POLYCYSTIC OVARIAN SYNDROME..
Polycystic ovary syndrome (PCOS) is a hormonal disorder common among women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone (androgen) levels. The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs.
Signs and symptoms of PCOS often develop around the time of the first menstrual period during puberty. Sometimes PCOS develops later, for example, in response to substantial weight gain.
Signs and symptoms of PCOS vary. A diagnosis of PCOS is made when you experience at least two of these signs:
Infrequent, irregular or prolonged menstrual cycles are the most common sign of PCOS. For example, you might have fewer than nine periods a year, more than 35 days between periods and abnormally heavy periods.
Elevated levels of male hormone may result in physical signs, such as excess facial and body hair (hirsutism), and occasionally severe acne and male-pattern baldness.
Your ovaries might be enlarged and contain follicles that surround the eggs. As a result, the ovaries might fail to function regularly.
Regardless of the diagnostic criteria used, the management of polycystic ovary syndrome (PCOS) includes treatment of individual components of the syndrome (hirsutism, oligomenorrhea, infertility, obesity, and glucose intolerance), depending upon the patient's goals.
●Weight loss, which can improve metabolic risk, restore ovulatory cycles and possibly improve live birth rates, is the first-line intervention for most women.
●Combined estrogen-progestin oral contraceptives (COCs) are the mainstay of pharmacologic therapy for women with PCOS for managing hyperandrogenism and menstrual dysfunction and for providing contraception.
●Our approach to the use of COCs in women with PCOS is the same as that for women without PCOS. Risk factors for venous thromboembolism (VTE), including obesity, patient age, and family history of VTE, should be assessed. More information can be found in the Centers for Disease Control and Prevention (CDC) United States Medical Eligibility Criteria for Contraceptive Use.
We suggest caution when prescribing COCs in obese women (body mass index [BMI] ≥30 kg/m2) over age 40 years because of their greater risk of VTE . Other relative and absolute contraindications to COC use are outlined in the CDC United States Medical Eligibility Criteria for Contraceptive Use.
●For hirsutism or other androgenic manifestations, we suggest a COC as the treatment of choice .
●We typically start with a COC containing 20 mcg of ethinyl estradiol combined with a progestin such as norethindrone or norethindrone acetate, progestins that have lower androgenicity, but similar VTE risk compared with levonorgestrel-containing COCs. Higher doses of ethinyl estradiol are needed in some women for optimal management of hyperandrogenic symptoms. Concerns about VTE risk with newer progestins and with drospirenone are reviewed separately.
●If the patient is not satisfied with the clinical response to six months of COC monotherapy (for hyperandrogenic manifestations), we suggest adding spironolactone.
●For prevention of endometrial hyperplasia and possibly cancer, we suggest COC therapy .
●For women with PCOS who choose not to or cannot take COCs, we suggest intermittent progestin therapy.
●For women with PCOS undergoing ovulation induction, we now suggest letrozole as first-line therapy over clomiphene citrate. Before starting letrozole, the clinician must discuss that this use of the drug is not approved by the US Food and Drug Administration (FDA) and that clomiphene is an alternative.
●For women with PCOS and a BMI >30 kg/m2, we also suggest diet and exercise to promote weight loss.
DR ATUL CHOWDHURY