MANAGEMENT OF HYPERANDROGENISM ASSOCIATED WITH POLYCYSTIC OVARY SYNDROME

HYPERANDROGENISM
Clinical manifestations:
Hirsutism Acne alopecia

TREATMENT OF HIRSUTISM
Use of local cosmetic measures in conjunction with pharmacologic treatment will achieve a quick and optimum response Medical treatment
Aims to reduce androgen levels Lower androgen production Augment androgen binding to specific plasma proteins Block androgen action at the level of the target tissue.

 ORAL CONTRACEPTIVES
Estrogen component:
suppresses LH and ovarian androgen production Enhances hepatic production of SHBG, thus reducing free and unbound fraction of plasma testosterone

Drospirenone + ethinyl estradiol

 ANTI-ANDROGENS
Cyprotenone acetate + ethinyl estradiol
Inhibits binding of testosterone to the androgen recetor

Spironolactone, flutamide, finasteride

 INSULIN SENSITIZERS
Minimal to modest improvement Improves hyperinsulinemia and hyperandrogenemia

Eflornithine HCl 13.9% cream GNRH agonist

TREATMENT OF ACNE
RETINOIDS
Elimination of microcomedones by preventing the inflammatory stages Topical retinoid + antimicrobial
Target abnormal follicle keratinization P. acnes proliferation Inflammation Increased sebum production

 ORAL CONTRACEPTIVES
Increase hepatic synthesis of SHBG, decreases free serum testosterone Inhibit FSH and LH production, decreases ovarian androgen synthesis OCP + dropirenone

 ANTI-ANDROGENS
Cyprotenone acetate + ethinyl estradiol Spironolactone

TREATMENT OF ALOPECIA
TOPICAL MINOXIDIL
Efficacy can be assessed 6-12months of treatment

ANTIANDROGENS
Not FDA approved

HAIR SURGERY

MANAGEMENT OF INFERTILITY ASSOCIATED WITH POLYCYSTIC OVARY SYNDROME

LIFESTYLE MODIFICATIONS
Obesity adversely affects reproduction and is associated with anovulation and pregnancy loss Obesity adversely affects reproduction and is associated with late pregnancy complications Obesity is associated with diminished response to clomiphene citrate treatment or laparoscopic ovarian drilling

 Obesity is associated with diminished response to gonadotropin therapy BMI 20-25kg/m2 Weight loss Diet and exercise

CLOMIPHENE CITRATE
Induction of ovulation in most anovulatory women with PCOS Patient selection: body weight/body mass index, female, age and the presence of other infertility factors Ovulation rate: 75-80% Conception rate: 22% per cycle Limited to the minimum effective dose and to no more than 6 ovulatory

AROMATASE INHIBITORS
Appears to be as effective as Clomiphene citrate for induction of ovulation

INSULIN-SENSITIZING AGENTS
Less effective than CC in inducing ovulation Metformin + CC provides more benefit than using CC alone

 Gonadotropins
Laparoscopic ovarian drilling 2nd line intervention Starting dose: 37.5-75IU/day Human menopausal gonadotropins Urinary FSH Recombinant FSH

 Strict cycle cancellation should be agreed upon with the patient before ovulation induction therapy to avoid potential higher order multiple pregnancies and ovarian stimulation syndrome

 Laparoscopic Ovarian Drilling

No risk of hyperstimulation syndrome or higher order multiple pregnancy Indications:
Cc resistance develops Those who require gonadotopin treatment but who cannot be monitored PCOS women who require laparoscopic assesment

ASSISTED REPRODUCTION TECHNIQUES

Intrauterine insemination
Indications:
Women with PCOS and an associated male factor Women with PCOS who failed to conceive after maximum of 6 successful induction of ovulation

 In-Vitro Fertlilization
Indications:
Tubal damage Endometriosis Male factor infertility

GnRH agonist + GnRH antagonist redces the risk of OHSS Metformin prior to or during IVF decreases the risk of OHSS