Polycystic ovary syndrome (PCOS) is characterised by an accumulation of incompletely developed follicles in the ovaries due to anovulation. It is diagnosed in up to 10% of women attending gynaecology clinics, but the prevalence in the population as a whole is unclear. PCOS has been associated with hirsutism, infertility, acne, weight gain, type 2 diabetes, cardiovascular disease (CVD), and endometrial hyperplasia.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments in women with PCOS? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 24 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: cyproterone acetate–ethinylestradiol (co-cyprindiol), finasteride, flutamide, interventions to achieve weight loss, ketoconazole, mechanical hair removal, metformin, and spironolactone.
PCOS is characterised by an accumulation of incompletely developed follicles in the ovaries due to anovulation, and is associated with increased ovarian androgen production. Clinical manifestations of PCOS include infrequent or absent menses, obesity, and signs of androgen excess including acne or seborrhoea.
PCOS is diagnosed in up to 10% of women attending gynaecology clinics, but the prevalence in the population as a whole is unclear.PCOS has been associated with hirsutism, infertility, acne, insulin resistance, elevated serum luteinising hormone (LH) levels, weight gain, type 2 diabetes, CVD, and endometrial hyperplasia.
Metformin in selected patients (who have abnormal LH/follicle-stimulating hormone [FSH] ratios) may improve menstrual pattern and oligomenorrhoea. The results of studies comparing metformin with placebo are conflicting for menstrual frequency and hirsutism. Metformin, alone or combined with cyproterone acetate–ethinylestradiol (co-cyprindiol), may be more effective than cyproterone acetate–ethinylestradiol alone at reducing hirsutism. Metformin combined with flutamide reduces hirsutism scores and improves menstrual frequency compared with placebo, but we don't know how the individual drugs compare with each other.
Cyproterone acetate–ethinylestradiol may reduce hirsutism, but increases the risk of venous thromboembolism compared with placebo.
Finasteride may reduce hirsutism compared with placebo, and seems as effective as spironolactone or cyproterone acetate–ethinylestradiol. Finasteride plus cyproterone acetate–ethinylestradiol may be more effective than cyproterone acetate–ethinylestradiol alone at reducing hirsutism.
Flutamide, alone and in combination with metformin, may reduce hirsutism compared with placebo, but has been associated with adverse hepatic effects. Flutamide may reduce hirsutism compared with finasteride, but studies have given conflicting results. Flutamide and spironolactone seem equally effective at reducing hirsutism.Combined treatment with flutamide plus cyproterone acetate–ethinylestradiol may reduce the proportion of women with oligomenorrhoea compared with flutamide alone.
We don't know whether weight loss improves clinical outcomes in women with PCOS.
We don't know whether ketoconazole or hair removal treatments are effective at reducing hirsutism compared with other treatments. Mechanical hair removal with certain types of lasers may be effective in the short term (6 months), but longer-term effects are less clear.