Polycystic ovarian syndrome: management

Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. Management is complicated and problem-based partly because the aetiology of PCOS is not fully understood. Hyperinsulinaemia is commonly seen in PCOS and there appears to be some overlap with the metabolic syndrome. Diagnosis is based on the Rotterdam criteria (oligo/anovulation, hyperandrogenism, polycystic ovaries on ultrasound).

• weight reduction if overweight
• if a woman requires contraception, then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below)

• a COC pill may be used to help manage hirsutism. Possible options include a third-generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action (should be used short-term due to increased VTE risk)
• if doesn't respond to COC then topical eflornithine may be tried
• spironolactone, flutamide and finasteride may be used under specialist supervision

• weight reduction if appropriate
• the management of infertility in patients with PCOS should be supervised by a specialist
• first-line pharmacological treatment is letrozole (aromatase inhibitor)
• clomifene may be used as an alternative
• there is a potential risk of multiple pregnancies with anti-oestrogen therapies such as clomifene
• work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion
• metformin is not first-line for ovulation induction but may be used in women with impaired glucose tolerance or metabolic features, particularly if overweight
• gonadotrophins