Anti-androgens may be used for hyperandrogenism in PCOS when oral contraceptives contraindicated

According to the researchers of this study, they have addressed critical gaps in the literature and directly informed the current 2023 update of the International Evidence-based Guideline for managing PCOS.

Based on the review, the guideline recommends that anti-androgen pharmacological agents be considered for treating clinical hirsutism in cases of contraindicated COCP and cosmetic therapies.

It is also mentioned that, where appropriate, using effective contraception is strongly recommended. They noted women should be advised that anti-androgens may cause under-virilisation of a male fetus.

Therefore, the recommendation remains general and should not override clinical judgment with consideration of individual circumstances and perspectives.

This study, "Efficacy and safety of anti-androgens in the management of polycystic ovary syndrome: a systematic review and meta-analysis of randomised controlled trials", is conducted by lead researcher Dr Simon Alesi. The co-author is Dr Maria Forslund.

Dr Alesi et al. explained that Anti-androgens and combined oral contraceptive pills (COCPs) may mitigate hyperandrogenism-related symptoms of PCOS.

There needs to be more research to determine their efficacy and safety in PCOS as this background remains unclear and previous reviews have focused on non-PCOS populations. We further investigated the background (to inform the 2023 International Evidence-based Guideline in PCOS) using databases like MEDLINE, Embase, PsycInfo, All EBM reviews, and CINAHL up to 28th June 2023 for relevant RCTs.

The critical points of this study are:

• Researchers identified 1660 studies.
• Twenty-seven articles had 20 unique studies.
• Thirteen studies (n = 961) were pooled in the meta-analysis.
• They included Anti-androgens finasteride, flutamide, spironolactone, or bicalutamide.
• They found a combo of anti-androgens and lifestyle to be superior to a combo of metformin and lifestyle for hirsutism but were not superior to placebo + lifestyle for hirsutism.
• There was more effectiveness with Daily usage compared to the use every three days for managing hirsutism. The levels of androstenedione lowered.
• A combo of anti-androgens, metformin and lifestyle caused lower testosterone than metformin and lifestyle.
• There were no differences in hirsutism when anti-androgens + metformin + lifestyle were compared with either anti-androgens + lifestyle or metformin + lifestyle.
• Combining anti-androgens with COCP caused poorer lipid profiles than COCP ± placebo, with no differences in other outcomes.

They wrote, "Current evidence does not support the use of anti-androgens preferentially to COCPs to treat hyperandrogenism in PCOS. "

As acknowledged, the study was funded by the National Health and Medical Research Council (NHMRC) of Australia Monash University.

They mentioned, "To our knowledge, this is the first systematic review and meta-analysis that has examined the use of anti-androgens specifically in women with PCOS. "

Further reading:

https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00339-5/fulltext