Treating PCOS

PCOS is a complicated disease that presents itself with many different symptoms. PCOS is variable and affected by the environment, so it will present itself slightly differently in each person. For this reason, treatment of PCOS will rarely be a single fix, instead it will likely involve multiple techniques to manage the different aspects of the disease.

In the past, treatment of PCOS was highly limited, often resorting to simply treating whatever symptom the sufferer first notified the doctor with, for example excess hair growth or irregular menstruation. However, as our understanding of PCOS is increasing, it is becoming increasingly obvious that it is necessary to implement regimes to monitor sufferers for signs of long term illness, like diabetes, and manage PCOS through lifestyle changes to reduce the severity of symptoms.

Here you can find out how each of the symptoms and risks of PCOS can be treated and managed. It is important to remember that not all treatments will be applicable to your specific case of PCOS, and you should see a doctor to decide which are the most appropriate treatments for you.

Treating Hair Growth and Acne

Managing Menstruation

Treating Infertility

Managing long term risks

Excess hair growth, or hirsutism, is a very common symptom of PCOS. The primary cause of hirsutism in women with PCOS is excess androgen, which stimulates hair follicles to produce thicker, darker hair, in places it normally wouldn’t, such as the back or face. Hirsutism can also lead to alopecia, or the thinning and loss of hair on the head [source].

Although hirsutism does not itself carry any immediate risks to someone’s health, it can be a major source of unhappiness for women that suffer from PCOS, often leading to stress, anxiety and depression. Thankfully, there are a number of ways that excess hair growth can be treated.

Almost all the treatments for hirsutism revolve around reducing the amount of androgen circulating in the body, which is an effective long term solution. Additionally, short term solutions such as waxing, laser hair removal or depilatory creams can be considered.

• Weight loss: a lifestyle change that reduces weight by around 2 - 5 % can reduce free testosterone by as much as 21 % [source]. It should be noted that some PCOS sufferers are naturally lean, so this does not apply to everyone! Any diet should be safe and sustainable.

• Oral contraceptives and insulin sensitizers: can both be used to significantly reduce the amount of circulating androgen. Oral contraceptives, such as CHC, taken in low dose have been shown to reduce the amount of androgen that your body produces as well as helping to remove existing androgen from circulation. Insulin sensitizers such as Metformin can be considered for women that cannot take oral contraceptives, for example if they are trying for pregnancy. It should be noted that insulin sensitizers are less effective than oral contraceptives at reducing hirsutism [source].

• Peripheral androgen blockades: are treatments that reduce the ability of androgen to stimulate hair to grow longer, thicker, and in different places. Peripheral androgen blockades can have unwanted and dangerous effects if used incorrectly though, and they should always be taken in conjunction with an oral contraceptive [source].

Acne is also primarily caused by excess circulating androgen which stimulates sebaceous glands in the skin to produce excess sebum, resulting in oily skin that is more prone to acne. For this reason, acne can be treated with oral contraceptives that reduce the amount of circulating androgen, just like hirsutism. Acne can also be treated with antibiotic creams. Just like hirsutism, diet and exercise that results in a healthy body fat level will greatly improve the symptoms of acne [source].

Most women with PCOS will experience some degree of menstrual dysfunction, which often takes the form of irregular, infrequent or absent bleeding. This is primarily caused by excess, unopposed action action of estrogen, due to anovulation.

For more information, check out: Ovulation, Menstruation and PCOS: What Goes Wrong?

Whilst irregular menstruation can have negative impacts on quality of life and happiness, it can also lead to more severe outcomes. The unchecked action of estrogen in the endometrium (the “wall” of the uterus) can lead to uncontrolled cell growth, in some cases resulting in malignancy like endometrial cancer. Women that suffer from PCOS are 3 times more likely to develop endometrial cancer [source]. This is why it is important to treat irregular menstruation.

• Weight loss: For PCOS sufferers that are obese (40-60% of sufferers), weight loss is the single best therapy to improve menstruation. Any diet should be safe and sustainable. Success of weight loss is improved even further by combining with exercise and stress management [source]. Just 30 minutes of moderate exercise has been proven to greatly improve PCOS conditions. A weight loss of 5-10% can improve menstrual regularity [source]. All studies show that weight loss results in improved ovulation and cycle regularity, as well as improved fertility.

• Oral Contraceptives: Some PCOS sufferers are not overweight or struggle to lose excess weight. PCOS sufferers can consider low dosage hormonal contraception, such as the oral contraceptive pill, together with their doctor (if they are not attempting pregnancy). Hormonal contraception works in several ways to ultimately reduce the production of testosterone in the body. Hormonal contraception also helps the body to remove existing excess androgen. Evidence suggests that continuous use of hormonal contraception is better than cycles of usage. Importantly, CHC will actively reduce the uncontrolled cell growth in the uterus, reducing the endometrial cancer risk, as well as helping the body into a regular cycle of menstruation [source].

  For more information, check out: Treating PCOS with the contraceptive pill: The complete guide

• Metformin: is an insulin sensitizer (increases your body’s sensitivity to insulin) and is commonly used to treat symptoms of PCOS [source]. Metformin reduces the amount of insulin and glucose circulating around the body, as well as reducing excessive androgen and estrogen production in the ovaries. For women who cannot take CHC and for who lifestyle changes are ineffective, metformin is recommended to help regulate the menstrual cycle [source]. A collection of studies totalling around 3500 women with PCOS show that metformin significantly increases ovulation and menstruation frequency [source]. A majority of women that take metformin report initial nausea and diarrhoea, however this typically disappears after 4-8 weeks [source]. Note that metformin is not as effective as CHC for regulating menstruation.

  For more information, check out: PCOS and Metformin: Everything you need to know

Infertility can be one of the most distressing symptoms of PCOS, however it is incredibly rare for women with PCOS to be completely infertile. With correct lifestyle management and treatment, almost all women with PCOS will be able to achieve pregnancy. PCOS related infertility is primarily caused by anovulation. Although it is similar in cause and treatment to menstrual dysfunction, there are some very important differences.

Before embarking on any fertility treatments, it is important to first check the fertility of whoever is providing the sperm. It may be that the woman with PCOS is perfectly capable of achieving pregnancy without intervention, possibly needing a few months of trying, and that problems actually stem from the fertility of the sperm used.

The majority of fertility treatments for women with PCOS work by altering sex hormone levels in order to allow the ovaries to progress past the pre-follicular stage and achieve ovulation. This is often done by raising the levels of Follicle Stimulating Hormone, through various methods.

• Weight Loss: As with nearly all PCOS treatments, the first line of defence is a healthy bodyweight and active lifestyle. The importance of this cannot be understated. Many overweight PCOS sufferers find that with relatively minor lifestyle changes they are able to achieve pregnancy without any medication. One study found that a 2-5% weight reduction resulted in half the women in the study achieving regular ovulation, with 2 women becoming pregnant during the study [source]. This was only a small study (18 women) so should not be interpreted as a hard rule, but all research in the area supports the fact that weight loss increases fertility. Always remember that weight loss regimes should be safe and sustainable, with long term goals in mind. Around 40-60% of women with PCOS are obese. For sufferers of PCOS who are considered lean, weight loss is not a viable option.

• Clomiphene Citrate: for women who do not respond to weight loss, or are already lean, clomiphene citrate is the next line of treatment used. Clomiphene works by reducing the action of estrogen in the ovaries. Reduced estrogen action results in higher levels of Follicle Stimulating Hormone, which allows the ovaries to ovulate. The lowest doses possible of clomiphene should be used, to avoid over-stimulating the ovaries. Clomiphene is considered very safe to be used in this manner and is effective at inducing ovulation in 80% of all PCOS sufferers.

• Metformin: is an insulin sensitizer that is an alternative to clomiphene, for women who do not respond to clomiphene or cannot take it for other reasons. Studies show that around 70% of women that cannot ovulate with clomiphene will ovulate with metformin [source]. It should be noted that metformin should be avoided by anybody with a history of liver or kidney issues, such as alcoholism, as it can cause lactic acidosis [source].

  For more information, check out: PCOS and Metformin: Everything you need to know

• Ovarian Drilling: is a surgery that is considered the last line of treatment for PCOS infertility. It should only be considered for women who do not respond to any of the above treatments. Ovarian drilling causes a dramatic increase in the amount of Follicle Stimulating Hormone produced. Whilst this does result in ovulation, PCOS sufferers are extremely sensitive to Follicle Stimulating Hormone and this may result in multiple pregnancy. To avoid complications, ovarian drilling should be used in conjunction with In-Vitro Fertility procedures (IVF) so that the number of embryos can be controlled [source].

If you suffer from PCOS and are struggling with fertility, schedule monthly check-ups with a doctor who is familiar with PCOS to track your progress and alter treatments where necessary. Your doctor will be able to monitor important health indicators like blood pressure, check for any side effects and discuss new treatments with you. Remember that it is extremely rare for women with PCOS to be completely infertile!

For more information, check out: How to Treat PCOS Infertility and Ovulation

As previously discussed, it is becoming increasingly apparent that PCOS carries not only short-term inconveniences but can also incur serous long-term health risks. In the past, treatment for PCOS focused almost exclusively on the visible symptoms present, such as hair growth or menstrual disruption. It is now understood that PCOS treatment must address the underlying causes of the symptoms. PCOS treatment should also be combined with regular check-ups to monitor overall health and detect early warning signs of health risks.

The first step in managing PCOS in the long-term is always to find a good doctor who understands the condition. We’ve talked previously about how poorly PCOS is understood, even in the medical community, so taking the time to find a GP or gynaecologist who is up-to-date with the current research on PCOS is key to effectively monitoring and managing your condition. If you feel that you and your symptoms have been dismissed in the past, do not hesitate to speak to other doctors until you find help that you are satisfied with. Once you have found a doctor and have been properly diagnosed, it is generally recommended that you schedule check-ups every 6 months, with extra check-ups every month if you are trying to get pregnant, however you should discuss this with your doctor as they may recommend more or less frequent check-ups depending on your specific symptoms [source].

In addition to the treatments discussed above, there are 4 key areas that you and your doctor will have to monitor and prevent:

• Diabetes

• Cardiovascular Disease

• Cancer

• Mental Health

In order to reduce the chances of experiencing these problems, treatment should focus on the underlying hormonal problems causing PCOS, which usually focuses on reducing testosterone levels or increasing insulin sensitivity. All treatments considered here should be sustainable in the long-term as they will likely be used for the next 40 years.

For all four long-term health risks weight loss is considered to be an effective preventative as it reduces levels of circulating testosterone and increase insulin sensitivity. Weight loss is not an option for around 40% of PCOS sufferers who are already lean, however 30 minutes of moderate exercise per day has been proven to improve PCOS even in women who are not overweight [source]. It is essential that any weight loss regime is safe and sustainable as many diets result in rebounding and weight gain if the diet cannot be continued indefinitely. Apart from safety and sustainability, no single diet has been shown to be more effective for managing PCOS [source]. Weight loss and exercise is particularly effective at preventing diabetes and cardiovascular disease, and it can also help to prevent cancer risk due to its positive effect on ovulation and menstrual regularity.

Combined Oral Contraceptives, also known as COC, or simply “oral contraceptives”, are combined doses of Estrogen and Progestogen. Oral contraceptives have historically been prescribed as a surface level treatment for the symptoms that women typically present with when their PCOS is first diagnosed (menstrual irregularity, acne, hirsutism). However, a growing body of scientific evidence shows that oral contraceptives are effective at treating the underlying causes of PCOS and helping to prevent many of the long term risks. Most notably, oral contraceptives are highly effective at inducing menstrual regularity. They achieve this by reducing the amount of testosterone produced by the body as well as removing existing testosterone from circulation. This allows the body to undergo a normal menstrual cycle, preventing the uncontrolled growth and build up of the endometrial lining, which is the key risk factor for endometrial cancer. For women who cannot achieve reduced testosterone and menstrual regularity through lifestyle changes, oral contraceptives are an effective cancer preventative as well as for treating hirsutism and acne. It should be noted that oral contraceptives are not an effective strategy if the patient is trying to get pregnant! [source].

For more information, check out: Treating PCOS with the contraceptive pill: The complete guide

Insulin sensitizers are another effective strategy for long term management of PCOS however they are mostly reserved for women who do not respond or cannot use strategies of weight loss, exercise or oral contraceptives. Insulin sensitizers, such as the commonly used Metformin, increase the sensitivity of the body to insulin and reduce circulating glucose levels. Metformin additionally reduces testosterone production. Therefore, Metformin can be used to improve menstrual regularity to prevent cancer risk [source] and can reduce diabetes and cardiovascular disease risk through increased insulin sensitivity [source]. However, Metformin is not as effective as oral contraceptives for improving menstrual regularity and can lead to unwanted side effects such as nausea and diarrhoea for the first 4-8 weeks [source]. Metformin should be avoided by anybody with a history of kidney or liver problems [source].

For more information, check out: PCOS and Metformin: Everything you need to know

PCOS is additionally linked to higher rates of anxiety, depression and binge eating. These disorders are often linked to the reduced quality of life caused by PCOS symptoms such as acne, hirsutism and infertility. For that reason, treatment often starts by treating these symptoms specifically, as discussed above. A relationship has been observed between higher circulating testosterone levels and depression in women with PCOS, however this may be due to the fact that increased testosterone results in the reduced quality of life symptoms just mentioned. If you feel you have been experiencing any of these disorders, talk to your doctor immediately. It is possible that managing PCOS in the long term may improve any mental health problems, but you can also be referred to a specialist to address these problems specifically.