5.
D3 is more potent and appropriate dosing to correct levels is still under investigation.
In chronic anovulatory patients with PCOS, persistently elevated estrogen levels, which are uninterrupted by progesterone, increase the risk of endometrial carcinoma (81,82). These endometrial cancers are usually well differentiated, stage I lesions with a cure rate of more than 90% (see Chapter 35). Endometrial biopsy should be considered in PCOS patients, because they may occasionally harbor these cancers as early as the third decade of life. Abnormal bleeding, increasing weight, and age are factors that should lower the threshold for endometrial sampling. Prevention of endometrial cancer is a core management goal for patients with
Treatment of Hyperandrogenism and PCOS
PCOS. If other dimensions of management do not induce regular ovulation (e.g. clomiphene) or impose continuous progestation inﬂuence (e.g., oral contraceptives), regular secrectory transformation and menstruation should be induced with periodic administration of a progestational agent. Even though the hyperestrogenic state is associated with an increased risk of breast cancer, studies examining the relationship between PCOS and breast cancer have not always identified a significantly increased risk (82–86). The risk of ovarian cancer is increased two-to threefold in women with PCOS (82,87).
The clinical features of PCOS, such as infertility, acne, hirsutism, and obesity, promote psychological morbidity. Women with PCOS face challenges to their feminine identity that can lead to loss of self-esteem, anxiety, poor body image, and depression (88).
A study examining the prevalence of depression and other mood disorders in women with PCOS reported a significantly increased prevalence of depression (35% to 40%) when compared with controls (10.7%), after adjusting for BMI, and a family history of depression and/or infertility. Other mood disorders such as anxiety and eating disorders were common in women with PCOS (89). The high prevalence of depression and other mental health disorders in women with PCOS suggests that assessment and treatment of mental health disorders should be included in the evaluation and management plan (89). Lifestyle management improves quality of life and depression in obese and overweight and women with PCOS (88).
Treatment depends on a patient’s goals. Some patients require hormonal contraception, whereas others desire ovulation induction. In all cases where there is significant ovulatory dysfunction, progestational interruption of the unopposed estrogen effects on the endometrium is necessary. This may be accomplished by periodic luteal function resulting from ovulation induction, progestational suppression via contraceptive formulations, or intermittent administration of progestational agents for endometrial or menstrual regulation. Interruption of the steady state of hyperandrogenism and control of hirsutism usually can be accomplished simultaneously. Patients desiring pregnancy are an exception, and for them effective control of hirsutism may not be possible. Treatment regimens for hirsutism are listed in Table 31.6. The induction of ovulation and treatment of infertility are discussed in Chapter 32.
Table 31.6 Medical Treatment of Hirsutism
Weight Reduction Weight reduction is the initial recommendation for patients with accompanying obesity because it promotes health, reduces insulin, SHBG, and androgen levels, and may restore ovulation either alone or combined with ovulation-induction agents (75). Weight loss of as little as 5% to 7% over a 6-month period can reduce the bioavailable or calculated free testosterone level significantly and restore ovulation and fertility in more than 75% of women (90). Exercise involving large muscle groups reduces insulin resistance and can be an important component of nonpharmacologic, lifestyle-modifying management.