The clinical management of a woman with PCOS should be focused on her individual problems. For instance obesity worsens both symptomatology and the endocrine profile and so obese women (BMI >30kg/m~) should therefore be encouraged to lose weight. Weight lose improves endocrine profile, the likelihood of ovulation and a healthy preduction.
Much has been written about diet and PCOS. The right diet for an individual is one that is practical, sustainable and compatible with her life style. It is sensible to keep carbohydrate content down and to avoid fatty foods. It is often helpful to refer to a dietician. Anti-obesity drugs may help with weight loss. Metformin has been shown to be valuable to aiding weight reduction.
The easiest way to control menstrual cycle is the use of low-dose combined oral contraceptive preparation (COCP).This will result in an artificial cycle and regular shedding of the endometrium. An alternative is progestogen (such as medroxyprogestorone acetate[Provera] or dydrogesterone [Duphaston] for 12 days every 1-3 months to induce a withdrawal bleed. It is also important once again to encourage weight loss.
Hyperandrogenism and Hirsutism
The bioavailability of testosterone is affected by the serum concentration of SHBG and so increase the free fraction of androgen. Elevated serum androgen concentration stimulate peripheral androgen receptors,resulting in an increase in 5alpha reductase activity directly increasing the conversion of testosterone to the more potent metabolite virilized (I.e do not develop deepening of the voice, increased muscle mass,breast atrophy or clictoromegaly).
Hirsutism is characterized by terminal hair growth in chest,upper and lower back ,upper and lower abdomen ,upper arm,thigh and buttocks.Drugs therapy may take 6-9 months or longer before any improvement of hirsutism is perceived. Physical treatment including electrolysis,waxing and bleaching maybe helpful while waiting for medical treatments to work. Electrolysis is time consuming ,painful and expensive and should be performed by an expert practitioner. Regrowth is not uncommon and there is no really permanent cosmetic treatment. Laser and photothermolysis techniques are more expensive but may have longer duration of effect. Repeated treatments are required for a near permanent effect because only hair follicles in the growing phase are obliterated at each treatment. Hair growth occurs in 3 cycle so 6-9 months of regular treatments are typical.
Medical regimens should stop further progression of hirsutism and decrease the rate of hair growth.Adequate contraception is important in women of reproductive age as trans place central passage of antiandrogens may disturb the genital development of a male fetus. First line therapy contains Ervin glossy radio (30ug) in combination with cyproterone acetate (2mg).Addition of higher doses of the synthetic progesterone cyproterone acetate (CPA,50-100mg) do not appear to confer additional benefit but are sometimes prescribed for the first 10 days of each 21-day cycle for women who are particularly resistance to treatment with Dianette alone. Other antiandrogens such as ketoconazole,finasteride and flutamide have been tried, but are not widely used for treatment of hirsutism in women due to their adverse side effects. Furthermore they are no more effective than cyproterone acetate.
PCOS and infertility
Annovulation is one major problem with PCOS. Overweight women with PCOS are at risk of obstetrical complications including gestational diabetes mellitus and preeclampsia.Ovulation can be induced with the antioestrogen clomifene citrate (50-100mg) taken from days 2-6 of a natural or artificially induced bleed.While clomifene citrate is successful in inducing ovulation in over 80% of women, pregnancy only occurs in about 40%. There is however 10% risk of multiple pregnancy which can be mitigated by ultrasound monitoring. A daily those of more than 100mg rarely confers any benefit and can cause thickening of the cervical mucus,which can impede passage of sperm through the cervix.
The therapeutic options for patient with an ovulatory infertility who are resistance to antioestrogens are either parenteral gonadotropin therapy or laparoscopic ovarian diathermy.A meta-analysis has shown that pregnancy rate are greater with 6 months gonadotropin therapy compared to 6 months after laparoscopic ovarian diathermy, although by 12 months the pregnancy rates are similar.
Insulin -sensitizing agent e.g metformin are showing promise for ovulation inducing but require further long- term evaluation and should only be prescribed by endocrinologists/reproductive endocrinologists.
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