Treatment of polycystic ovary syndrome
Patient information: Treatment of polycystic ovary syndrome Kathryn A Martin, MD Robert L Barbieri, MD David A Ehrmann, MD UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on April 21, 2006. The next version of UpToDate (14.3) will be released in October 2006. These materials are for your general information and are not a substitute for medical advice. You should contact your physician or other healthcare provider with any questions about your health, treatment, or care. Please do not contact UpToDate or the physician authors of these materials. DEFINITION — Polycystic ovary syndrome (PCOS) is a chronic condition in women that is characterized by irregular menstrual periods and elevated levels of androgens (male hormones), which can cause excessive facial hair growth, acne, and/or male-pattern baldness. Medications and lifestyle modifications can help control the signs and symptoms of PCOS. Medical and surgical treatment can also help women who are having difficulty becoming pregnant. Women with PCOS should take an active role in their medical care by learning as much as they can about the condition and by working with their doctor to develop the best treatment plan. SYMPTOMS AND TREATMENTS — Signs and symptoms of PCOS usually begin around the time of puberty, though some women do not develop symptoms until adulthood. Women with PCOS can have mild to severely elevated levels of androgens; some women have only mild acne, while others have more severe acne, facial hair growth, and scalp hair loss. Menstural irregularity — Women with PCOS usually have fewer than six to eight menstrual periods per year. Oral contraceptives — Oral contraceptives are the most commonly used treatment for establishing normal menstrual periods in women with PCOS. In addition to protecting the uterine lining by inducing a monthly menstrual period, they are also effective for treating hirsutism and acne. Women with PCOS can occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although the pill results in monthly menstrual periods, this does not mean that the PCOS is "cured"; irregular cycles generally return when the pill is stopped. (See "Patient information: Menstrual cycle disorders"). Before prescribing oral contraceptives, a clinician will perform an examination or a blood -*test*-('") to be certain that a woman is not pregnant. If a woman hasn't had a period for six weeks or longer, her doctor may first prescribe medroxyprogesterone acetate (Provera®) to induce a menstrual period. * Side effects — Some women who take oral contraceptives (not just those with PCOS) may notice amenorrhea (lack of menstrual periods) or breakthrough bleeding (bleeding that occurs at the wrong time of the month). Breakthrough bleeding usually resolves after a few menstrual cycles. Many women worry that they will gain weight on the pill. This is not a concern with the low-estrogen-dose pills that are now used. Some women develop nausea, breast tenderness, and bloating after beginning the pill, but these symptoms usually resolve after two or three months. The pill is very safe and effective, but it can occasionally raise blood pressure, cholesterol, blood sugar, and insulin levels. This is rarely a concern in normal, healthy women, but it is sometimes a concern in women with PCOS who are also obese. Therefore, it is important that women be followed closely by a doctor to have blood pressure, blood sugar, and blood cholesterol levels checked. Oral contraceptives slightly increase the risk of developing blood clots, although this is a rare complication in young, healthy women. The risk is higher in women older than 35 years and in smokers. Medroxyprogesterone acetate — Another method to treat the menstrual irregularity (and reduce the risk of uterine cancer), is to give medroxyprogesterone acetate for 10 to 14 days every one to three months. This will cause a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hirsutism and acne) and does not provide contraception. A modest amount of weight loss can also restore normal periods in some women. For example, many overweight women with PCOS who lose 5 to 10 percent of their body weight notice that their periods become more regular. Other medications — Insulin-sensitizing agents may be used to treat irregular menstrual periods (see "Insulin sensitizing drugs" below). Hirsutism and acne — Hirsutism is the growth of coarse body hair in a male pattern; ie, on the chin, neck, sideburn area, chest, and upper abdomen. Excess hair can be removed with local measures such as shaving, use of depilatories, electrolysis, and laser therapy. Many women worry that these local measures make hair grow faster, but this is not true. (See "Patient information: Causes and treatment of hirsutism"). Medications may be used for treatment of hirsutism and acne. Oral contraceptives decrease the body's production of androgens, and anti-androgen drugs (such as spironolactone) decrease the effect of androgens. Both treatments can lessen and slow hair growth. Oral contraceptives and antiandrogens can also reduce acne, although some women may also need topical and/or oral antibiotics. Persistent cases of acne may require consultation with a dermatologist. Insulin abnormalities — Obesity and insulin abnormalities are common among women with PCOS. Treatment of both conditions can decrease the ovary's production of androgens and reestablish the body's normal hormone balance. The end result is that some symptoms of PCOS improve. Weight loss — Weight loss is one of the simplest, yet most effective, approaches for managing insulin abnormalities, menstrual irregularities, and other symptoms of PCOS. Weight loss can often be achieved with a program of diet and exercise. However, many women with PCOS find it unusually difficult to lose weight. Insulin sensitizing drugs — Insulin-sensitizing drugs are another option for treating the insulin abnormalities associated with PCOS. This class of drugs includes metformin (Glucophage), a drug that is prescribed primarily for the treatment of diabetes. There are also other experimental drugs such as D-chiro-inositol that are now being -*test*-('")ed in PCOS. Metformin for women with PCOS has been receiving much attention in magazines, on television, and on the internet. In some women with PCOS, metformin is a reasonable alternative. In preliminary studies, metformin helps restore normal menstrual cycles in approximately 50 percent of women with PCOS. Blood androgen levels sometimes decrease, but there may not be much improvement in hirsutism or acne. In addition, metformin does not provide contraception. In fact, it might stimulate ovulation, so women must be careful in their use of this drug if they do not want to become pregnant. Because metformin often stimulates ovulation, it is sometimes used to help women with PCOS who are trying to conceive (see "Infertility" below). Metformin may also help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added. If metformin is used, it is essential that diet and exercise are also part of the recommended regimen. The weight that is lost in the early phase of metformin treatment is typically regained as time goes on. Infertility — If a woman with PCOS and her partner are having difficulty getting pregnant, a doctor usually first recommends that both individuals have thorough medical exams to determine the exact cause of infertility. These exams may include -*test*-('")s of the fallopian tubes in the woman and a semen analysis in the man. If -*test*-('")s determine that lack of ovulation due to PCOS is the cause of infertility, three options are available to promote ovulation and pregnancy. It is important to know that all of these options work best for women who are not obese. However, even a modest amount of weight loss can make these treatments more effective. (See "Patient information: Evaluation of the infertile couple"). Clomiphene citrate — The first line of treatment is the fertility drug clomiphene citrate, which stimulates the ovaries to release one or more eggs. Clomiphene triggers ovulation in about 80 percent of women with PCOS, and about 50 percent of these women will become pregnant. In women taking clomiphene, ovulation can be confirmed by blood and urine -*test*-('")s or by measurement of body temperature. If the original dose of clomiphene does not trigger ovulation, a woman's doctor may prescribe a higher dose. Several studies have shown that the insulin-sensitizing drug, metformin, increases the effectiveness of clomiphene in producing ovulation. However, it is unknown if this drug is safe during pregnancy, so we recommend that the drug be stopped once the woman is pregnant. Although there is some very preliminary information that metformin may lower the risk of early pregnancy loss, we do not yet recommend using metformin for this indication, because it requires taking the medication while pregnant. Gonadotropin therapy — If a woman does not ovulate or is unable to conceive with clomiphene, gonadotropin therapy may be used. This medical treatment for PCOS-related infertility uses gonadotropins (LH and FSH). FSH is used for women with PCOS, and is given as a daily injection under the skin for 7 to 10 days. These drugs trigger ovulation in almost all women with PCOS and can lead to pregnancy in approximately 60 percent. However, these drugs are expensive; In addition, there is a risk of overstimulating the ovaries and multiple gestations (twins, triplets, etc). Pregnancy complications — Studies suggest that pregnant women with PCOS have an higher rate of miscarriage and risk of developing gestational diabetes (diabetes during pregnancy) compared to women without PCOS. However, infants of women with PCOS do not appear to have differences in height, weight, motor, or social development. Pregnant women with PCOS should discuss these issues with her doctor. ASSOCIATED HEALTH PROBLEMS — Although PCOS is primarily a problem of the ovaries, the condition alters hormone levels and affects tissues throughout the body. Most of these effects can be anticipated and thus prevented or promptly treated before they pose significant health problems. All women with PCOS should be monitored by a doctor and should discuss treatment options for their condition. In some women, symptoms of PCOS may be minor and simply annoying, and treatment may seem unnecessary. However, untreated PCOS may increase a woman's risk of other health problems over time. Weight gain and obesity — PCOS is associated with gradual weight gain and obesity in about one-half of the women with this condition. Diet and exercise can help maintain a normal body weight. For some women with PCOS, the obesity develops at the time of puberty. (See "Patient information: Diet and health" and see "Patient information: Therapy for obesity"). Insulin abnormalities and diabetes — PCOS is also associated with abnormal blood insulin levels, the hormone that regulates blood sugar levels. These abnormalities may include: * Hyperinsulinemia (excess production of insulin) * Insulin resistance (poor response of body tissues to insulin) * Impaired glucose tolerance (a condition of borderline diabetes mellitus) * Type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus, a condition characterized by elevated blood sugar levels) Insulin resistance and hyperinsulinemia can occur in both normal-weight and overweight women with PCOS. By age 40, up to 35 percent of obese women with PCOS develop impaired glucose tolerance, and up to 10 percent of obese women with PCOS develop type 2 diabetes. These rates are much higher than expected for normal women at this young age. Impaired glucose tolerance and diabetes are usually detected by blood -*test*-('")s. Often a fasting blood -*test*-('") is sufficient, but sometimes a glucose tolerance -*test*-('") is needed. Weight loss, exercise, and drugs can help normalize blood sugar levels. (See "Patient information: Diabetes mellitus"). Heart disease — The presence of both obesity and insulin resistance might increase a woman's risk for coronary artery disease, which is the narrowing of the arteries that supply blood to the heart. Both weight loss and treatment of insulin abnormalities can decrease this risk. Women with PCOS should discuss with their doctor other measures for keeping their cardiovascular system healthy. Uterine cancer — The hormonal imbalance of PCOS can promote persistent growth of the endometrium (the lining of the uterus), increasing a woman's risk of uterine cancer over time. Treatment with oral contraceptives or intermittent progesterone-like drugs can promote normal menstrual bleeding and lessen overgrowth of the endometrium. Sleep apnea — Sleep apnea has been reported to occur in up to 30 percent of women with PCOS. This is a disorder characterized by excessive snoring at night with brief spells where breathing stops (apnea). Patients with this problem experience fatigue and daytime sleepiness. It can be diagnosed on a sleep study, and there are a variety of treatments available. (See "Patient information: Sleep apnea"). WHERE TO GET MORE INFORMATION — Your healthcare provider is the best resource for finding out important information related to your particular case. Not all patients with PCOS are alike, and it is important that your situation is evaluated by someone who knows you as a whole person. This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for health care professionals are also available for those who would like more detailed information. Some of the most pertinent include: Professional Level Information: Clinical features and diagnosis of polycystic ovary syndrome in adolescents Treatment of polycystic ovary syndrome in adolescents Clinical manifestations of polycystic ovary syndrome in adults Diagnosis and treatment of polycystic ovary syndrome in adults Treatment of hirsutism Laparoscopic surgery for ovulation induction in polycystic ovary syndrome Steroid hormone metabolism in polycystic ovary syndrome A number of other sites on the internet have information about PCOS. Information provided by the National Institutes of Health, national medical societies, and some other well-established organizations are often reliable sources of information, although the frequency with which their information is updated is variable. * National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.html) * The Hormone Foundation (www.hormone.org) * U.S. Department of Health and Human Services (www.4woman.gov/faq/pcos.htm) * American Academy of Family Physicians (www.familydoctor.org) * The Nemours Foundation (http://kidshealth.org/teen/sexual_health/girls/pcos.html) <1-4> Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ehrmann, DA, Cavaghan, MK, Barnes, RB, et al. Prevalence of impaired glucose tolerance and diabetes in women with Polycystic Ovary Syndrome. Diabetes Care 1999; 22:141. 2. Adams, J, Polson, DW, Franks, S. Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism. BMJ 1986; 293:355. 3. Huber-Buchholz, MM, Carey, DG, Norman, RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: Role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab 1999; 84:1470. 4. Nestler, JE, Jakubowicz, DJ, Evans, WS, Pasquali, R. Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 1998; 338:1876.
Patient information: Treatment of polycystic ovary syndrome Kathryn A Martin, MD Robert L Barbieri, MD David A Ehrmann, MD UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on April 21, 2006. The next version of UpToDate (14.3) will be released in October 2006. These materials are for your general information and are not a substitute for medical advice. You should contact your physician or other healthcare provider with any questions about your health, treatment, or care. Please do not contact UpToDate or the physician authors of these materials. DEFINITION — Polycystic ovary syndrome (PCOS) is a chronic condition in women that is characterized by irregular menstrual periods and elevated levels of androgens (male hormones), which can cause excessive facial hair growth, acne, and/or male-pattern baldness. Medications and lifestyle modifications can help control the signs and symptoms of PCOS. Medical and surgical treatment can also help women who are having difficulty becoming pregnant. Women with PCOS should take an active role in their medical care by learning as much as they can about the condition and by working with their doctor to develop the best treatment plan. SYMPTOMS AND TREATMENTS — Signs and symptoms of PCOS usually begin around the time of puberty, though some women do not develop symptoms until adulthood. Women with PCOS can have mild to severely elevated levels of androgens; some women have only mild acne, while others have more severe acne, facial hair growth, and scalp hair loss. Menstural irregularity — Women with PCOS usually have fewer than six to eight menstrual periods per year. Oral contraceptives — Oral contraceptives are the most commonly used treatment for establishing normal menstrual periods in women with PCOS. In addition to protecting the uterine lining by inducing a monthly menstrual period, they are also effective for treating hirsutism and acne. Women with PCOS can occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although the pill results in monthly menstrual periods, this does not mean that the PCOS is "cured"; irregular cycles generally return when the pill is stopped. (See "Patient information: Menstrual cycle disorders"). Before prescribing oral contraceptives, a clinician will perform an examination or a blood -*test*-('") to be certain that a woman is not pregnant. If a woman hasn't had a period for six weeks or longer, her doctor may first prescribe medroxyprogesterone acetate (Provera®) to induce a menstrual period. * Side effects — Some women who take oral contraceptives (not just those with PCOS) may notice amenorrhea (lack of menstrual periods) or breakthrough bleeding (bleeding that occurs at the wrong time of the month). Breakthrough bleeding usually resolves after a few menstrual cycles. Many women worry that they will gain weight on the pill. This is not a concern with the low-estrogen-dose pills that are now used. Some women develop nausea, breast tenderness, and bloating after beginning the pill, but these symptoms usually resolve after two or three months. The pill is very safe and effective, but it can occasionally raise blood pressure, cholesterol, blood sugar, and insulin levels. This is rarely a concern in normal, healthy women, but it is sometimes a concern in women with PCOS who are also obese. Therefore, it is important that women be followed closely by a doctor to have blood pressure, blood sugar, and blood cholesterol levels checked. Oral contraceptives slightly increase the risk of developing blood clots, although this is a rare complication in young, healthy women. The risk is higher in women older than 35 years and in smokers. Medroxyprogesterone acetate — Another method to treat the menstrual irregularity (and reduce the risk of uterine cancer), is to give medroxyprogesterone acetate for 10 to 14 days every one to three months. This will cause a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hirsutism and acne) and does not provide contraception. A modest amount of weight loss can also restore normal periods in some women. For example, many overweight women with PCOS who lose 5 to 10 percent of their body weight notice that their periods become more regular. Other medications — Insulin-sensitizing agents may be used to treat irregular menstrual periods (see "Insulin sensitizing drugs" below). Hirsutism and acne — Hirsutism is the growth of coarse body hair in a male pattern; ie, on the chin, neck, sideburn area, chest, and upper abdomen. Excess hair can be removed with local measures such as shaving, use of depilatories, electrolysis, and laser therapy. Many women worry that these local measures make hair grow faster, but this is not true. (See "Patient information: Causes and treatment of hirsutism"). Medications may be used for treatment of hirsutism and acne. Oral contraceptives decrease the body's production of androgens, and anti-androgen drugs (such as spironolactone) decrease the effect of androgens. Both treatments can lessen and slow hair growth. Oral contraceptives and antiandrogens can also reduce acne, although some women may also need topical and/or oral antibiotics. Persistent cases of acne may require consultation with a dermatologist. Insulin abnormalities — Obesity and insulin abnormalities are common among women with PCOS. Treatment of both conditions can decrease the ovary's production of androgens and reestablish the body's normal hormone balance. The end result is that some symptoms of PCOS improve. Weight loss — Weight loss is one of the simplest, yet most effective, approaches for managing insulin abnormalities, menstrual irregularities, and other symptoms of PCOS. Weight loss can often be achieved with a program of diet and exercise. However, many women with PCOS find it unusually difficult to lose weight. Insulin sensitizing drugs — Insulin-sensitizing drugs are another option for treating the insulin abnormalities associated with PCOS. This class of drugs includes metformin (Glucophage), a drug that is prescribed primarily for the treatment of diabetes. There are also other experimental drugs such as D-chiro-inositol that are now being -*test*-('")ed in PCOS. Metformin for women with PCOS has been receiving much attention in magazines, on television, and on the internet. In some women with PCOS, metformin is a reasonable alternative. In preliminary studies, metformin helps restore normal menstrual cycles in approximately 50 percent of women with PCOS. Blood androgen levels sometimes decrease, but there may not be much improvement in hirsutism or acne. In addition, metformin does not provide contraception. In fact, it might stimulate ovulation, so women must be careful in their use of this drug if they do not want to become pregnant. Because metformin often stimulates ovulation, it is sometimes used to help women with PCOS who are trying to conceive (see "Infertility" below). Metformin may also help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added. If metformin is used, it is essential that diet and exercise are also part of the recommended regimen. The weight that is lost in the early phase of metformin treatment is typically regained as time goes on. Infertility — If a woman with PCOS and her partner are having difficulty getting pregnant, a doctor usually first recommends that both individuals have thorough medical exams to determine the exact cause of infertility. These exams may include -*test*-('")s of the fallopian tubes in the woman and a semen analysis in the man. If -*test*-('")s determine that lack of ovulation due to PCOS is the cause of infertility, three options are available to promote ovulation and pregnancy. It is important to know that all of these options work best for women who are not obese. However, even a modest amount of weight loss can make these treatments more effective. (See "Patient information: Evaluation of the infertile couple"). Clomiphene citrate — The first line of treatment is the fertility drug clomiphene citrate, which stimulates the ovaries to release one or more eggs. Clomiphene triggers ovulation in about 80 percent of women with PCOS, and about 50 percent of these women will become pregnant. In women taking clomiphene, ovulation can be confirmed by blood and urine -*test*-('")s or by measurement of body temperature. If the original dose of clomiphene does not trigger ovulation, a woman's doctor may prescribe a higher dose. Several studies have shown that the insulin-sensitizing drug, metformin, increases the effectiveness of clomiphene in producing ovulation. However, it is unknown if this drug is safe during pregnancy, so we recommend that the drug be stopped once the woman is pregnant. Although there is some very preliminary information that metformin may lower the risk of early pregnancy loss, we do not yet recommend using metformin for this indication, because it requires taking the medication while pregnant. Gonadotropin therapy — If a woman does not ovulate or is unable to conceive with clomiphene, gonadotropin therapy may be used. This medical treatment for PCOS-related infertility uses gonadotropins (LH and FSH). FSH is used for women with PCOS, and is given as a daily injection under the skin for 7 to 10 days. These drugs trigger ovulation in almost all women with PCOS and can lead to pregnancy in approximately 60 percent. However, these drugs are expensive; In addition, there is a risk of overstimulating the ovaries and multiple gestations (twins, triplets, etc). Pregnancy complications — Studies suggest that pregnant women with PCOS have an higher rate of miscarriage and risk of developing gestational diabetes (diabetes during pregnancy) compared to women without PCOS. However, infants of women with PCOS do not appear to have differences in height, weight, motor, or social development. Pregnant women with PCOS should discuss these issues with her doctor. ASSOCIATED HEALTH PROBLEMS — Although PCOS is primarily a problem of the ovaries, the condition alters hormone levels and affects tissues throughout the body. Most of these effects can be anticipated and thus prevented or promptly treated before they pose significant health problems. All women with PCOS should be monitored by a doctor and should discuss treatment options for their condition. In some women, symptoms of PCOS may be minor and simply annoying, and treatment may seem unnecessary. However, untreated PCOS may increase a woman's risk of other health problems over time. Weight gain and obesity — PCOS is associated with gradual weight gain and obesity in about one-half of the women with this condition. Diet and exercise can help maintain a normal body weight. For some women with PCOS, the obesity develops at the time of puberty. (See "Patient information: Diet and health" and see "Patient information: Therapy for obesity"). Insulin abnormalities and diabetes — PCOS is also associated with abnormal blood insulin levels, the hormone that regulates blood sugar levels. These abnormalities may include: * Hyperinsulinemia (excess production of insulin) * Insulin resistance (poor response of body tissues to insulin) * Impaired glucose tolerance (a condition of borderline diabetes mellitus) * Type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus, a condition characterized by elevated blood sugar levels) Insulin resistance and hyperinsulinemia can occur in both normal-weight and overweight women with PCOS. By age 40, up to 35 percent of obese women with PCOS develop impaired glucose tolerance, and up to 10 percent of obese women with PCOS develop type 2 diabetes. These rates are much higher than expected for normal women at this young age. Impaired glucose tolerance and diabetes are usually detected by blood -*test*-('")s. Often a fasting blood -*test*-('") is sufficient, but sometimes a glucose tolerance -*test*-('") is needed. Weight loss, exercise, and drugs can help normalize blood sugar levels. (See "Patient information: Diabetes mellitus"). Heart disease — The presence of both obesity and insulin resistance might increase a woman's risk for coronary artery disease, which is the narrowing of the arteries that supply blood to the heart. Both weight loss and treatment of insulin abnormalities can decrease this risk. Women with PCOS should discuss with their doctor other measures for keeping their cardiovascular system healthy. Uterine cancer — The hormonal imbalance of PCOS can promote persistent growth of the endometrium (the lining of the uterus), increasing a woman's risk of uterine cancer over time. Treatment with oral contraceptives or intermittent progesterone-like drugs can promote normal menstrual bleeding and lessen overgrowth of the endometrium. Sleep apnea — Sleep apnea has been reported to occur in up to 30 percent of women with PCOS. This is a disorder characterized by excessive snoring at night with brief spells where breathing stops (apnea). Patients with this problem experience fatigue and daytime sleepiness. It can be diagnosed on a sleep study, and there are a variety of treatments available. (See "Patient information: Sleep apnea"). WHERE TO GET MORE INFORMATION — Your healthcare provider is the best resource for finding out important information related to your particular case. Not all patients with PCOS are alike, and it is important that your situation is evaluated by someone who knows you as a whole person. This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for health care professionals are also available for those who would like more detailed information. Some of the most pertinent include: Professional Level Information: Clinical features and diagnosis of polycystic ovary syndrome in adolescents Treatment of polycystic ovary syndrome in adolescents Clinical manifestations of polycystic ovary syndrome in adults Diagnosis and treatment of polycystic ovary syndrome in adults Treatment of hirsutism Laparoscopic surgery for ovulation induction in polycystic ovary syndrome Steroid hormone metabolism in polycystic ovary syndrome A number of other sites on the internet have information about PCOS. Information provided by the National Institutes of Health, national medical societies, and some other well-established organizations are often reliable sources of information, although the frequency with which their information is updated is variable. * National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.html) * The Hormone Foundation (www.hormone.org) * U.S. Department of Health and Human Services (www.4woman.gov/faq/pcos.htm) * American Academy of Family Physicians (www.familydoctor.org) * The Nemours Foundation (http://kidshealth.org/teen/sexual_health/girls/pcos.html) <1-4> Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ehrmann, DA, Cavaghan, MK, Barnes, RB, et al. Prevalence of impaired glucose tolerance and diabetes in women with Polycystic Ovary Syndrome. Diabetes Care 1999; 22:141. 2. Adams, J, Polson, DW, Franks, S. Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism. BMJ 1986; 293:355. 3. Huber-Buchholz, MM, Carey, DG, Norman, RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: Role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab 1999; 84:1470. 4. Nestler, JE, Jakubowicz, DJ, Evans, WS, Pasquali, R. Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 1998; 338:1876.