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Side effects include:

• Fluid retention
• Mood swings
• Weight gain
• Headaches
• Nausea
• Fatigue

Ketoconazole

Ketoconazole is an antifungal agent that inhibits androgen biosynthesis. It is toxic to the liver) and, therefore, is not a first-line antiandrogen therapy.

Oral Contraceptives

Oral contraceptives are synthetic hormones that mimic the natural hormones produced by the body. They consist of synthetic estrogen and progestin (alone or combined). Oral contraceptives reduce gonadotropin stimulation of the ovary and by doing so, reduce the production of androgen. They also raise the SHBG concentrations, thereby reducing the level of free testosterone in the blood. In addition, by manipulating the amount of these synthetic hormones, it is possible to cause the build up of the endometrium to a sufficient level so that if there is no conception, it will slough off in a menstrual cycle. Thus the oral contraceptive can be used also to regulate the menstrual cycle.

There are few studies that have compared different types of oral contraceptives. Responses to oral contraceptives are very individualized and can vary from woman to woman. Since the oral contraceptives contain different progestogens with different androgen potencies, it is reasonable to prescribe one with a low androgenic profile, such as drospirenone. The effect of oral contraceptives on obesity is not clear.

Oral contraceptives are often given together with other types of medication since they seem to enhance the effects of other drugs and the combined action of both drugs is sometimes greater than for each drug separately.

Limitations of oral contraceptive may include:

• Reappearance of symptoms when treatment is stopped
• No effect on the metabolic aspects of PCOS (insulin resistance)

Side effects of oral contraceptives include:

• Stroke
• Blood clots
• Liver cancer

These side effects are rare but the risk of stroke is elevated if the woman smokes cigarettes while taking oral contraceptives.

Insulin Sensitizing Drugs

Whereas many medications treat the symptoms of PCOS, insulin-sensitizing drugs are given to correct the underlying metabolic dysfunction of insulin resistance and do so at a relatively low risk and low cost. They are effective in decreasing hyperinsulinemia and thereby improving almost all symptoms, including reproductive function.

There is ongoing debate regarding whether treatment of women with PCOS who are insulin resistant reduces the risk of developing type II diabetes.

There are two types of insulin sensitizing agents - biguanides and glitazones. Neither has been approved by the FDA specifically for use in women with PCOS.

Biguanides

Metformin (Glucophage) was approved by the FDA for the treatment of Type II diabetes and insulin resistance that could not be adequately controlled by diet. It has not received FDA approval for treatment of PCOS though it is widely used. Metformin is considered a first-line drug therapy of the various insulin sensitizing agents. It lowers insulin levels by inhibiting hepatic (liver) glucose production, reduces the amount of glucose absorbed from food, and enhances the effect of insulin to reduce blood glucose.

Benefits of reduced glucose include:

• Increase in ovulatory rates
• Resumption of menstrual cycle
• Reduced waist:hip ratio
• Lower levels of androgens