens, improve insulin sensitivity, and facilitate weight loss in patients with polycystic ovarian syndrome as early as adolescence.10,11
  • The patient may desire mechanical removal of excess hair. Options include electrolysis, waxing, bleaching, tweezing, depilatories, shaving, and laser removal.
  • Clomiphene citrate is used to stimulate ovulation when fertility is desired. Other approaches use gonadotropin-releasing hormone (GnRH) analogues in combination with pulsatile luteinizing hormone (LH)-releasing hormone (LHRH) treatment.

Surgical Care

  • Ovarian wedge resection was formerly considered an effective treatment for polycystic ovarian syndrome. Since the advent of hormonal therapies, this treatment is not often used but may be effective in alleviating ovarian dysfunction. Laparoscopic "ovarian drilling" is now performed.
  • If desired, clitoromegaly may be corrected with surgery.

Consultations

  • Consultation with an endocrinologist is necessary for performing an adrenocorticotropic hormone (ACTH) stimulation test or for other causes of menstrual irregularity such as thyroid disease or pituitary adenoma.

Diet

  • Nutritional counseling that addresses obesity and dyslipidemia is an important aspect of medical management.
  • Weight loss may help to decrease insulin resistance and also may decrease adverse long-term cardiovascular effects.

Activity

  • Discourage smoking because of increased risk of cardiovascular disease.

Medication

Low-dose combination oral contraceptive pills (OCPs)

OCPs are the mainstay of treatment for women with polycystic ovarian syndrome (PCOS) who are not actively trying to conceive. OCPs suppress LH production, which suppresses ovarian production of androgens and decreases the level of free testosterone by increasing the level of SHBG circulating in the blood. OCPs also decrease adrenal androgen production and 5-alpha-reductase activity. OCPs improve acne and hirsutism. Restoration of regular menstrual cycles prevents endometrial hyperplasia associated with anovulation. Improvements of hyperandrogenic effects are seen in 60-100% of women but usually require a minimum of 6-12 months of use. A pregnancy test should be performed before initiating therapy. If the woman has had no menstrual period for 3 months, withdrawal bleeding should be induced by administration of 5-10 mg of medroxyprogesterone acetate (Provera) daily for 10 days; then, therapy is begun with OCPs.


Ethinyl estradiol with progestins (Demulen, Ortho 1/35)

Use 30-35 mg ethinyl estradiol combined with any form of progesterone.
Restoration of regular menstrual cycles prevents endometrial hyperplasia associated with anovulation. Improvements of hyperandrogenic effects are seen in 60-100% of women but usually require a minimum of 6-12 mo of use. A pregnancy test should be performed before initiating therapy. If the woman has had no menstrual period for 3 mo, withdrawal bleeding should be induced by administration of 5-10 mg of medroxyprogesterone acetate (Provera) daily for 10 d; then, therapy is begun with OCPs.

Adult

1 tab PO qd

Pediatric

Not established

Decreased effectiveness and breakthrough bleeding are associated with concomitant use with rifampin, barbiturates, phenylbutazone, phenytoin sodium, carbamazepine, griseofulvin, ampicillin, tetracycline, anticonvulsants, or warfarin

Deep vein thrombosis, thrombophlebitis, thromboembolic disorders, cerebral vascular or coronary vascular disease, breast carcinoma, hepatic carcinomas or adenomas, pregnancy, cholestatic jaundice of pregnancy or jaundice with prior estrogen use, carcinoma of the endometrium or other estrogen-dependent neoplasias

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in women >35 y who smoke or have undiagnosed vaginal bleeding or breast mass

Antiandrogens

These agents block active androgen production. Cyproterone acetate is a progestin with antiandrogen activity used to treat hirsutism but has not been approved for use in the United States. In Europe, it is offered as the progestin component of an OCP.


Spironolactone (Aldactone)

Antiandrogen that is a nonspecific androgen receptor blocker. May be used in conjunction with OCPs to treat hirsutism by reducing hair diameter. Begin OCPs 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). Is also used as a potassium-sparing diuretic.

Adult

50-100 mg PO bid

Pediatric

0.5-1.5 mg/kg PO bid

Use with potassium-sparing diuretics, ACE inhibitors, or NSAIDs is associated with severe hyperkalemia; increases half-life of digoxin; potentiates orthostatic hypotension when taken with alcohol, opioid analgesics, benzodiazepines, or barbiturates; reduces clearance of lithium

Documented hypersensitivity; hyperkalemia, hyponatremia, and severe renal impairment; Addison disease

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause fluid and electrolyte imbalance; low-potassium diet recommended


Leuprolide (Lupron)

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

Adult

Suggested dosing: 3.5-7.5 mg/mo IM; not to exceed 6 mo without adding low-dose estrogen and progestin therapy

Pediatric

Not established

Documented hypersensitivity; pregnancy; may cause malformations of the genital tract in the male fetus

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Urinary tract obstruction, tumor flare, and bone pain may occur; monitor patients for weakness and paresthesias


Finasteride (Proscar, Propecia)

5-alpha-reductase inhibitor approved for use in benign prostatic hypertrophy and in male-patterned alopecia. Blocks conversion of testosterone to its more active metabolite, dihydrotestosterone. More effective when used in combination with OCPs.

Adult

1 mg PO qd

Pediatric

Not established

Documented hypersensitivity; pregnancy

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Pregnant women should not handle broken or crushed tab because the drug can be absorbed through the skin; not FDA-approved for use in women; caution in hepatic impairment; may cause a large residual urinary volume; avoid use in patients with severely diminished urinary flow

Progesterones

These agents are used to treat secondary amenorrhea.


Medroxyprogesterone (Provera)

Has no effect on androgen production. Progestins stop endometrial cell proliferation, allowing organized sloughing of cells after withdrawal.

Adult

10 mg PO qd for 10 d q2-3mo in amenorrhea or oligomenorrhea

Pediatric

Not established

Aminoglutethimide may decrease effects by increasing hepatic metabolism of medroxyprogesterone

Documented hypersensitivity; cerebral apoplexy, undiagnosed vaginal bleeding, thrombophlebitis, and liver dysfunction

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in asthma, depression, renal or cardiac dysfunction, or thromboembolic disorders

Antidiabetic agents

These agents are used to treat insulin resistance and overt diabetes mellitus.


Metformin (Glucophage, Glucophage XR)

Improves hepatic insulin sensitivity. Available in 500-mg, 850-mg, or 1000-mg tab. The XR form provides 500 mg or 750 mg for once daily administration.

Adult

500 mg PO qd initially, may titrate upward, not to exceed 1000 mg PO bid

Pediatric

<5 years: Not established
>5 years: Not established; limited experience suggests that doses up to 2000 mg/d can be safely tolerated

Diuretics, thyroid products, OCPs, phenytoin, calcium channel blocking drugs, phenothiazines may decrease effects of metformin; cimetidine may increase metformin levels

Documented hypersensitivity; acute myocardial infarction, septicemia, renal disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal or hepatic insufficiency; discontinue therapy before performing any surgical procedures


Insulin (Humulin)

Effective when metformin cannot control hyperglycemia. Several short-acting and long-acting dosage forms are available. Must be initiated in conjunction with dietary assessment and nutritional management by a registered clinical dietitian as part of an overall weight management system. Seldom indicated as a first-line agent for PCOS.

Adult

0.5-1 U/kg/d SC in divided doses; higher dosage requirement may be needed during pregnancy or with obesity

Pediatric

Daily requirements for a prepubertal child with PCOS (not type 1 diabetes) typically range from 0.5-1 U/kg SC
Daily requirements for a pubertal adolescent with PCOS (not type 1 diabetes) typically range from 0.75-1.2 U/kg SC

Medications that may decrease hypoglycemic effects of insulin include acetazolamide, AIDS antivirals, asparaginase, phenytoin, nicotine, isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid hormone, estrogens, ethacrynic acid, calcitonin, OCPs, diazoxide, dobutamine, phenothiazines, cyclophosphamide, dextrothyroxine, lithium carbonate, epinephrine, morphine sulfate, and niacin
Medications that may increase hypoglycemic effects of insulin include calcium, ACE inhibitors, alcohol, tetracyclines, beta blockers, lithium carbonate, anabolic steroids, pyridoxine, salicylates, MAO inhibitors, mebendazole, sulfonamides, phenylbutazone, chloroquine, clofibrate, fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone

Documented hypersensitivity; hypoglycemia

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hyperthyroidism may increase renal clearance of insulin and may need more insulin to treat hyperkalemia; hypothyroidism may delay insulin turnover, requiring less insulin to treat hyperkalemia; monitor glucose carefully; dose adjustments of insulin may be necessary in patients diagnosed with renal and hepatic dysfunction

More on Polycystic Ovarian Syndrome

Overview: Polycystic Ovarian Syndrome
Differential Diagnoses & Workup: Polycystic Ovarian Syndrome
Treatment & Medication: Polycystic Ovarian Syndrome
Follow-up: Polycystic Ovarian Syndrome
Multimedia: Polycystic Ovarian Syndrome
References
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References

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Further Reading

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Keywords

polycystic ovarian syndrome, PCOS, Stein-Leventhal syndrome, hyperandrogenism, functional ovarian hyperandrogenism, sclerocystic disease of the ovary, insulin resistance, perimenarchal onset, amenorrhea, obesity, menstrual dysfunction, HAIR-AN syndrome, treatment, diagnosis

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Contributor Information and Disclosures

Author

Robert J Ferry Jr, MD,, Chief, Division of Pediatric Endocrinology and Metabolism, Le Bonheur Children's Medical Center, University of Tennessee Health Science Center at Memphis, and St. Jude Children's Research Hospital; Brigade Surgeon, 36th Sustainment Brigade, 13th Expeditionary Sustainment Command, U.S. Army
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, Lawson-Wilkins Pediatric Endocrine Society, Society for Pediatric Research, and Texas Pediatric Society
Disclosure: Nutropin Speakers Bureau Honoraria Speaking and teaching; Genotropin Speakers Bureau Honoraria Speaking and teaching; Eli Lilly & Co. Grant/research funds Independent contractor; MacroGenics, Inc. Grant/research funds Independent contractor; Ipsen, S.A. (formerly Tercica, Inc.) Grant/research funds Independent contractor

Medical Editor

Phyllis W Speiser, MD, Chief of Pediatric Endocrinology, Schneider Children's Hospital; Professor of Pediatrics, New York University School of Medicine
Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Lynne Lipton Levitsky, MD, Chief, Pediatric Endocrine Unit, Massachusetts General Hospital; Associate Professor, Department of Pediatrics, Harvard University 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, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Pfizer Grant/research funds P.I.; Tercica Grant/research funds PI, also occasional consultant

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD, Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas and 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: Genentech, Inc. Honoraria Speaking and teaching; Pfizer, Inc. Honoraria Consulting

 
 
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