Current aspects of polycystic ovary syndrome II: treatment of hyperandrogenism, insulin resistance and infertility

Abstract

Abstract This work is a continuation of an earlier article published in this journal (no. 91/1: “Current aspects of polycystic ovary syndrome I: definition, pathophysiology, clinical manifestations, diagnosis and complications”). As the pathology of polycystic ovary syndrome is not fully known, the treatments used do not constitute a causal therapy, only pathogenetical interventions to break the vicious circles of pathological events. It does not currently have a universal therapeutic procedure or an approved specific drug. Treatment may be aimed at reducing hyperandrogenism, inducing ovulation and preventing complications. The patient’s complaints and desire for becoming pregnant should also be taken into account. In mild cases, an appropriate lifestyle (prevention/treatment of obesity) is sufficient, i.e. a 5-10% reduction in body weight can already result in significant improvement and also serves to prevent late complications (diabetes, hypertension, cardiovascular disease, hyperlipidemia). Oral contraceptives and antiandrogens are mainly used to treat hyperandrogenism (hirsutism, acne, and alopecia). A contraceptive whose progestogen component has antiandrogenic properties, or at least is androgen-neutral, is preferred, such as third-generation contraceptives. However, combined contraceptives (containing gestodene, desogestrel, drospirenone and cyproterone acetate) may increase the risk of venous thromboembolism and are therefore contraindicated in case of hypercoagulability. Antiandrogens (cyproterone acetate, spironolactone, finasteride, etc.) can also be used independently, but only with effective contraception (as these can cause feminization of the male fetus). Insulin resistance plays a crucial role in the development of this disease. Metformin is used as primary therapy, as it also has many other beneficial effects (e.g. cardiovascular and anti-cancer) described in recent years. These pleiotropic effects and their subtle mechanisms are discussed in detail. We highlight the possibilities of avoiding side effects and the current interpretation of rare contraindications (acidosis, hypoxic conditions, renal damage). Insulin resistance lowering agents include thiazolidinediones, acarbose, GLP-1 agonists, vitamin D, resveratrol, octreotide, but the beneficial effects of myoinositol and D-chiro-inositol are also mentioned. In the last part of the paper, the treatment options for infertility are discussed, highlighting the efficacy of clomiphene citrate, gonadotropins (“step-up”, “step- down” methods), IVF techniques, and ovarian drilling used for ovulation induction. We detail the importance and possibilities of the prevention of ovarian hyperstimulation syndrome and multiple pregnancies.