Similarly, hirsutism rarely improves with OCP (oral contraceptive pill) therapy alone and the combination of OCP and spironolactone is often effective in reducing and lightening unwanted hair. Glucocorticoids, like prednisone, often have no effect on excessive hair growth and in some patients may worsen the condition. In addition, the tendency to increased insulin resistance makes this choice less appealing. Women with alopecia have some improvement in reducing hair loss with combination therapy of OCP and up to 150 to 200 milligrams a day of spironolactone in divided doses. Outside of the USA, cyproterone acetate in combination with OCP is equally or, in some instances, more effective in the treatment of hirsutism and male pattern baldness than combined treatment of OCP and spironolactone.

Women with abnormal menstrual cycles, and mild skin manifestations may be treated with oral contraceptives alone. In obese women, although there are indications for OCP use, infertility or increasing weight gain may be an indication for using insulin sensitizing therapy. Metformin, in a dosage of 1,500 to 2,000 milligrams a day in divided doses with meals, and given in small increments, frequently improves menstrual cycles and tends to enhance weight reduction.

There are several reports indicating that metformin, used in combination with clomiphene citrate, leads to a higher rate of ovulation. The mechanism is not clear, but it appears that insulin sensitizers, including a new non-FDA drug D-chiro-inositol (which is almost ready for Phase III of FDA trial) may be useful in treatment of women with PCOS, and perhaps reduce some of the long-term unfavorable effects of the syndrome. However, the use of insulin sensitizer drugs should not be viewed as a reflex response of treatment for all women with polycystic ovaries. More studies are underway to define the role that such agents should play in treatment strategies.

Conclusion

PCOS is a common endocrine disorder that should be considered in any woman with irregular menses, infertility, and skin manifestations of male hormone excess. The potential of metabolic complications such as diabetes mellitus and lipid disorders, as well as the long-term risk of cardiovascular disease, makes it imperative that a diagnosis be established. It is possible to effectively treat many of the skin manifestations of the syndrome as well as the menstrual dysfunction in most women with PCOS. Moreover, with the advent of insulin sensitizer therapy, some of the other complications may also be modified. Further studies are needed however, to fully appreciate the role of these newer treatments.

Dr. Walter Futterweit is Clinical Professor of Medicine of the Division of Endocrinology of the Mount Sinai School of Medicine, New York, NY. He is also Chief of the Endocrine Clinic at the Mount Sinai Medical Center, and Attending in Medicine. He is board certified in Internal Medicine and Endocrinology and Metabolism. His main interest has been the study of polycystic ovary syndrome (PCOS) for the last 25 years, and has written extensively in this area and wrote the first textbook on the subject, "Polycystic Ovarian Disease", in 1984. His extensive practice which comprises mostly of patients with PCOS has allowed him the means to study insulin dynamics as well as recent genetic studies of the syndrome. As an international expert in the field of PCOS, he is invited to speak at many meetings, and still maintain his busy practice and teaching committments at the Mount Sinai Medical Center.