Important: This is intended as general information only. It may not apply to your specific situation. It is not a substitute for medical advice. If you have a question or concern, please raise it with me at your next appointment or contact me sooner if it's urgent.
Treating Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome (PCOS) is a big topic so I’ve divided it into two sections. In this section, we will look at the various treatment options available to women with PCOS. If you want to know more about how PCOS works and what is happening in your body, check out the What is Polycystic Ovarian Syndrome? page.
There are a few things to consider when treating PCOS. Because different women have different symptoms, treatment can vary greatly depending on what we are trying to address. The treatments we use to help people get pregnant are very different from those we use to regulate periods or to help with excess hair growth. In all cases, we also need to consider the long term health consequences of PCOS and take steps to prevent them.
We’ll look at the different symptoms of PCOS and how they are treated. Depending on your particular issue or issues, some of these may not be relevant for you.
If you are overweight, weight loss is going to be an important part of your management. Losing weight will make you more sensitive to insulin and help to improve your hormone imbalance. A sensible diet and regular exercise is the way to do this. It’s important to avoid radical diet and exercise plans that no one can stick to for long. What I mean by a sensible diet and regular exercise is a long term lifestyle change that will improve you general health and make you feel (and look) better. Normal weight or underweight women should not try to lose weight, although they may benefit from regular moderate exercise.
Treating irregular periods
This is usually done with the Oral Contraceptive Pill (OCP or ‘the pill’) . This medication supplies you with a combination of oestrogen and progesterone so that your ovaries don’t have to produce any. The part of your brain that, in the normal course of events, stimulates your ovaries to produce hormones and ovulate is temporarily switched off and your ovaries are suppressed. There are many different versions of the OCP and usually, with a bit of trial and error, we can find one that suits you. When you’re on the OCP, it’s not necessary to have a period every month. It’s possible to arrange things so that you have a period every three months.
Another option is to use progesterone only, usually for two weeks out of every month. This is a bit more fiddly to do and usually has more side effects but it may be a good solution for some women.
The OCP, by restoring a more normal hormone balance, can help with acne. Some versions of the OCP are better at this than others as they have an ‘anti-androgen’ effect.
Various topical treatments may also be effective. In severe cases, we may enlist the help of a dermatologist.
Normalising the hormone balance by using the OCP may also help with hirsuitism, particularly if we use one of the ‘anti-androgen’ pills. While this often helps prevent further hair growth, it may not do much for hair you already have. Cosmetic measures such are waxing, plucking, electrolysis and laser hair removal may be of use here.
There are other ‘anti-androgen’ drugs available that may be used in severe cases.
Women with PCOS may find it hard to get pregnant because they don’t ovulate regularly. There are a few ways to help you ovulate more regularly and thereby improve your chances of pregnancy.
If you are overweight or obese, losing weight is really important here. Losing weight will make it more likely that you will ovulate and conceive spontaneously. In addition, many pregnancy complications are more common in overweight women so losing weight may improve the outcome of any future pregnancies.
Metformin is often used as first line treatment, particularly in younger women. This drug, also used to treat type II diabetes, makes you more sensitive to insulin and makes it more likely that you will ovulate. While it may cause some side effects (such as nausea and stomach upset), it is generally considered safer than some of the other options and does not require such close monitoring.
Other drugs such as clomiphene and gonadotropins can be used to make you ovulate – a process known as ovulation induction. These medications have a bit more in the way of side effects and there is a risk that your ovaries may become over stimulated which can make you quite sick. For this reason, these drugs are only prescribed by gynaecologists and some of them are only prescribed by infertility specialists (gynaecologists with additional expertise in the treatment of infertility). If you require these drugs, you will be closely monitored with blood tests and ultrasounds to make the process as safe as possible. With any of these treatments we usually start with the simplest, safest option at the lowest dose and assess your response. We can then gradually increase doses as required to get the response we are after – ovulation and, ultimately, pregnancy.
Another treatment that has been used in the past to induce ovulation is Laparoscopic Ovarian Drilling. This is a surgical procedure in which, using keyhole surgery, a gynaecologist ‘drills’ into the ovarian tissue. It is though that by damaging some of the ovarian tissue, you can get a temporary improvement in the hormone imbalance at that heart of PCOS which can, in turn, result in ovulation. This treatment has fallen out of favour as it had the potential to damage healthy ovarian tissue and, in particular, reduce the supply of eggs the ovary has in reserve. Generally speaking, I do not recommend it for this reason. However, it may be an option for some women, particularly if other treatments have been unsuccessful.
Preventing the long term consequences of PCOS
As mentioned on the What is PCOS? page, women with PCOS are more likely than the average person to have high blood pressure and high cholesterol which, in turn, place them at higher risk of heart attacks and strokes. Having insulin resistance also puts these women at increased risk of developing type II diabetes. The biggest problem with having high blood pressure, high blood cholesterol or high blood sugar is that you can have them for a long time without realizing it. During this time, your high blood pressure, high cholesterol and high blood sugar can be damaging your blood vessels, heart muscle and kidneys.
If you’ve been diagnosed with PCOS you have something of an advantage – as they say, forewarned is forearmed. Since you know that these things may develop later in life, you can set up a schedule to check regularly so that if you do develop high blood pressure, high cholesterol or high blood sugar, we can address them promptly to prevent their consequences. I recommend that women with PCOS get into the habit of seeing their GP once a year to get their blood pressure, cholesterol and blood sugar levels checked. It may be many years before any of these things become a problem but you want to put yourself in a position where you can find them as soon as they develop and address them straight away.
You also need to do everything else you can lower your risk of heart attacks and strokes. If you are a smoker, you need to stop now. You also need to exercise regularly, eat a healthy balanced diet low in saturated fats and maintain a healthy body weight. Of course, everyone should be doing these things. A diagnosis of PCOS just gives you a little extra incentive to lead a healthy lifestyle.
Women with PCOS often go for long periods of time without ovulating. In a normal ovulatory cycle, there is a balance between the production of oestrogen and progesterone. Oestrogen stimulates the lining of the uterus to grow and progesterone stabilizes it, or ‘calms it down’. In PCOS, the ovaries produce oestrogen as they are trying to grow follicles. However, if ovulation does not occur, no progesterone is produced. This leads to lots of stimulation of the lining of the uterus and not enough calming down. Over long periods of time, this can cause an overgrowth of the lining of the uterus which is known as endometrial hyperplasia. Endometrial hyperplasia can lead to cancer of the lining of the uterus (endometrial carcinoma).
Fortunately, this situation is easy to fix – women with PCOS who don’t ovulate just need to take some extra progesterone whenever they are not trying to get pregnant. This is most easily accomplished by taking the oral contraceptive pill. However, there are lots of other ways to do it if that doesn’t suit you ranging from tablets to injections to patches to implants to intrauterine devices.