What are the effects of steroids on a female patient with a history of menstrual irregularities and difficulty conceiving, such as polycystic ovary syndrome (PCOS)?

Steroids in PCOS: Effects and Management Considerations

Direct Answer

Corticosteroids are not recommended for treatment of PCOS and can worsen the condition by exacerbating insulin resistance, promoting weight gain, and potentially triggering or worsening metabolic complications including gestational diabetes. 1

Understanding Steroid Effects in PCOS

Endogenous Steroid Abnormalities in PCOS

Women with PCOS demonstrate characteristic alterations in their endogenous steroid profile that contribute to the pathophysiology of the condition:

• Elevated androgens including testosterone (>2.5 nmol/L) and androstenedione are hallmark features, with the ovary being the primary source of excess androgen production 1
• Increased 17-hydroxyprogesterone levels are commonly observed, reflecting altered ovarian steroidogenesis 1
• Multiple androgen biosynthetic pathways are upregulated, including the classic pathway, backdoor pathway, and C11-oxy pathways, with overall higher steroid metabolite levels across all pathways compared to healthy women 2
• Enhanced 3β-hydroxysteroid dehydrogenase activity (product:precursor ratio 22% vs 20% in controls) contributes to increased androgen production 3

Exogenous Corticosteroid Risks

When corticosteroids are administered to women with PCOS (such as for other medical conditions), they pose specific risks:

• Worsening insulin resistance and hyperglycemia, which are already problematic in PCOS patients who frequently have baseline glucose/insulin ratio >4 1
• Promotion of weight gain, which can trigger or worsen PCOS manifestations in predisposed women, as obesity reduces insulin sensitivity and promotes PCOS development 1
• Exacerbation of gestational diabetes if used during pregnancy 1
• Increased infection risk, osteopenia, hypertension, and cataract formation with prolonged use 1

Clinical Implications and Monitoring

When Corticosteroids Cannot Be Avoided

If a woman with PCOS requires corticosteroid therapy for another medical condition (e.g., autoimmune disease, organ transplantation):

• Screen for type 2 diabetes with fasting glucose and 2-hour glucose tolerance test before initiating therapy and monitor regularly 4
• Obtain fasting lipoprotein profile to assess baseline dyslipidemia risk 4
• Monitor weight changes closely every 6-12 months, as even 5% weight gain can worsen metabolic and reproductive abnormalities 4
• Check blood pressure at least annually, as both PCOS and corticosteroids independently increase hypertension risk 1, 4
• Consider metformin co-therapy for patients with abdominal obesity and insulin resistance, though be aware that metformin can increase homocysteine levels (a cardiovascular risk factor) 5

Distinguishing Steroid Effects from PCOS

When evaluating a patient on corticosteroids with menstrual irregularities:

• Document medication use carefully, as corticosteroids can cause menstrual irregularities independent of PCOS 6
• Measure LH/FSH ratio: A ratio >2 strongly suggests PCOS, while corticosteroid-induced menstrual dysfunction typically does not show this pattern 1, 6
• Assess androgen levels: Testosterone >2.5 nmol/L and elevated androstenedione suggest PCOS rather than isolated corticosteroid effect 1, 6
• Evaluate for polycystic ovaries on ultrasound: >10 peripheral cysts (2-8 mm diameter) with thickened ovarian stroma supports PCOS diagnosis 1

Critical Pitfalls to Avoid

• Do not assume corticosteroids will improve PCOS symptoms—they will not address the underlying hyperandrogenism and may worsen metabolic complications 1
• Do not overlook the cumulative metabolic burden when corticosteroids are combined with PCOS, as both conditions independently increase cardiovascular disease risk through insulin resistance, dyslipidemia, and hypertension 1, 4
• Do not fail to counsel about contraception, as women with PCOS on corticosteroids can still ovulate unpredictably, and corticosteroids pose teratogenic risks during pregnancy 1
• Do not neglect bone health monitoring, as both PCOS (through potential vitamin D deficiency and irregular cycles) and corticosteroids independently affect bone mineral density 1