Tailoring treatment for PCOS phenotypes

ABSTRACT

Introduction: Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in reproductive-aged women. Hyperandrogenism, polycystic ovaries, chronic anovulation, and metabolic aberrations are its common features. The treatment approach focuses on the main aberrations, which characterize the different phenotypes.

Areas covered: Management strategies targeting the metabolic phenotype include lifestyle modifications for weight loss and improvement of dietary habits, as well as medication, such as insulin-sensitizers. The treatment of hyperandrogenic phenotype includes cosmetic procedures and the combined oral contraceptives with or without antiandrogens. The therapeutic approach to reproductive phenotype includes diet and lifestyle modifications, clomiphene citrate, and aromatase inhibitors. Alternative treatments include dietary supplements, herbs, resveratrol, myo-inositol, and acupuncture.

Expert opinion: New studies have shown that higher anti-Müllerian hormone levels, gut microbiome composition, and plasma metabolomics are new parameters that are related to the most severe phenotypes. The clinical phenotypes can change over the lifespan with weight gain and can coexist in the same individual. Individualized treatment remains the main approach but grouping the phenotypes and following therapeutic recommendations may prove to be also clinically appropriate.

KEYWORDS:

• Anovulation
• hyperandrogenism
• insulin resistance
• obesity phenotypes of PCOS
• polycystic ovary syndrome

Article highlights

• The diagnostic criteria involve clinical or biochemical hyperandrogenism, oligo- or anovulation, and for adult women presence of polycystic ovarian morphology on ultrasound examination. Ultrasound is not recommended in diagnosis in those within 8 years of menarche due to overlap with normal reproductive physiology [1]. Different combinations of these features result in different phenotypes.

• The therapeutic approach to the metabolic phenotype of PCOS includes diet, exercise, weight loss, bariatric surgery, insulin sensitizers, liraglutide, and statins.

• The therapeutic approach to the reproductive phenotype of PCOS includes oral contraceptives, weight loss, clomiphene citrate, letrozole, gonadotropins, and laparoscopic ovarian drilling.

• The therapeutic approach to the hyperandrogenic phenotype of PCOS includes oral contraceptives, antiandrogens, cosmetic procedures, eflornithine hydrochloride, and GnRH-agonists.

• Alternative therapies have emerged for the treatment of PCOS, including herbs and supplements, dietary interventions and acupuncture.

• According to new studies, abnormalities of anti-Müllerian hormone, stool microbiome, and plasma metabolomics could coexist in different PCOS phenotypes, without representing specific phenotypes as yet.

• The clinical phenotypes can also overlap, change over the lifespan, and can be modified especially if weight gain occurs.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.