The Benefits of Anti-Androgens in Managing PCOS Symptoms

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects many women worldwide. It is characterized by high levels of androgens, such as testosterone, which can lead to a variety of symptoms including hirsutism (excessive hair growth), acne, and irregular menstrual cycles. While combined oral contraceptive pills are often used to manage PCOS symptoms, they may not be suitable for all patients. A recent systematic review and meta-analysis has found that anti-androgens, in combination with metformin and lifestyle intervention, may be beneficial for managing certain hyperandrogenism-related symptoms of PCOS.

The study, conducted by Aya Mousa, PhD, and colleagues from Monash University, analyzed data from 13 studies involving a total of 961 patients. The researchers found that combination treatment with antiandrogens, metformin, and lifestyle intervention was effective in lowering testosterone levels in patients with PCOS compared to metformin and lifestyle intervention alone. Adding anti-androgens to lifestyle intervention also showed superiority in managing hirsutism, sex-hormone binding globulin (SHBG), fasting insulin, and fasting insulin to glucose ratio.

However, the combination of anti-androgens and lifestyle intervention was not found to be superior to lifestyle intervention alone in terms of hirsutism and SHBG. It is important to note that the study recommends considering the use of anti-androgen pharmacological agents for treating clinical hyperandrogenism (hirsutism) only when other treatments are contraindicated or ineffective. The use of anti-androgens may cause under-virilization of a male fetus, and therefore, caution should be exercised in prescribing these medications to women of childbearing age.

The study did not provide specific recommendations on optimal doses or formulations of anti-androgens 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. On the other hand, higher doses of cyproterone acetate (10+ mg) could potentially lead to meningioma or venous thromboembolism. Flutamide and bicalutamide were associated with increased risks of liver toxicity.

Despite the benefits of anti-androgens in managing PCOS symptoms, the study emphasizes that combined oral contraceptive pills should still be strongly recommended as the first-line treatment option. Anti-androgens should only be considered in cases where combined oral contraceptive pills are contraindicated, poorly tolerated, or present suboptimal response after a minimum period of six months.

Individual circumstances and perspectives should also be taken into account when making treatment decisions. Clinical judgment is crucial in determining the appropriate course of action for each patient. Additionally, daily use of anti-androgens was found to be more effective in managing hirsutism and lowering androstenedione levels compared to dosing every 3 days.

Safety Concerns

The study highlighted safety concerns regarding the combination of anti-androgens with combined oral contraceptive pills. Limited meta-analysis of two trials showed that lipid profiles were worse in patients taking both medications compared to those taking oral contraceptive pills alone. This suggests that caution should be exercised when combining these two treatment modalities.

Anti-androgens, when used in combination with metformin and lifestyle intervention, may be beneficial in managing certain symptoms of PCOS. They have been shown to effectively lower testosterone levels and improve hirsutism, SHBG, fasting insulin, and fasting insulin to glucose ratio. However, it is important to consider individual circumstances and perspectives when making treatment decisions. The use of anti-androgens should be reserved for cases where other treatments are contraindicated, poorly tolerated, or ineffective. Further research is needed to determine the optimal doses and formulations of these medications. The findings of this study have directly informed the recommendations of the upcoming International Evidence-based Guideline for the Assessment and Management of PCOS.