PCOS Treatment Options
Ovarian drilling can be performed during laparoscopy. Using an electrosurgical needle or a laser the ovary is punctured approximately 10- to 12 times. This treatment results in a dramatic lowering of the male hormones, androgens, within a few days.
Studies have shown that this is effective in helping PCOS women ovulate in up to 80 percent of cases. Many who failed to ovulate with medical treatment will respond when to these medications after ovarian drilling.
Ovarian drilling can cause ovarian failure or pelvic adhesions, which could affect the fallopian tubes. Therefore, this procedure is indicated in those who want conservative fertility treatment and avoid aggressive medical treatment.
Recently, using insulin lowering medications such as metformin, (Glucophage 500 or 850 mg three times per day or 1000mg twice daily with meals), pioglitazone (Actos 15-30 mg once a day), rosiglitazone (Avandia 4-8 mg once daily) or a combination of these medications have been shown ameliorates hyperandrogenism, by reducing ovarian enzyme activity that results in male hormone production. These medications have been shown to reverse the endocrine abnormalities seen with polycystic ovary syndrome within two or three months.
This results in decreased hair loss, diminished facial and body hair growth, regulation of menses, weight loss and restores normal fertility. We have seen pregnancies result in approximately 3 months after initiating these medications.
Literature suggests that women with PCOS and Insulin Resistance can develop medical problems that can affect them in the future. The metabolic consequences include high blood pressure, elevated triglyceride / cholesterol levels, elevated blood clotting factors, heart problems, and arteriosclerosis which is associated with strokes and heart attacks. Treating this condition early may help ameliorate future health problems.
The cosmetic problem of increased facial hair and acne brings many women to the doctor. This is due to an increased amount of androgens which affect the skin. Oral contraceptives have several clear benefits in treating this condition:
- Reduces LH secretion and consequently decreases ovarian androgens.
- Increases sex hormone binding globulin that lowers the amount of free hormones that cause these symptoms.
It usually takes 8 – 10 months to see an improvement. Oral contraceptives can also cause regular withdrawal bleeding which reduces the risk for endometrial hyperplasia, a precursor for uterine cancer.
If symptoms still persist then spironolactone, Aldactone, is added. This is a blood pressure medication but it also blocks the androgen hormone at the receptor at the skin level. We usually start off at a low dose and increase slowly over 1 month. Side effects include lightheadedness, dizziness and low blood pressure. Other anti – androgen medications have been used, flutamide or finasteride, but the side effects could be severe.
Metformin improves insulin sensitivity by significantly reducing sugar production from the liver. When you start taking this medication, you may experience an upset stomach or diarrhea. This usually resolves after the first week but could take up to one month.
The side effects can be minimized by taking metformin with a meal and starting with a low dose. We recommend our patients start with one 500 mg pill daily for the first week and increase to twice a day during the second week, followed by one pill three times a day. If needed, after two months we can change the dose to 850 mg twice daily.
When beginning metformin we obtain blood work that evaluates liver and kidney function. Women with reduced kidney (renal) function are at a higher risk for a rare side effect called lactic acidosis, and should not be used.
Pioglitazone, (Actos), Rosiglitazone, (Avandia)
These medications belong to a class of medications called PPAR gamma agonists. They enhance peripheral glucose utilization in smooth muscle and pancreatic function. This improves metabolic abnormalities, decreases androgen production, increases sex-hormone binding globulins, and reduces the ability for blood clotting problems.
With metformin, you will return to our office in three months after initiating therapy. Women taking rosiglitazone or pioglitazone will be seen at two month intervals for monitoring liver function tests.
If you have had regular cycles within three months therapy you may continue this treatment for an additional three months, or you could elect to proceed with fertility medication. If you have not become regular, we would discuss adding fertility medication to facilitate ovulation.
The type of fertility medication used is dependent on your age, baseline blood work, prior history, and your desire for aggressive fertility methods.
Metformin has been shown to reduce the incidence of first trimester losses in women with PCOS and Insulin Resistance. Continuing this medication throughout the pregnancy has reduced the risk of developing gestational diabetes.
To date, there have not been any reports of abnormal babies in women who conceived using metformin or continued this medication throughout pregnancy. Metformin is a category B medication, meaning that insufficient human data is available but no animal data suggesting a risk for birth defects.
PCOS and Miscarriages
Women with PCOS who conceive either spontaneously or after ovulation induction with fertility medication have an increased risk of miscarriage. The cause for this is still unclear. Hypersecretion of LH and high androgen levels appear to be the contributory factors. The high LH level could potentate the production of immature eggs and poor embryos. The elevated androgens could adversely affect the uterine lining and implantation.
Hyperinsulinemia may also be a contributing factor in the higher rate of miscarriage. Elevated levels of insulin interfere with the normal balance between factors promoting blood clotting and those promoting breakdown of the clots.
Increases in plasminogen activator inhibitor activity (PAI-Fx) associated with high insulin levels may result in increased blood clotting at the interface between the uterine lining (endometrium) and the placenta. This could lead to placental insufficiency and miscarriage.
There have been several studies to indicate pregnancy outcomes are improved in pregnancies conceived while on insulin-lowering medications. These medications lower androgen and LH levels and therefore potentially improving egg quality and the uterine environment.