PCOS Treatment: Use of Combination Therapy More Effective Long-Term

With Ricardo Azziz, MD, MPH, MBA, and Lubna Pal, MBBS

Focusing on excessive hair growth, or hirsutism, one of several visible symptoms of polycystic ovary syndrome (PCOS), a commonly used combination treatment proven effective for severe acne also suppresses new hair growth, providing significant symptom improvement,1 based on results of a study published in the Journal of Women’s Health.

About 1 in 10 women have polycystic ovary syndrome (PCOS), a condition marked by hormonal imbalances and metabolic complications.2 Symptoms such as excess hair growth (hirsutism), acne and unpredictable menstrual periods are can be frustrating, cause undue angst, and adversely affect self-esteem.2

PCOS symptoms can be managed with a long-term combination of medications.Symptoms of PCOS such as excessive hair growth, acne, and absent periods respond well to OC-spironolactone treatment, with greater improvements with longer-term use.

Now, there is confirmation, that commonly prescribed combination therapy consisting of a low dose oral contraceptive and spironolactone, a drug also used for blood pressure, does indeed provide sustained improvement in PCOS symptoms.1

"This therapy combination has been around for at least 20 years," says study author Ricardo Azziz, MD, MPH, MBA, professor of medicine at the State University of New York (SUNY) and professor, State University of New York at Albany and Albany Medical College.

"What the results of the study show are that women begin to experience an improvement in their PCOS symptoms in 6 to 12 months, with continued improvement over time," says Dr. Azziz, is also Senior Executive Director at the Androgen Excess and PCOS Society.

His research team followed 200 women with PCOS who were receiving treatment to lessen their symptoms with what is known as suppressive therapy.1

More than half of the participants (69%) were given a combination of a low dose oral birth control pill (OC) and spironolactone.1 The remaining women received other commonly prescribed therapies such as glucocorticoids, insulin sensitizers, flutamide, finasteride, and other medications.

Did the Choice of Treatment for Hirsutism Matter?

Overall, 90% of women taking the combination OC-spironolactone therapy said their excess hair growth declined.Similarly, almost 85% of women receiving combination therapy reported noticing a greater regularity of their menstrual periods in comparison to 75% who felt there was improved among for those taking other medications. About 80% of the women receiving combo therapy felt there was noticeably less acne.1

The women self-reported their perceived changes with regard to hair growth or hirsutism. The researchers also evaluated differences in hair growth by using a more objective measure, called the modified Ferriman-Gallwey score, to analyze the difference in how much hair remained after treatment. The symptom score arrived at values based on the results of hair evaluated in nine different body areas to arrive at a final objective score.

“The changes recorded by self-report, with 90% of patients in the combination treatment group saying they noticed a reduction in hair growth, was confirmed by objective measure with 93% scoring favorably for less hair at the end of the study,” says Dr. Azziz. These findings were compared with just 70% of those among in the other treatment groups reporting a satisfactory reduction in hair growth.1

Extending Combination Treatment OK  

While the change in hirsutism was dramatic, the differences in another common symptom, that of acne, was similar in both groups.1 However, the greatest change was noted for the dramatic reduction in facial and body hair, with less erratic menstrual period similarly rated as significantly better at the end of the study among those in the group taking the combination oral pill-spironolactone therapy than those taking other suppressive therapies.

Side effects were similar between the groups and typically were mild, such as the blood pressure pill leading to a feeling of faintness,1 Dr. Azziz says. The average follow-up was about three years. Suppressive therapies dial down the overproduction of male hormones that lead to the symptoms.

Both birth control pills and anti-androgens like spironolactone (usually prescribed to reduce blood pressure) tend to lead to weight loss, which is a very appealing side effect, Dr. Azziz says, although they did not track weight status. This is another reason in favor of women considering the combination OC-spironolactone therapy over other options since increased weight is another common occurrence in women with PCOS.

While the therapy has long been available, Dr. Azziz believes this study may offer the longest period of follow-up, which he tells EndocrineWeb, “confirms that women will continue to improve on the therapy with continued use.”

Treatment Only Holds Off New Hair Growth

In another finding from the study, about half the women taking the combination treatment also elected to have electrolysis to remove existing hair, and their results were even better than women receiving only combination therapy.2  Electing to undergo electrolysis was effective in removing preexisting hair growth. This is important because the combination therapy aims only to prevent further new hair growth from occurring.

One note of caution, women who are trying to conceive must stop both therapies ahead of time due to the risk of birth abnormalities, Dr. Azziz says.

Clinical Insights of PCOS Symptom Management

Lubna Pal, MBBS, MS, FRCOG, FACOG, professor of obstetrics and gynecology and interim section chief for the division of reproductive endocrinology at Yale University, reviewed the study findings for EndocrineWeb.

She points out that one strength of the study is that it looks at ''real patient users," making the findings valuable to other women with PCOS. She notes that the excess hair growth in PCOS can have a dramatically negative impact on the women's quality of life so the need for effective and lasting hair removal options is extremely valuable and necessary.

One of the most constructive new insights presented in this study is the introduction of a timeline, with the researchers noting that it takes at least six months of steady treatment before full results can be expected. The information about electrolysis giving an additional improvement is also good for women with PCOS to know, Dr. Pal says.

Another important take home: "The magnitude of the benefit for combination therapy was less when you had less hair [growth] to start with," she says. So the worse the hirsutism at the start of therapy, the more dramatic the effect will be down the road.

She also confirms that weight gain is usually not a worrisome side effect for women using this therapy, and often women may notice a slight weight decline. However, ''about 2/3 of those [women] with PCOS are either overweight or obese to begin with, so weight management must also be addressed as an integral part of treatment."

Seeking the Best Treatment for Your PCOS Symptoms

Treatments recommended by doctors for polycystic ovary syndrome vary, according to Dr. Pal.  Reproductive endocrinologists, for example, are more likely than other specialists or generalists to use the combination therapy. More often, doctors may start with the birth control (OC) pill and add on other suppressive therapies if the OC isn’t effective after several months.

Data from this SUNY-led study doesn't indicate that women can stay on treatment forever, Dr. Pal tells EndocrineWeb, as the average follow-up was about three years.  

Another take-home message: "No two patients with PCOS are alike," Dr. Pal says, “what works for one may not give relief to another,” so therapy must be based on symptoms and responsiveness to treatments.

Neither Dr. Azziz nor Dr. Pal has any financial conflicts with regard to this study.

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