Medications for PCOS

PCOS is a complex hormonal disorder affecting 1 in 5 menstruators in India. Research suggests that there is no permanent cure for PCOS. However, it is a manageable condition provided you undertake the required efforts. A holistic approach is crucial wherein you target the root cause of your PCOS, take steps to manage the various PCOS symptoms and adopt a recommended lifestyle consistently.

Why its important to understand medications for PCOS?

PCOS is a hormonal disorder and can be associated with numerous symptoms. Medications and supplements may be necessary in some cases for the treatment of PCOS and its symptoms. There is a huge amount of confusion and misunderstanding regarding use of medications in PCOS.Dr. Aakriti Gupta, our gynaecologist at Proactive For Her will help us understand the doctor's rationale behind prescribing these medicines. Let's understand the thought process and bust some myths together!

1. Birth control or oral contraceptive pills (OCP)

PCOS women tend to have problems with ovulation (egg production) every cycle. If you have missed more than 3 menstrual cycles, your doctor may prescribe birth control or oral contraceptive pills that could help regulate the hormones and normalise your menstrual cycle.

How do birth control pills help in PCOS ?

There could be one of the following reasons for giving OCP:-

i . To regularise the menstrual menstrual cycles: Oestrogen and progesterone are two female hormones which are responsible for period wellness. Some women with PCOS have irregular or delayed menstrual cycles due to alteration of this hormonal milieu. The use of birth control pills act at the level of the brain and ovaries to correct this hormonal imbalance to some extent and hence help regularise the periods.

ii . To lower the symptoms due to excess male hormone ( androgen): Some of the troublesome symptoms of PCOS can be down to raised male hormones leading to acne, unwanted hair growth on face or body, hair loss or frontal baldness . Oral contraceptive pills in such cases can help lower the raised androgen (male hormone) levels. This can in turn suppress these frustrating androgenic symptoms. (As per current evidence Combined oral contraceptive pills can be considered in adolescents and adults with a clear diagnosis of PCOS for the management of clinical androgen ( Male hormone ) excess and/or irregular menstrual cycles

iii. Combined oral contraceptive pills in addition would help reduce the risk of endometrial cancer in pcos women.

1. Combined birth control pills - These pills are a combination of estrogen and progestin. There are different types of progestogens in different pills - each one having a specific function.

Ethinyl estradiol (E) + LNG / Levonorgestrel (P): Ethinyl estradiol is an estrogen, while levonorgestrel is a progestin. Mostly taken for regularising the period cycle .
Ethinyl estradiol (E) + Drospirenone (P): Drospirenone is an anti androgenic progestin . Hence this combination is useful in correcting the pcos related androgenic features( as mentioned above) in addition to maintaining cycle regularity .
Ethinyl estradiol (E) + Cyproterone acetate (P): Cyproterone acetate is a powerful anti androgenic progestin . Hence it helps with hirsutism and acne.

2. Progestin-only pills - This is another class of oral contraceptive pills which help in withdrawal bleeding. As discussed above PCOS leads to a ovulation or delayed ovulation and hence delayed or absent periods .It is important to shed the endometrial lining of your uterus after a delay of periods otherwise it may lead to thickened endometrial lining and heavy menstrual bleed in the subsequent cycle. Hence for inducing periods we need progesterone pills in case of anovulatory cycles of PCOS

Medroxyprogesterone: Most commonly recommended synthetic progesterone by your gynaecologist for inducing periods .

Dosage

Birth control pills are taken from day 1 of the period cycle for 21 days every month. In PCOS they can be given for three to six continuous months followed by a gap of a few months and again starting the same course . Maximum one can use these safely till 2 years after your doctor has checked all contraindications to its use. However, even with the use of pills, it is recommended to continue with lifestyle changes to improve your insulin resistance.

Side effects

Your body may take 3-6 weeks to get used to them. Until then, you may experience some side effects such as:

Nausea
Breast tenderness
Headaches and Migraines
Fluctuation in weight
Breakthrough bleeding
Mood changes

Precautions

If your prescribed pill is not suiting you, you can talk to your doctor and opt for the lowest dose of estrogen and progesterone.

1. Metformin

Why is it relevant?

Metformin is the standard drug prescribed for the treatment of diabetes. For understanding the role of metformin in PCOS we need to first understand the link between PCOS and insulin resistance. Most women with PCOS have increased insulin resistance, especially obese pcos women compared to lean Pcos. In insulin resistance, your body does not respond to existing insulin in the body, a hormone that controls the level of sugar in your bloodstream. When insulin is unable to do its job properly, it leads to excessive glucose in your blood, in turn causing excess insulin level in the body eventually. Excess insulin can increase your cravings and contribute to weight gain. This whole cycle can eventually lead to prediabetes and diabetes. Metformin breaks this cycle by improving insulin sensitivity without causing serious hypoglycaemia (low blood sugar). Hence,metformin is given in PCOS especially obese Pcos to reduce insulin resistance and its symptoms.

Signs to look out for when it comes to insulin resistance are -

A fasting glucose level over 100 mg/dL

Skin tags

Patches of dark, velvety skin called acanthosis nigricans

Blood pressure readings of 130/80 or higher

A fasting triglyceride level over 150 mg/dL

A HDL cholesterol level under 40 mg/dL in men and 50 mg/dL in women

How does metformin help?

i . Reduces insulin resistance

As discussed above metformin increases your insulin sensitivity and helps the body respond to the already present insulin in your blood. It helps your tissues, especially the liver and muscles to increase the glucose ultilisation from the blood. This medication also stops the liver from making new glucose and promotes fat synthesis. (Current evidence states that metformin in addition to lifestyle changes could be recommended in adult women and adolescent females with PCOS for the treatment of weight , hormonal and metabolic disturbances

Moreover , metformin can also be considered in adult women with PCOS with BMI ≥ 25kg/m2 )

ii . Improves ovarian function by causing ovulation

As Metformin reduces Insulin resistance, it thus reduces the androgen production in the ovaries. This suppression of androgens in turn has a positive effect on ovulation or egg production, hence doctors use this as an add on. This also reduces cravings and also takes care of the androgenic symptoms of pcos.

(There is sufficient evidence to believe that pcos women with anovulation can ovulate with metformin alone or in combination with other ovulation drugs/ ovulogens which also helps pcos women to achieve pregnancy )

Dosage: It is best to adhere to the dosage that your doctor decides for you. Current evidence states that starting at a low dose, with 500mg increments 1-2 weekly and extended release preparations may minimise side effects of metformin .

Side-effects: Taking metformin does not drop your blood sugar levels dangerously low. However, it can have the following ill-effects.

Nausea
Diarrhoea
Bloating
Loss of appetite
Metallic taste in the mouth
Headaches

Precautions

i . It is okay if you miss a dose. But, never take a double dosage to compensate for the missed dose.

ii . A few people taking metformin may develop B12 deficiencies. It is crucial to be aware of it.

iii . Do not take it if you have skipped a meal or are sick.

iv . Do not use it with the sole purpose to lose weight but instead continue lifetsyle changes that are recommended by your gynaecologist.

**2. Antiandrogens (*like spironolactone)***

Why is it relevant?

Androgens or male hormones such as testosterone are usually responsible for the hair growth on the face, chest and stomach, acne and male pattern hair loss in PCOS. Spironolactone is essentially a diuretic (water tablet) usually prescribed to reduce high blood pressure. However, some of its effects are antiandrogenic and can be beneficial for people with PCOS to reduce aforementioned symptoms of androgen excess.

How does spironolactone help?

Spironolactone use in PCOS lowers the androgen( male hormones ) levels in the body and blocks its effects.Thus , you may find a reduction in frontal hair loss, unwanted hair growth and acne. (As per available scientific research it is recommended to use antiandrogens to treat hirsutism and androgen-related alopecia only when combined oral contraceptives are contraindicated or poorly tolerated. Antiandrogens may be used as an adjunct to the COCP after six months or more of COCP use and cosmetic therapy has failed to adequately improve symptoms. )

Dosage

Your doctor will advise on the dosage of this medicine. You have to continue it for at least 6 months to get positive results.

Precautions:

1 . If you are planning a pregnancy, consult a doctor about discontinuing the medication as it is harmful for the growing baby.

2 . Since the medicine is a diuretic, you may have the urge to pee often. Hence, in the beginning, consume the medication during the day to avoid frequent bathroom trips at night.

Side-effects:

For the first 3-4 weeks, you may experience the following side-effects.

Nausea
Loose stools
Headaches
Breast tenderness
Dizziness
Irregular periods (if not taking the pill)

3. PCOS supplements

Myo-Inositol/ D-chiro-Inositol

Myo-Inositol and D-chiro-Inositol are present naturally in our bodies. They balance some of the metabolic reactions in your body, particularly those that are involved with your reproductive hormones and insulin resistance. Hence, they can help improve insulin sensitivity, ovarian function and hormonal balance.

How do Myoinositol and D-chiro-inositol help?

Both Myoinositol and D-chiro-inositol act as insulin sensitizers. They improve the uptake of glucose from your blood into your muscles , liver and other organs.
They prevent the release of fatty acids from fat that helps in controlling blood sugar levels.
They reduce androgen production in the ovary.
They decrease the androgenic ovarian environment and hence lead to ovulation
They also have a positive effect on your cholesterol profile.

(Most of the scientific data available on Inositol use in pcos states its effective role in improving insulin sensitivity and ovulation and hence achieving natural pregnancy in PCOS women. However, as per the ESHRE (2018) guidelines still believes it to be an experimental drug with no robust evidence to support its use in PCOS women)

Dosage

Follow your doctor’s advice. Ideally, for these medicines to show their effects, you need to continually take them for 2 - 3months.

Precautions:

i . It is okay to miss doses, but do not take the double dosage.

ii . There is no fixed time to take this medicine. But, consuming it after food reduces any nausea or acidity.

iii. It is safe to consume even if you are trying to conceive.

4. Vitamin D

Vitamin D plays a vital role in ovarian follicular development or egg maturation. Recent studies have found out that almost all women affected with PCOS have decreased Vitamin D levels. The deficiency of this vitamin has also been linked to the development of certain conditions such as insulin resistance, excess androgens and lack of ovulation and which can be seen in PCOS. Obesity is known to be inversely related to vit D deficiency .

How does Vitamin D help?

Adequate Vitamin D consumption through natural means and supplementation can be beneficial if you are diagnosed with PCOS.

It can help to regulate the menstrual cycle and ovulation
It may decrease androgens or male hormones
It can Improve insulin sensitivity
It can Improve ovarian follicular development or egg maturation

Dosage

60,000 IU of Vitamin D3 per week for 8 weeks. You can have solution or capsule formulations. Discuss maintenance dose with your doctor.

Sources of Vitamin D

The human skin is capable of naturally creating Vitamin D after receiving sunlight exposure. You must go for morning walks to get your daily dose of Vitamin D. 9 AM - 2 PM is the best time to get Vitamin D from the sun.

You can also get Vitamin D through food and supplements. Food sources include:

Oily and deep marine fish - salmon, sardines, herring and mackerel
Red meat
Egg yolks
Mushrooms
Fortified foods
Dietary supplements

5. Vitamin B12 and Folic acid

It has been seen that the nutrition-associated signaling pathways play a significant role in the regulation of ovarian follicle or fluid-filled sac that contains an immature egg and chances of ovulation. This is how Vitamin B12 and Folic acid supplements intake in pcos leads to improvement in pcos symptoms.Also, when metformin is taken for a long period, it decreases the absorption of Vitamin B12 through the gut. Hence, supplementation is required in these cases.

Dosage: 200 micrograms of Vitamin B12 and 5 mg of folic acid tablet once every day for 30 days.

Evidence: Recent studies have recommended some nutrients such as vitamins, minerals, and vitamin-like nutrients for the therapy of PCOS because each has at least one functional property in PCOS-induced pathways. Therefore, it is presumed that the cause of PCOS could be vitamin or mineral deficiency.

Conclusion

Depending on the severity of PCOS symptoms and goals to be achieved, the doctor will decide which kind of treatment will be most beneficial. While medications and supplements will help regulate various bodily functions, lifestyle modifications are equally important too. With regular exercising, stress and sleep management and the right diet plans, managing PCOS will become a whole lot easier.

Disclaimer: This information is provided for educational purposes and should not be construed as medical advice. Please consult with your healthcare practitioners before undertaking any changes in your diet or adding supplements.

ProactiveForHer is a digital clinic for women, offering accessible, personalized, and confidential health-care solutions. We offer products and services for out-patient health concerns of Indian women, across their lifetime - from puberty to pregnancy to menopause. To know more on the sexual and reproductive health of women, visit https://www.proactiveforher.com/