Dr. Cobin discusses how polycystic ovarian syndrome (PCOS) is treated.
There are a number of ways to treat polycystic ovary syndrome. I like to lump those ways, or divide those ways, into when a woman is presenting to me, and what her individual goals are. So for instance, if it’s a young girl, a teenager whose major problem is acne or facial hair, then there are medications that we can use to suppress the output of these abnormal hormones from the ovary, as well as medications that reduce the impact of those hormones on the skin tissue itself. So that might be one thing that we want to treat.
Irregular periods–again, in the younger woman, may be very disturbing and difficult to manage, so there again sometimes we will use birth control pills, particularly the kind of pill that has in it as part of its chemical nature a chemical that’s called an anti-androgen, and that may be actually a part of the constituent of the birth control pill itself. So that can be very useful.
When we believe that metabolic syndrome or insulin resistance is a major part of this disorder, as it often is, we will often use insulin sensitizers, and the most frequently used and most well studied is Metformin which is a drug that improves the body’s sensitivity to insulin by acting at some sites where insulin works within the cell.
Metformin has been shown to improve menstrual regularity and frequency. It can, to some degree, lower the androgen output, the output of testosterone, and improve some of the clinical features in the skin, most remarkably acanthosis. If you use Metformin in high enough doses and lower the insulin level, the acanthosis is in part dependent upon how high the insulin level is, so that can be a very satisfactory treatment for the acanthosis.
When we are concerned about fertility, Metformin or Clomiphene both are useful and various doctors have different ways that they decide to go about treating. One can start with one or the other, and both of them are successful in the majority of women to help them ovulate and achieve pregnancy. Each has its benefits and each has its possible risks, so we leave that to the discretion of the treating physician how he or she thinks it would best suit that individual patient.
When a person is getting closer to menopause or when fertility is no longer an issue, that woman is getting a little bit older, there may be some issues in using birth control pills, a risk of venous thrombosis, that takes it a little bit out of play. So it depends upon the age that the woman is presenting to us, depends upon what’s disturbing her the most and what her goals are for treatment.
Now, beyond that, we know, the physicians know that there is this very high risk of insulin resistant syndrome and with it, increased risk of impaired glucose tolerance, impaired fasting glucose, type 2 diabetes, lipid abnormalities, and hypertension, all of which can lead to heart attack, stroke, and all of the microvascular complications of type 2 diabetes.
So in those women who are diagnosed with polycystic ovary syndrome, the wise physician will look for all of the markers of insulin resistance syndrome and will treat those as well.
There is some guidance now on looking for pre-diabetes and treating pre-diabetes at a stage when, hopefully it has not resulted in complications yet, and a very, very important part of treating these women is not only looking for insulin resistance, but treating it.
How do you treat insulin resistance? Well, the best way to treat insulin resistance that has no side effects at all is diet and exercise. And so, making this diagnosis and understanding that it is tightly linked to insulin resistance gives us the opportunity, even with young teenagers to say, “You have a disorder that may ultimately lead to something that’s a very serious medical problem. You’d better exercise; you’d better try to keep your weight as close to ideal body weight as you can. Learn to eat correctly and you’ll improve your body’s sensitivity to insulin, reduce the risk of having type 2 diabetes, lipid abnormalities, hypertension, and then all the results.”
So a very important part of the treatment is counseling to make certain that these women follow the proper lifestyle in terms of their diet and their exercise.
About Dr. Cobin, M.D., M.A.C.E.:
Dr. Rhoda Cobin is Past-President of the American College of Endocrinology, a Past-President of the American Association of Clinical Endocrinologists (AACE), and a Master of the American College of Endocrinology (ACE). Dr. Cobin has been in private practice in northern New Jersey for 31 years. She is a Clinical Professor of Medicine at Mount Sinai School of Medicine in New York City and is Co-Chief of the Mount Sinai's Thyroid/Endocrinology Clinic.