Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects approximately 5-10% of women of reproductive age. It is characterized by hyperandrogenism, ovarian dysfunction, and polycystic ovaries. The underlying cause of PCOS is unclear but it often runs in families. Women with PCOS typically present with symptoms such as irregular menstrual cycles, excess hair growth (hirsutism), acne, and obesity. Many women with PCOS also struggle with infertility.
An endocrinologist is a physician who specializes in disorders of the endocrine system, which is made up of the glands that produce hormones. Endocrinologists are experts in treating hormonal conditions like PCOS. They use a multifaceted approach to manage PCOS that focuses on regulating menstrual cycles, treating symptoms like hirsutism and acne, promoting ovulation for fertility, and reducing metabolic complications.
Diagnosis
The first step an endocrinologist will take when seeing a patient with suspected PCOS is confirming the diagnosis. To diagnose PCOS, at least two of the following criteria must be met:
– Irregular or absent menstrual cycles
– Hyperandrogenism – either clinical signs like hirsutism, acne, and alopecia or elevated testosterone levels on lab testing
– Polycystic ovaries on ultrasound – this requires an ovary to contain at least 25 follicles.
Additionally, other disorders that could cause similar signs and symptoms must be ruled out such as congenital adrenal hyperplasia, Cushing’s syndrome, and androgen-secreting tumors.
To confirm the diagnosis, the endocrinologist will typically order the following tests:
– Physical exam – Assess hirsutism, acne, alopecia, and other hyperandrogenism signs
– Pelvic ultrasound – Evaluate ovarian morphology
– Labs:
– Complete blood count (CBC) – Rule out thyroid disorder, anemia
– Thyroid panel – TSH, free T4
– 17-hydroxyprogesterone – Rule out congenital adrenal hyperplasia
– Prolactin – Rule out pituitary tumor
– Testosterone – Assess hyperandrogenism
– Hemoglobin A1c – Screen for diabetes
– Lipid panel – Evaluate cholesterol and triglycerides
Treatment Overview
Once a diagnosis of PCOS is established, the endocrinologist will create a customized treatment plan for the patient. The main treatment goals are:
– Regulate menstruation and ovulation
– Treat hyperandrogenism and associated symptoms
– Reduce metabolic complications
– Promote fertility if desired
The endocrinologist has many treatment options to choose from to meet these goals including:
– Lifestyle modifications
– Birth control pills
– Antiandrogens
– Insulin-sensitizing drugs
– Ovulation induction agents
Additionally, the endocrinologist may enlist other specialists like a dermatologist or fertility specialist to assist with treatment. Ongoing monitoring and medication adjustments are necessary to optimize symptom control.
Lifestyle Changes
The endocrinologist will recommend lifestyle modifications as the first-line treatment approach for all patients with PCOS. Losing weight through diet and exercise can significantly improve PCOS symptoms like irregular periods, hirsutism, and acne. Weight loss also reduces the risk of diabetes and cardiovascular disease.
The endocrinologist may refer patients to a nutritionist to help design an optimal PCOS diet. In general, a diet low in refined carbohydrates and high in lean proteins, fruits, and vegetables is recommended. Regular exercise of at least 150 minutes per week of moderate activity like brisk walking is also advised. Even a modest 5-10% loss of body weight can dramatically improve PCOS.
Birth Control Pills
Oral contraceptives (birth control pills) are commonly prescribed by endocrinologists for women with PCOS. Birth control pills regulate menstrual cycles and reduce hirsutism and acne by decreasing androgen production. Popular pills prescribed for PCOS contain a combination of estrogen and progestin.
There are two main types of pills:
– Monophasic pills provide the same levels of hormones in each active pill. These are good choices for regulating periods.
– Multi-phasic pills change hormone dosages during the pill pack. These can provide better hormonal control but may increase spotting.
The endocrinologist may try different pill formulations to find the optimal one for each patient’s symptoms. The pill may be taken in extended cycles or continuously to reduce menstrual periods to four per year.
Antiandrogens
Medications that block androgen receptors or reduce androgen production can treat hirsutism and alopecia in women with PCOS. Common antiandrogens prescribed by endocrinologists include:
– Spironolactone – Aldosterone antagonist that also blocks androgen receptors
– Finasteride – Inhibits 5-alpha reductase to reduce DHT production
– Flutamide – Nonsteroidal antiandrogen that blocks receptors
– Cyproterone acetate – Progestin with antiandrogenic effects
These medications can take 3-6 months to see maximal hair reduction benefits. Antiandrogens are often used in combination with birth control pills for optimal improvement in hirsutism. The endocrinologist will monitor for potential side effects like low blood pressure with spironolactone.
Table 1: Comparison of Antiandrogen Medications
| Medication | Mechanism of Action | Dosing | Side Effects |
|---|---|---|---|
| Spironolactone | Blocks androgen receptors | 50-200 mg daily | Breast tenderness, irregular periods, low blood pressure |
| Finasteride | Inhibits 5-alpha reductase | 2.5-5 mg daily | Headaches, decreased libido |
| Flutamide | Blocks androgen receptors | 250-500 mg daily | Hot flashes, liver toxicity |
| Cyproterone acetate | Blocks androgen receptors | 50-100 mg daily | Headaches, decreased libido |
Insulin-sensitizing Drugs
Since insulin resistance and hyperinsulinemia contribute to the pathogenesis of PCOS, medications that improve insulin sensitivity are commonly used. Metformin is the first-line insulin sensitizer prescribed. It reduces testosterone levels, regulates menstrual cycles, and promotes ovulation.
Typical dosing of metformin is 1500-2000 mg daily, divided into 2-3 doses with meals. Extended release formulations can allow for once daily dosing. The endocrinologist will monitor kidney function and vitamin B12 levels on metformin. Gastrointestinal side effects like nausea and diarrhea are common initially but improve with time and gradual dosage increases.
Other insulin-sensitizing drugs the endocrinologist may use include:
– Thiazolidinediones like pioglitazone – Improve insulin resistance but have side effects like weight gain, fluid retention, and bone loss.
– GLP-1 agonists like liraglutide – Enhance insulin secretion and aid with weight loss but require injection.
Ovulation Induction Agents
To address infertility in women with PCOS, endocrinologists can prescribe oral agents that stimulate ovulation. The first-line is clomiphene citrate, a selective estrogen receptor modulator. It blocks estrogen feedback, increasing FSH secretion from the pituitary to stimulate follicle development.
If clomiphene is ineffective, other options include:
– Letrozole – Aromatase inhibitor that improves ovulation rates compared to clomiphene
– Metformin – Can be added to clomiphene to enhance its efficacy
– Gonadotropins like FSH injections – More invasive but higher ovulation success rates compared to oral medications
Prior to ovulation induction, the endocrinologist will evaluate the patient’s uterine cavity and fallopian tube patency to assess fertility potential. Ovulation induction requires careful monitoring with ultrasound and lab testing to reduce multiple gestation risks.
Dermatology Referral
Women with PCOS often have associated acne and hirsutism that can be challenging to treat. Severe acne or cases unresponsive to standard oral medications may warrant referral to a dermatologist. A dermatologist can provide treatments like:
– Prescription topical acne medications
– Isotretinoin for severe nodular cystic acne
– Photodynamic therapy
– Chemical peels
– Laser hair removal such as diode laser and intense pulsed light
These specialized dermatology treatments offer superior acne and hair reduction benefit compared to medications alone. The endocrinologist and dermatologist will work together to optimize treatment results.
Fertility Specialist Referral
If oral ovulation induction agents fail, the endocrinologist may advise referral to a reproductive endocrinologist fertility specialist. These specialists can provide advanced treatments like:
– Ovarian wedge resection – Ovarian drilling to stimulate ovulation
– Gonadotropin therapy with FSH injections – More aggressive ovulation stimulation
– In vitro fertilization (IVF) – Egg retrieval and embryo transfer
– Intracytoplasmic sperm injection (ICSI) – Injection of sperm into egg as part of IVF
– Assisted hatching of embryos
IVF with or without ICSI produces high pregnancy success rates in infertile women with PCOS. However, these treatments are expensive and involve substantial time commitments and medical interventions. The endocrinologist and fertility specialist will help patients weigh the pros and cons.
Monitoring Treatment
Since PCOS requires long-term treatment, ongoing monitoring by the endocrinologist is necessary to assess response and adjust medications accordingly. Follow-up visits are usually every 3-6 months. The endocrinologist will:
– Evaluate menstrual regularity and ovulation with a menstrual calendar
– Assess hirsutism improvement and acne changes
– Check lab results like testosterone levels
– Monitor for metabolic complications like impaired glucose tolerance
– Review side effects of medications
– Perform any necessary pelvic ultrasounds
Dose adjustments, drug changes, or additions are often needed over time to control symptoms in PCOS. Lifelong treatment is usually required. Weight changes also necessitate treatment modifications. The endocrinologist aims to use the lowest doses of medications necessary to provide adequate symptom relief.
Referrals to Other Specialists
In addition to fertility and dermatology specialists, the endocrinologist may refer PCOS patients to other specialists like:
– Nutritionist – For medical nutrition therapy and weight loss counseling
– Mental health professional – To address associated anxiety and depression
– Ophthalmologist – For eye exams to check for retinopathy if diabetes develops
– Cardiologist – For cardiovascular risk assessment if hyperlipidemia, hypertension, or impaired glucose tolerance are present
– Obstetrician – For preconception counseling and pregnancy management
– Endocrine surgeon – If adrenal or ovarian tumors are suspected that may require surgical resection
Managing all aspects of PCOS requires an interdisciplinary approach, so the endocrinologist relies on other specialists to provide optimal care.
Conclusion
Endocrinologists play a pivotal role in caring for women with PCOS. They confirm the diagnosis, provide treatment to regulate menstrual cycles and hormones, address infertility, and reduce metabolic complications. Lifestyle changes, birth control pills, antiandrogens, and insulin-sensitizing drugs are commonly prescribed. Ovulation induction agents and referrals for advanced fertility treatments may be utilized for infertility. Dermatologists and reproductive endocrinology fertility specialists are also enlisted to improve symptoms and fertility outcomes. Ongoing monitoring and medication adjustments are key to successfully managing this chronic condition long-term. With comprehensive endocrinology care, the symptoms and complications of PCOS can be effectively controlled.