PCOS Treatment Options: Overview

In the past, we have talked about PCOS (Polycystic Ovarian Syndrome), its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

Now, we are doing an overview of treatment options for PCOS (beyond fertility treatment options; fertility issues and their treatment will be discussed in a separate post later on).

The question on the mind of most women with PCOS is how to minimize the risks for long-term health problems, how to minimize the distressing symptoms, and what does research say about the benefits and risks of treatment options?

This mini-series on PCOS treatment protocols will discuss a wide variety of treatment options, from insulin-sensitizing medications, anti-androgenic medications, the Pill, and cosmetic treatments. In future posts, we will also cover nutritional/lifestyle and "alternative" medicine approaches, as well as fertility treatment and options.

Because of the lengthy nature of discussing these options, the PCOS Treatment Options posts will be broken down into sub-topics. The pros and cons of metformin treatment, for example, deserve a post all its own, as do other insulin-sensitizing drugs, anti-androgen drugs, cosmetic treatments, etc.

Therefore, this post serves only as an introduction to the treatment topic ─ an overview of the possibilities ─ and subsequent posts will have more in-depth coverage of various treatment options. Because of the in-depth nature of these posts, they may not all be in a continuous series but may be spread out over time.

Trigger Warning and Caveats

The purpose of this series is to provide a basic introduction to PCOS with a size-acceptance approach that is rare on PCOS websites. 

However, as we discussed previously, this presents a dilemma when exploring treatment protocols, since weight loss is considered the traditional first-line-of-treatment for "obese" women with PCOS, and fair coverage of the topic demands examining the pros and cons of all possible treatments. So to be fair, sometimes research will be quoted that promotes weight loss ─ not because I believe weight loss is the best treatment, but because this represents the typical treatment protocols recommended, and it's only fair to mention that when doing an overview of PCOS treatments.

This does not mean I endorse or promote weight loss as a treatment. Instead, we will try to disentangle weight loss agendas from other information about PCOS treatment, and we will also discuss the possible risks of weight loss regimens. Unlike most other PCOS articles, we will not promote weight loss as the "best" or "first" treatment, we will suggest care alternatives that do not have to involve weight loss, and we will offer support for women with PCOS who are not interested in pursuing weight loss. 

My intent is to have a size-friendly guide to PCOS, but intellectual ethics demands that the evidence both for and against weight loss as a treatment be discussed too. If this is too triggering for you, you might want to skip this post, the Fertility posts, and the Nutrition and Lifestyle Treatment Options post. Most of the other Treatment Options posts should be okay, but read the research references with caution, as official sources on PCOS are always full of weight-loss promotion. Any posts with more than a passing mention of weight loss will also have a trigger warning, so look for that as well, if you want to avoid any mention of such things.

You should know that this approach has been discussed with and approved by the Fatosphere monitors.  

The Goals of Treatment for PCOS

What treatments (if any) are selected for PCOS depend on the goals of the woman and her specific circumstances. As soulcysters.com notes:

Management of polycystic ovary syndrome focuses on each woman's main concerns...Long term, the most important aspect of treatment is managing cardiovascular risks.

Different women with PCOS will have different goals for treatment. Some desperately want children, and most of their focus is going to go to fertility-related treatments at first. Some don't want children but are concerned about the long-term consequences of PCOS, so their choice of treatment will probably be insulin-sensitizing agents. Others are most concerned with appearance issues such as facial hirsutism, and so they may prefer to concentrate on anti-androgen medications or cosmetic options.

There is no one "right" way to treat PCOS, and you have the right to opt into or out of any form of treatment, regardless of what the authorities or others tell you that you "should" do. 

For example, although metformin is an extremely effective insulin-sensitizing drug that lowers the risk for diabetes and other complications, it also has some distressing gastro-intestinal side effects in some people. Some women choose to opt out of metformin because of these side effects, despite the known risks of hyperinsulinemia and diabetes. To them, the effect on their quality of life overrides the possible benefits the drug might bring.

Similarly, there is nothing that says that you have to treat facial hair or thinning scalp hair. Treatments like anti-androgenic drugs are somewhat effective for this in some women, but are associated with severe birth defects. Because even the most efficient birth control method still has a small chance of pregnancy, some women choose to opt out of these drugs and simply address these issues cosmetically instead. Others chose not to address them at all because the treatments are too onerous or they reject society's outdated and sexist standard of feminine beauty.

Weight loss is another commonly-recommended treatment that many women opt out of. Many have a long personal history of yo-yo dieting and know that even the usual recommendation of  "a small, 5-10% weight loss" tends to trigger a far greater regain afterwards for them. Or they may have an eating disorder and find restrictive diet approaches to be triggering. Or because weight loss is rarely successful long-term and carries significant risks of its own, they may prefer to avoid something so unlikely to succeed and that may introduce additional risks.

The purpose of this post is merely to explore as many options for PCOS treatment as possible, not to imply that anyone "should" choose any particular option.  

The treatment plan for one woman with PCOS is likely different than someone else's treatment plan. It all depends on her symptoms, her goals, her values, and her tolerance of the various treatment options.

Summary of The Most Common Treatments

The most common treatment goals for PCOS usually involve:

• minimizing the effect of androgens in the body
• lessening hyperinsulinemia (excess insulin) and normalizing blood sugar 
• normalizing menstrual cycles as much as possible
• minimizing or concealing the cosmetic symptoms of PCOS
• preventing or minimizing the long-term health risks associated with PCOS

Meeting these treatment goals typically involves using drugs such as anti-androgen medications, insulin-sensitizing medications, and birth control pills. It also may involve cosmetic treatments for hirsutism or hair loss, or alternative treatments such as herbs and acupuncture.

Of course, we all know that weight loss is emphasized by doctors as the primary form of treatment for PCOS symptoms. Unfortunately, they rarely acknowledge that weight loss has its own risks, that it rarely lasts long-term, and that it often results in rebound gain. What they rarely mention to PCOS patients is that lifestyle and nutritional modifications can often help without having weight loss as a goal.

Here is a summary of the most common treatment options from one website (with a few edits, additions, and added emphasis by me). Because this is a quote from a mainstream website, be aware that it does emphasize weight loss (trigger warning).  However, this quote is included because it's important to point out the traditional approach to treating PCOS before discussing its pros and cons:

There is no cure for PCOS...Treatment of PCOS is aimed at reducing its symptoms and prevention of further complications. 

The goals are to promote ovulation, prevent endometrial hyperplasia, counterbalance the effects of androgens, and reduce insulin resistance. Treatment options depend on the type and severity of the individual woman's symptoms and her desire to become pregnant.

Low-dose oral contraceptives are often used to stabilize hormones and oppose estrogenic stimulation of the endometrium. Within several months, they can usually regulate menstrual periods, eliminate or minimize uterine bleeding, and reduce androgen levels - improving hirsutism and clearing up acne. 

Anti-androgens such as spironolactone, flutamide, and cyproterone are sometimes combined with oral contraceptives to help address more severe hirsutism and acne. Waxing, shaving, depilatory and electrolysis may be used to remove unwanted hair, and antibiotics or retinoic acids may be used to treat acne.

Metformin is being used to reduce insulin resistance. It has also shown promising initial results in women with PCOS hirsutism and in helping to regulate menstrual cycles, but its effects on infertility and other symptoms are not yet known. 

Fertility Drugs - If a woman with PCOS wants to become pregnant, she is usually given clomiphene citrate, a drug that helps induce ovulation. She may also be given human menstrual gonadotropin, although this drug increases the risk of multiple pregnancies. However, as with any drug regimen, certain side effects and risks may be present.

Surgery - Although sometimes performed in the past, surgery is a rare PCOS treatment option now. One surgical option, a "wedge resection," involves removing the part of the ovary that contains the cystic follicles to try to restore ovulation. Another option, ovarian drilling, involves using a needle with an electric current to make holes in the ovary. Both of these procedures may temporarily increase fertility but may also lead to scarring and adhesions; concerns in long-term ovarian function limit this practice. 

Lifestyle changes through better diet, weight loss, and exercise are recommended to help decrease insulin resistance and to minimize lipid abnormalities. Weight reduction can also decrease testosterone, insulin, and LH levels. Regular exercise and healthy foods, such as vegetables, fruits, nuts, and whole grains, will also lower blood pressure and cholesterol as well as improve sleep apnea problems. Smoke cessation also may lower androgen levels.

Again, these are the choices offered by a traditional approach to PCOS. But there are other choices.

Some women choose other insulin-sensitizing agents besides metformin, such as the glitazones or the inositols. Some emphasize Health At Every Size® via lifestyle choices like moderating carb intake, increasing exercise, or eliminating gluten/grains without focusing on weight loss. Other women find help for their PCOS through "alternative" medicine, like herbs or acupuncture.

There are many choices available for women with PCOS; there is no one "right" way in treating it. Again, the best approach depends on the needs and priorities of each individual woman. Most women with PCOS arrive at their optimal treatment plan after considerable experimentation, so it's important to learn as much as possible about the pros and cons of each option.

Concluding Thoughts

In future posts, we will look at most of these treatment options in a little more detail. As you read these, keep in mind the goals of treatment:

• to regulate the cycle (to restore menstruation and thereby lower the risk for endometrial cancer; also to increase ovulation/fertility if desired)
• to lessen the effects of androgens (to minimize the negative effects of hormonal imbalances in the body; to minimize distressing side-effects like hirsutism, thinning hair or cystic acne ─ or to utilize cosmetic treatments to lessen the social impact of these symptoms)
• to decrease insulin resistance (to lower the risk for diabetes and other long-term complications of the metabolic syndrome)

Treatment usually involves a combination of therapies; most often, a combination of medication, cosmetic treatments, and lifestyle modifications is utilized.

Remember, though, that you are your own boss. Only you get to decide what the right course of treatment is for your body.

References

*These references are included here because they are overviews of medical approaches to treating PCOS, which is the purpose of this post. However, most research studies strongly emphasize weight loss as the first line of treatment for PCOS. If you find discussion of this triggering or distressing, definitely don't read this reference list!

General Summary of Treatment Options 

• http://labtestsonline.org/understanding/conditions/pcos/?start=3 - summary of treatment options
• http://www.inciid.org/faq.php?cat=infertility101&id=2#89 - INCIID's PCOS FAQ, which discusses treatment options fairly extensively
• http://www.hormone.org/Polycystic/treatment.cfm - treatment options as summarized by The Hormone Foundation (an endocrinology educational group)

A Few Studies on Treatment Options

Int J Womens Health. 2011 Feb 8;3:25-35. Treatment options for polycystic ovary syndrome.Badawy A, Elnashar A. PMID: 21339935

...Management of women with PCOS depends on the symptoms. These could be ovulatory dysfunction-related infertility, menstrual disorders, or androgen-related symptoms. Weight loss improves the endocrine profile and increases the likelihood of ovulation and pregnancy...In PCOS, anovulation relates to low follicle-stimulating hormone concentrations and the arrest of antral follicle growth in the final stages of maturation. This can be treated with medications such as clomiphene citrate, tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins or surgically by laparoscopic ovarian drilling. In vitro fertilization will remain the last option to achieve pregnancy when others fail. Chronic anovulation over a long period of time is also associated with an increased risk of endometrial hyperplasia and carcinoma, which should be seriously investigated and treated. There are androgenic symptoms that will vary from patient to patient, such as hirsutism, acne, and/or alopecia. These are troublesome presentations to the patients and require adequate treatment. Alternative medicine has been emerging as one of the commonly practiced medicines for different health problems, including PCOS. This review underlines the contribution to the treatment of different symptoms.

Womens Health (Lond Engl). 2009 Sep;5(5):529-40; quiz 541-2. Polycystic ovary syndrome, obesity and reproductive implications. Hirschberg AL. PMID: 19702452

...Lifestyle interventions resulting in weight loss comprise the most successful strategy to improve symptoms of PCOS. However, many patients fail to lose weight or may quickly regain weight. It is an important challenge to develop effective lifestyle programs and adjuvant pharmacologic treatments in order to improve reproductive and metabolic health among women with PCOS.

Minerva Med. 2007 Jun;98(3):175-89. Comprehensive clinical management of polycystic ovary syndrome. Setji TL, Brown AJ. PMID: 17592439

...Menstrual cycle control is necessary to prevent endometrial hyperplasia, and this can be accomplished with hormonal contraception, progesterone therapy, and weight loss (if overweight). In women desiring pregnancy, commonly used ovulation induction therapies include weight loss, clomiphene citrate, and/or metformin. Cosmetic issues such as hirsutism, acne and male-pattern hair loss can be challenging to cope with. Treatment options include estrogen-containing hormonal contraceptive agents, antiandrogens, and topical agents. More permanent hair reduction can be achieved with electrolysis and laser therapy. Evaluation of metabolic complications includes risk assessment for diabetes, dyslipidemia, hypertension, and nonalcoholic fatty liver disease. Women with PCOS should also be screened for sleep apnea, as this has been reported to occur more commonly in women with PCOS. Finally, mental health issues such as depression and eating disorders may be present. Many of the complications associated with PCOS can be managed with therapeutic lifestyle change, including a healthy diet, exercise, weight loss (if overweight), and psychological support. Pharmacological therapies are also available to effectively regulate menstrual cycles and manage cosmetic complications.

Exp Clin Endocrinol Diabetes. 2010 Oct;118(9):633-7. doi: 10.1055/s-0029-1237705. Epub 2009 Dec 8. The effect of metformin treatment for 2 years without caloric restriction on endocrine and metabolic parameters in women with polycystic ovary syndrome. Oppelt PG, Mueller A, Jentsch K, Kronawitter D, Reissmann C, Dittrich R, Beckmann MW, Cupisti S. PMID: 19998243

...MATERIAL AND METHODS: Twenty-six obese women with PCOS were treated with metformin over 2 years without caloric restriction. Clinical, metabolic and endocrine parameters and the body mass index were measured and an oral glucose tolerance test was carried out to calculate insulin resistance indices at the beginning and at the follow-up after 2 years. The Homeostatic Model for Assessment of Insulin Resistance (HOMA-IR) was calculated...CONCLUSIONS: Long-term treatment with metformin in women with PCOS appears to reduce androgen excess due to increased SHBG and decreased TT levels resulting in improvement of hirsutism as a clinical sign of androgen excess. Furthermore a significant decrease in fasting and 2-h insulin levels and slightly improved insulin resistance indices were observed.