The introduction of the concept of evidence-based medicine caused a radical overhaul of the way that medicine was practised. No longer was it enough to prescribe treatments based on age-old traditions, or even on anecdotal evidence ("Jack Smith used such-and-such a remedy for his condition, and now he is cured!"). Instead, the scientific method gained prominence, with all old and new ideas being rigorously tested in massive clinical trials. Because of this, treatment modalities are constantly evolving, with trends being developed and either accepted or rejected by the medical community.

Nowhere is this more prominently illustrated than in the attempted development of a consistent treatment plan for polycystic ovarian syndrome. PCOS consists of a complex and highly variable collection of symptoms, which respond in an almost erratic way to individual treatment modalities. In other words, what works for a certain symptom in one person, may not work for that symptom in another, or may only work to a much lesser extent. Add this to the fact that endocrinologists and gynaecologists differ significantly in their management of PCOS, and you have a recipe for confusion.

However, a few consistently effective treatment strategies have emerged. The first of these targets individual symptoms as and when they occur, whereas the second approach attempts to address the underlying hormonal and metabolic disturbances. These include insulin resistance and its associated long-term risks of developing type 2 diabetes and cardiovascular disease, as well as increased levels of luteinising hormone and consequent elevated free androgen levels. Although the first approach is more commonly used than the second, addressing the underlying problems often leads to a marked improvement in individual symptoms.

Women with PCOS tend to present to their doctors with specific problems. These include hirsutism (with male pattern hair distribution as well as male pattern hair loss), acne, menstrual irregularities, and most distressing of all, infertility. Acne and hirsutism are both due to excess androgens (such as testosterone) and are therefore usually treated by prescribing the combined oral contraceptive, or COC. Some COC's are more frequently used than others, as they contain progestins which are less androgenic than those in other COC's. One of the newer COC's (Yasmin), contains drosperinone, which is actually antiandrogenic.

Use of the COC is not without problems, though. It is associated with an increased risk of thromboembolic disease (or clotting problems), including heart attacks and strokes, especially in those with underlying risk factors like obesity, high blood pressure, cholesterol abnormalities and diabetes (which are all very common in PCOS). The COC is not recommended for smokers, especially over the age of 35. Recent studies have shown a possible tendency for the COC to actually aggravate insulin resistance. And the COC is, by definition, not suitable for women who want to conceive. It may therefore be best to reserve the COC for younger women who don't smoke, and who have fewer risk factors, and less severe insulin resistance.

Other medications that have been used with some success in the management of hirsutism and acne include spironolactone, flutamide and cyproterone acetate. Eflornithine is a topical cream which is used for facial hirsutism - it inhibits hair growth. Metformin and the newer insulin sensitisers (such as Actos and Avandia) have also been successful in treating acne and hirsutism, probably also by decreasing androgen levels. It is important to be aware that most acne treatments will only show an improvement after two months, and hirsutism may take up to six months to respond to medication.

Both metformin and the COC have been used to treat menstrual irregularities; metformin having the added advantage of inducing ovulation in many women. Because of this it has been used for the treatment of infertility, with or without clomiphene, which also induces ovulation. Gonadotropins are also used to stimulate ovulation, but should be used with caution in PCOS sufferers, as there is an up to seven-fold increased risk of causing ovarian hyperstimulation syndrome, which can be very serious.

Laparoscopic ovarian drilling also stimulates ovulation, and, like metformin, results in the lowering of circulating androgen levels. Metformin also appears to reduce the risk of early miscarriage as well as the risk of abnormalities in the foetus, and prevents the onset of gestational diabetes in a significant number of women who take it during pregnancy.

The reason for the success of metformin in treating most, if not all, the aspects of PCOS probably lies in its ability to target the underlying insulin resistance. This property also targets the more long-term problems associated with polycystic ovarian syndrome. The risk of developing type 2 diabetes is reduced. Blood pressure and cholesterol levels are lowered, in this way further reducing the risk of cardiovascular disease.

Unfortunately metformin does not work equally effectively for everyone with PCOS. This is most likely due to the enormous variability of PCOS, especially with regard to the degree of insulin resistance experienced by each individual woman. It seems that, in general, metformin works best for those who have more severe insulin resistance. Having said this, however, it is very difficult to predict anyone's clinical response to this versatile drug, and it may be a good idea for every woman who has been diagnosed with PCOS to have a trial of treatment with metformin, both to assess its clinical effects as well as any potential side effects. Other newer insulin sensitisers may be used instead, but their full effects need to be studied further.

As you can see, treating PCOS is no easy task. Not only are the medications and their effects hugely complicated, they are also being used off code for the time being. In spite of the fact that PCOS is the most common hormonal condition affecting younger women today, there are currently no FDA approved medications for its treatment!

Fortunately there is one final management option that is open to everyone, and that is lifestyle modification. Weight loss works wonders for all the symptoms of PCOS, and the higher the starting body mass index, the more marked the response to weight loss. It's not the easiest option, as anyone with insulin resistance will tell you, but it's cheap and doesn't involve taking tablets every day, depending on what doctors prescribe for you.

As far as PCOS is concerned, lifestyle changes are very underrated. Stopping smoking, a low carb diet, and moderate regular exercise can make an enormous difference both for quality of life, and for long-term risk factors. It's one way in which sisters can do it for themselves!

About the Author
Dr. Guin Van Niekerk qualified as a medical doctor at the University of Cape Town in 1997. It was while working a few years later as a general practitioner that she developed a strong interest in insulin resistance and its associated conditions. She discovered that the concept of insulin resistance was largely unknown to the public. This led to her decision to write the book, "Why Fat Sticks - An Introduction To Insulin Resistance." For m