Management of patients with PCOS is usually directed toward their mode of presentation. Related medical problems could be controlled but not totally cured and therapies would change with the age and needs of the patient. Accordingly prolonged follow up is necessary to prevent long term medical problems
Excessive weight problems should be addressed through significant changes in life style including more exercise and healthy eating. Adequate loss of weight could lead to significant improvement in insulin resistance, regulates ovulation and menstruation and improves chances of getting pregnant. It could as well improve the pattern of blood lipids and reduces other cardiovascular risks.
Losing weight without any professional help could be a daunting task. Accordingly all our patients are given a chance to see our group dietician to offer them a tailored programme to suite their needs. We do not encourage losing weight by starving oneself but rather through changes in life style. Most patients who lose weight through starving will regain their initial weight within 2 - 3 years.
Infertility management
Infertile obese women with PCOS should be offered fertility treatment only after a good effort has been invested in losing weight. This has been shown to improve ovulation and increase their chances of natural conception.
Most patients respond to medical treatment with clomid to induce ovulation. However the pregnancy rate is not as high as the ovulation rate. About 15-20% of patients with PCOS might prove to be resistant to incremental doses of clomid. Treatment with clomid should not be continued for more than 6 cycles. Patients resistant to clomid could be treated with gonadotrophins injections to induce ovulation. This however increases the risks of multiple pregnancy and ovarian hyperstimulation.
Metformin is a drug used to treat women with insulin resistance. Its main effects are on the liver reducing gluconeogenisis and glucose formation and on the muscles and other tissues improving their utilization of glucose. It might take 4 months before a full molecular effect is achieved. Recent reports suggested that it might have a direct effect on the ovaries even in women who are not insulin resistant. This could lead to reduction in androgen production by the ovaries, better ovulation and reduced miscarriage rates. Furthermore it has been shown to reverse the metabolic and endocrine risk factors associated with increased miscarriage rate in women with PCOS. Other than reducing the level of androgens it also reduces the levels of PAI-1 and luteinising hormone.
One further benefit of this drug is its ability to convert clomid resistant patients into responsive ones improving the pregnancy rate. However there are no prospective data to show that using metformin as a first line of treatment has lead to improved pregnancy or live birth rates. Before starting metformin medications liver and renal function tests could be done and repeated annually. This is to guard against the rare side effect of lactic acidosis even in patients with mild renal impairment. As well it is contra indicated in patients at risk of developing this problem. This includes infection, dehydration, alcoholism, heart failure, recent myocardial infarction and use of x-ray contrast media. Another side effect which could be seen after prolonged use of metformin is reduced absorption of vitamin B12 which should be kept in mind especially for those who are at risk. However it does not cause hypoglycaemia though it could normalise blood glucose level.
One important point to mention is that taking metformin does not negate the need for sensible eating and maintaining a reasonable level of activity to lose weight.
Laparoscopic ovarian drilling is an option for those who are resistant or did not conceive after clomid treatment. Ovarian drilling is more successful in women with high luteinising hormone (LH) levels. It could give a pregnancy rate equivalent to gonadotrophins injections with no risk of hyperstimulation and low risk of multiple pregnancies. In fact 50% of patients conceive after ovarian drilling. Lower miscarriage rate has be reported after ovarian drilling compared to gonadotrophins treatment. Though laparoscopy is an intrusive procedure which is done under general anaesthesia, it offers a good chance to examine the pelvis for other infertility factors at the same time. The risk of developing pelvic adhesions after ovarian drilling should be assessed against the prospective benefits expected in these patients.
Androgenic skin problems
Recently many young women are coming forward seeking treatment to regulate their cycles and for skin hyperandrogenic problems. Different oral contraceptive pills have been used with variable responses. We are now more aware of the effect of the different progestagens used in different contraceptive pills on insulin resistance. Androgenic progestogens are shown to have a bad effect in this respect. Accordingly we should be more selective in our choice when prescribing the pill to women with PCOS. Merciolon and cilest are just 2 of the good pills to prescribe to women with PCOS.
For younger women spironolactone could offer an adequate effect for androgenic skin problems with minimal side effects. It could take few months before seeing an effect.
Metformin has also been shown to reduce androgens production and could help with skin problems especially in those who are insulin resistant.
All these medications should be combined with wise use of good skin care, avoiding skin irritants and professional help with hair removal.
We always advise our patients to take a Polaroid (or digital photograph) before starting treatment and at regular intervals thereafter for comparison purposes in the future.
