Clinical Inquiries

What therapies alleviate symptoms of polycystic ovary syndrome?

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EVIDENCE-BASED ANSWER:

Treatment of polycystic ovary syndrome (PCOS) in women not actively seeking to become pregnant is symptom-specific. Lifestyle modification (LSM) reduces body weight by 3.5 kg (strength of recommendation [SOR]: A, meta-analysis) and metformin reduces it by 3 kg (SOR B, cohort trial).

LSM may be better tolerated; adding metformin to LSM doesn’t lead to additional weight loss (SOR: B, randomized controlled trial [RCT]).

Spironolactone improves hirsutism scores by an absolute 8% to 22% (SOR: A, multiple RCTs); adding metformin to spironolactone improves Ferriman-Gallwey (FG) hirsutism scores an additional absolute 1.4% (SOR: B, RCT). Oral contraceptive pills (OCPs) are 12 times more likely to result in complete menstrual regularity than metformin (SOR: A, meta-analysis). Combining OCPs with metformin improves hirsutism scores by 8% over using an OCP alone (SOR: A, meta-analysis).

Statin medications don’t alter weight, hirsutism, or menstruation (SOR: B, small meta-analysis).

EVIDENCE SUMMARY

Women with PCOS who are not seeking pregnancy commonly have symptoms such as excessive weight, hirsutism, and menstrual irregularities. This review focuses on interventions to manage those symptoms. The TABLE summarizes the results of the interventions.

Lifestyle modification improves symptoms; no benefit to adding metformin

A Cochrane meta-analysis of 6 RCTs with 164 patients compared LSM (with diet and exercise) and no or minimal intervention. LSM reduced weight more than minimal intervention (mean difference [MD]=-3.5 kg; 95% confidence interval [CI], -4.5 to -2.0).1 It also improved hirsutism, assessed with the 36-point FG score, where a lower score corresponds to less hirsutism (MD=-1.2 points, 95% CI, -2.4 to -0.1). No data were available on menstrual regularity.

A double-blind RCT comparing LSM alone with LSM plus metformin in 114 patients with PCOS found no difference in mean weight reduction (-2- to -3 kg, data from graph), ovulation rate, or androgen levels at 6 months.2 Six patients dropped out of the LSM-with-metformin group, whereas no patients dropped out of the LSM-alone group.

Evidence-based answers from the Family Physicians Inquiries Network

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