Analysis of the current recommendations for pharmacologic interventions and lifestyle modifications for treatment of polycystic ovarian syndrome
Haserot, Kristen M.
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Polycystic ovarian syndrome (PCOS) is the most prevalent female endocrine disorder affecting between 5-15% of women. Characterized by a combination of polycystic ovaries, androgen excess, and abnormal ovulation, untreated PCOS may progress to metabolic abnormalities and increase the risk of adverse health outcomes. Adult PCOS is evaluated using the Rotterdam Consensus Criteria, which requires two of three clinical findings. PCOS is a condition of exclusion, and it is essential to consider differential pathologies before diagnosis. PCOS is a heterogeneous condition, and treatment is fitted to the symptoms that each individual experiences. The physiological effects of PCOS present during puberty, typically around the average age of menarche. The exact etiology of PCOS is unknown, and preventing and curing the condition is not yet possible. Metabolic disturbances caused by PCOS, including insulin resistance and increased blood glucose level, are treated with similar methods as diabetes type 2. Insulin sensitizing agents are used to treat insulin resistance caused by PCOS. The primary treatment for insulin resistance in this population is metformin (Glucophage) due to its relatively safe use and effectiveness in normalizing insulin sensitivity and assisting with normalizing weight. The correlation of PCOS with insulin resistance, central obesity, and metabolic syndrome highlights the importance of diet and exercise supplementation for this population. Weight loss of only 5% in obese and overweight PCOS patients can significantly improve PCOS symptoms, including insulin resistance, androgen levels, and fertility. Exercise alone helps increase the sensitivity of skeletal muscle to insulin and decreases metabolic syndrome risk. The effect of PCOS on the hypothalamic-pituitary-gonadal axis can be detrimental to ovulation and implantation of a fertilized egg. Treatments that suppress the HPG-axis cannot be continued during attempts to become pregnant and throughout pregnancy. Ovulation-inducing agents can improve the rate of ovulation and increase fertility; however, some women may become resistant to these treatments. Clomiphene citrate (Clomid) is often the primary drug used to induce ovulation; however, monotherapy with letrozole has shown greater improvements in pregnancy and live birth rates. Gonadotropins may also be successful treatments, but there is an accompanied increased risk of ovarian hypersensitivity syndrome and multiple pregnancies. Laparoscopic ovarian drilling may help decrease androgen production in the ovary and briefly increase pregnancy capability. During pregnancy, metformin may help decrease the risk of gestational diabetes; however, the long-term effect of fetal exposure to metformin is not well studied. Cosmetic symptoms of PCOS, including hirsutism and acne vulgaris, may cause severe social stress. PCOS women are at additional risk of depression and anxiety. Cosmetic and mental health concerns, combined with the stress caused by the high prevalence of infertility in PCOS, highlight the need for psychological help to be considered in improving the overall quality of life. Combining cognitive behavioral therapy with treatments may help PCOS women maintain treatment and improve their quality of life. The most effective treatment may require modification throughout a patient’s life due to the variance in gonadocorticoid levels throughout a female’s life. Post-menopausal women continue to have excess androgens and estrogens in circulation. High levels of ovarian and adrenal production of gonadocorticoids combined with decreased circulating binding globulins can lead to stress on the metabolic and cardiovascular systems in PCOS after menopause. Continuous levels of increased triglycerides increase the risk for atherosclerosis and adverse cardiac events. PCOS women have an increased risk of endometrial and ovarian cancer, while a link between breast cancer and PCOS is widely disputed. There is 1.66 times higher risk for cardiovascular events, including 1.96 times greater risk for stroke in women with PCOS compared to non-PCOS women when controlled for weight. As we begin to understand the increased risk factors for hypertension, hyperlipidemia, and cardiovascular stress with PCOS, it is crucial to understand how to diagnose and treat PCOS patients in the early stages of the disorder. Irregularities in typical puberty and menarche in adolescents increase the difficulty of diagnosis and may delay a diagnosis.