Polycystic Ovary Syndrome (PCOS) is one of the most common female endocrine disorders and is now recognized to be a Metabolic Syndrome. The World Health Organization estimates that it affects 116 million women worldwide as of 2010 (3.4% of the population).
What is PCOS?
Polycystic Ovary Syndrome (PCOS) is a common disorder, affecting 5-10% of women of reproductive age. Women with PCOS have a number of conditions that may include irregular menstrual cycles, an increase in facial and body hair, increased weight, hyperinsulinemia and infertility. Diagnosis is made on the basis of a combination of clinical, laboratory and ultrasound findings.
How is PCOS diagnosed?
PCOS is diagnosed based on the inability to release an egg from the ovaries on a regular (monthly) basis, increased male hormone levels and/or an increase in hair in the midline of the body (hyperandrogenism), and polycystic-appearing ovaries on ultrasound. Because of the variable nature of PCOS, its diagnosis is based upon the combination of clinical, ultrasound and laboratory features.
What risks do women with PCOS have?
Lack of ovulation in women with PCOS results in continuous exposure of their uterine lining (endometrium) to estrogen. This may cause excessive thickening of the uterine lining and abnormal bleeding. The bombardment of estrogen without ovulation may lead to eventual uterine cancer or pre-cancer. Metabolic syndrome along with hyperinsulinemia is more common in obese women with PCOS. This condition is characterized by abdominal Obesity, Cholesterol abnormalities, Hypertension and Insulin Resistance/ Diabetes Mellitus. Each of these increases the risk of Heart Disease. Obesity is noted in over 70% of women with PCOS. Diet and exercise that result in weight loss improve the frequency of ovulation, enhance the ability to get pregnant, lower the risk of Diabetes and lower androgen levels in many women with PCOS. All hyperinsulinemic PCOS patients need long-term Metformin therapy for the above-mentioned beneficial effects.
What is the link between PCOS and Insulin/ Glucose Abnormalities?
A majority of women with PCOS have decreased sensitivity to Insulin due to increased weight. Higher levels of Insulin are needed to keep sugar levels under control in overweight PCOS patients. The resulting high levels of Insulin may contribute to excessive production of male hormones (such as Testosterone) and can lead to problems with Ovulation (timely release of an egg).
Can Metformin be taken by Hyperinsulinemic teenage PCOS girls? How long can uninterrupted Metformin be taken?
Metformin is safe to use in teenage girls who have PCOS and Hyperinsulinemia. Long-term Metformin therapy can be started when PCOS is first diagnosed, with the goal of lowering the risks of Diabetes, Infertility and Heart Disease after the age of 40 years. There is no particular time limit for the use of Metformin. For patients on long term Metformin, Serum Insulin levels and Liver Function Tests should be done on a yearly basis.
If no beneficial effect is seen even after 6 months of Metformin, there is no point in continuing it.
How is Insulin Resistance diagnosed?
A 12-hour fasting Serum Insulin of more than 10 mIU/mL diagnoses Hyperinsulinemia and Insulin Resistance.
What are the options to treat Insulin Resistance?
Regular exercise, weight loss and improved nutrition are very important. Behavioral change should be the first line of therapy for an overweight woman with PCOS. Oral Insulin Sensitizing Agents like Metformin are used in conjunction with other sensitizers like Chromium Picolinate.
How is infertility in women with PCOS treated?
Ovulation may often be induced with Clomiphene Citrate (CC), an orally administered fertility medication. In hyperinsulinemic PCOS women, a 1-3 month pre-treatment with Metformin helps in the ovulation induction process. Gonadotropins (injectable fertility medications) may be used to induce ovulation if CC does not result in ovulation or pregnancy. However, gonadotropins are associated with a higher risk of Multiple Pregnancy and/or overstimulation of the ovaries (Ovarian Hyperstimulation Syndrome). Therefore, PCOS patients must be monitored very carefully when gonadotropins are utilized.
Should all PCOS patients be started on Metformin?
No. Metformin should be given only if associated Hyperinsulinemia is diagnosed.
Should Metformin continue during fertility treatment & pregnancy?
For hyperinsulinemic PCOS patients, the continuation of Metformin during fertility treatment improves pregnancy rates.
While safety during pregnancy has not yet been established, patients who inadvertently continued Metformin during their entire pregnancy delivered normal babies.Continued use during pregnancy has been shown to reduce the risk of miscarriage and of developing Diabetes during pregnancy.
Are women with PCOS at a greater risk of complications during pregnancy?
Women with PCOS are at a greater risk of complications during pregnancy, including Miscarriage, Diabetes (Gestational Diabetes), Preterm Birth, and increased Fetal and Neonatal Death.
– Dr. Gautam Allahbadia
