Polycystic ovary syndrome (PCOS) is a complex endocrine disorder that affects many women worldwide. It is characterized by hyperandrogenism, which results in symptoms such as hirsutism, acne, and irregular menstrual cycles. Traditionally, combined oral contraceptive pills (COCPs) have been the primary treatment for PCOS; however, they may not be suitable for all patients. In recent years, there has been growing interest in the use of anti-androgens as an alternative treatment for PCOS symptoms. A systematic review and meta-analysis conducted by Aya Mousa and colleagues shed light on the potential benefits and limitations of using anti-androgens in managing PCOS symptoms.
The study included data from 13 studies involving 961 patients. The findings revealed that combination treatment with anti-androgens, metformin, and lifestyle intervention led to a significant reduction in testosterone levels compared to metformin and lifestyle intervention alone. Additionally, the combination treatment was superior in managing hirsutism, sex-hormone binding globulin (SHBG) levels, fasting insulin, and fasting insulin to glucose ratio. These results indicate that anti-androgens could be a viable option for managing certain PCOS symptoms, particularly when COCPs are contraindicated, poorly tolerated, or ineffective.
However, it is important to note that the combination of anti-androgens and lifestyle intervention did not show superiority in managing hirsutism and SHBG levels when compared to lifestyle intervention alone. This suggests that anti-androgens may not be the sole solution for these specific symptoms of PCOS.
The authors of the study recommend considering the use of anti-androgens in situations where COCPs and cosmetic therapies are not suitable or do not provide adequate results after a minimum period of six months. Nevertheless, they emphasize that COCPs should still be strongly recommended for managing PCOS symptoms when appropriate. It is also crucial to inform patients about the potential risk of under-virilization of a male fetus when using anti-androgens.
It is important to view these recommendations as general guidelines and to take individual circumstances and perspectives into account when making treatment decisions. Clinical judgment should always prevail in determining the most suitable approach for each patient.
The study did not provide specific recommendations regarding optimal doses or formulations of anti-androgen therapies due to the heterogeneity of the included studies. However, general population recommendations suggest that spironolactone at doses of 25-100 mg daily may have lower risks of adverse effects, while higher doses of cyproterone acetate (10+ mg) could potentially lead to meningioma or venous thromboembolism. Flutamide and bicalutamide are associated with increased risks of liver toxicity.
Regarding safety, combining anti-androgens with COCPs may lead to worse lipid profiles compared to taking COCPs alone. This should be taken into consideration when deciding on the appropriate treatment option for each patient.
The use of anti-androgens in managing symptoms of PCOS shows promise as an alternative treatment option. The combination of anti-androgens with metformin and lifestyle intervention has demonstrated benefits in lowering testosterone levels and managing certain PCOS symptoms. However, it is important to consider individual circumstances, safety considerations, and the potential limitations of anti-androgen therapies. The forthcoming International Evidence-based Guideline for the Assessment and Management of PCOS is expected to provide more detailed recommendations for the use of anti-androgens in PCOS management.