Chronic anovulation associated with PCOS may be treated after identifying the desires of the patient. Patients may be concerned about their lack of menstruation, not hirsutism, or infertility. The endometrium of these individuals should be protected from the environment of unopposed estrogen that accompanies the anovulatory state. Oral contraceptives are a good alternative for those patients who require contraception. For those patients who are not candidates for oral contraceptive use, cyclic administration of progestogen is advised. Progestogen withdrawal will occur if there is an adequate estrogenic environment to induce proliferation of the endometrium, and it is not sufficient to cause withdrawal bleeding in patients who are hypoestrogenic (e.g., those who have amenorrhea associated with anorexia nervosa). Women with PCOS may require treatment for insulin resistance, dyslipidemia, and obesity. Regular periodic screening with an oral glucose load test and lipid panel is recommended for women with PCOS. Reduction in weight in obese women with PCOS leads to improved pregnancy rates, decreases hirsutism, and improves glucose and lipid levels (79). Insulin-sensitizing medications such as metformin and cholesterol-lowering medications such as statins can be considered. Ovulation induction is performed if pregnancy is desired, as described below.
A common progestogen used to induce withdrawal bleeding and thus protect the endometrium from hyperplastic transformation is medroxyprogesterone acetate (10 mg for 12 to 14 days per month). Occasionally, ovulation may occur; therefore, patients should be made aware that pregnancy is possible, and appropriate contraceptive measures should be used. Because there is theoretical concern that medroxyprogesterone acetate used in early pregnancy may increase the incidence of pseudohermaphroditism, a pregnancy test should be obtained if a woman fails to have a withdrawal bleed (128). Alternatively, progesterone suppositories (50 to 100 mg) or oral micronized progesterone (200 mg) can be given for 12 to 14 days per month to protect the endometrium from hyperplasia and induce withdrawal bleeding. No increased incidence of birth defects is associated with the use of natural progesterone (129).
In hypoestrogenic individuals such as those with POI, estrogen replacement must be added to the progestogen for successful menstrual regulation and prevention of osteoporosis. The doses of estrogen needed for relief of symptoms in young women with POI are often higher than those that are used for older menopausal women (130). Women with POI (who would normally still be making hormone if the ovaries were functioning normally) are different from those reaching menopause at a median age of 51. Therefore, data regarding hormone therapy that were collected from women reaching menopause at the median age should not be extrapolated to younger women. Although there are no comparative data and no long-term prospectively collected data regarding hormone therapy for women with POI, the risks of hormone therapy are likely to be lower and the benefits potentially greater for younger women than for older women reaching menopause after the age of 50 (131).
When chronic anovulation is caused by congenital adrenal hyperplasia, glucocorticoid administration (i.e., dexamethasone 0.5 mg at bedtime) is sometimes successful in restoring the normal feedback mechanisms, thereby permitting regular menstruation and ovulation.
Hirsutism Patients who have oligomenorrhea or amenorrhea resulting from chronic anovulation may have hirsutism. The most common cause of hirsutism and oligo-ovulation is PCOS. After ruling out androgen-secreting tumors and congenital adrenal hyperplasia, treatment may be aimed at decreasing coarse hair growth.