PCOS

PCOS – Polycystic Ovary Syndrome. A common condition with many small cysts around the periphery of the ovaries and a tendency to be  overweight. Those resistant to treatment may respond to cauterising a few  small spots on the ovarian surface.

PCOS-diagnosisPCOS-presentation-treatment

Video on Polycystic Ovary Syndrome

  • 1 What are polycystic ovaries (PCO)?
  • 2 What is polycystic ovary syndrome (PCOS)?
  • 3  What causes polycystic ovary syndrome?
  • 4  How long will I have PCOS?
  • 5 Is polycystic ovary syndrome a serious condition?
  • 6 I have polycystic ovary syndrome. How common is this condition?
  • 7 What hormone changes are typical of polycystic ovary syndrome?
  • 8 What is the significance of elevated LH levels?
  • 9 What is the significance of body weight in PCOS?
  • 10 I have pelvic pain and ultrasound has shown polycystic ovaries. Are the polycystic ovaries causing the pain?
  • 11 Does PCOS cause excessive body hair production (hirsutism)?
  • 12 Are there any concerns if my periods are infrequent or absent in association with PCOS?
  • 13 How can my polycystic ovary syndrome be treated?
  • 14 I have heard there is a relatively new treatment for PCOS metformin. Could you explain this?
  • 15 We are trying for a baby. Could metformin cause problems for our baby?
  • 16 How should irregular or absent periods associated with PCOS be treated?
  • 17 How is infertility associated with PCOS treated?
  • 18 My periods are irregular and I have PCO. Do I need contraception?
  • 19 Can PCOS be treated by surgery?
  • 20 Where can I obtain more information?
  • 21 Support Groups.

What are polycystic  ovaries?

Polycystic ovaries are characterised by the presence of many small cysts (fluid filled swellings) around the surface of the ovaries. The cysts are quite small ranging from 2 to 8 mm (Figure 7.1).

Polycystic ovaries are usually larger than normal ovaries and their central substance is generally more dense.

Over recent years, with the advent of ultrasound examination, we have learned that about one woman in five has polycystic ovaries. At ultrasound examination, the ovaries appear larger and more dense and the cysts look like a “necklace” around the periphery of the ovaries.

Polycystic Ovaries

Polycystic Ovaries

Related Medical  Abstracts – Click on the paper title:-

  • Polycystic ovaries A common finding in normal women. (1988)
  • Polycystic ovaries: A new ultrasonic classification. (1995)
  • Interrelationship between ultrasonography and biology in the diagnosis of polycystic ovarian syndrome. (1993)

What is polycystic   ovary syndrome and what are the PCOS symptoms?

When patients develop symptoms associated with their polycystic ovaries, they are said to have polycystic ovary syndrome   (or polycystic ovarian syndrome).

Other names include polycystic ovary disease (PCOD), functional ovarian hyperandrogenism, Stein-Leventhal syndrome, ovarian hyperthecosis and sclerocystic ovary syndrome.

Of the 20% of women who have PCO only one in three will have symptoms – PCOS.

In addition to abnormal menstrual cycles and infertility, some women may be troubled by skin problems, notably acne and greasy skin or unwanted hair production (hirsutism).

PCOS was first described by Stein and Leventhal in 1935 and the condition is therefore also known as Stein-Leventhal syndrome.

Many women with PCOS find it difficult to understand why they have developed symptoms, such as irregular and infrequent periods (oligomenorrhoea), after many years of normal cycles. Usually, the key factor to account for the change is an increase in weight. In association with PCOS there may be an increased level of insulin which encourages the body to lay down excessive amounts of fat tissue leading to obesity. This excess fat tissue aggravates the hormonal imbalance. A spiral may be set up as the hormone problems increase fat production and the excess fat has a further adverse effect on the hormone balance.

Part of the difficulty in understanding polycystic ovary syndrome (PCOS) and interpreting the large medical literature surrounding it has been that there was no universally accepted clinical definition.(0301)

There has been a recent consensus on the diagnosis of polycystic ovary syndrome.(0401)

PCOS is defined as the presence of any two   of the following three   criteria:

  1. polycystic ovaries (either 12 or more follicles measuring 2-9 mm in diameter, or increased ovarian volume (> 10 cm3)    on ultrasound.
  2. oligomenorrheoa / anovulation              (reduced periods / failure to release eggs).
  3. clinical or biochemical evidence of hyperandrogenism    (excessive male hormone).

As PCOS is often associated with reduced menstruation, it is helpful to understand the relationship between hormones and the menstrual cycle as in this following video:

From 2004, most gynaecologists follow these criteria to make the diagnosis of PCOS.

Related Medical  Abstracts – Click on the paper title:-

  • Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. (2004-01)
  • Diagnostic criteria in polycystic ovary syndrome.(2003-01)
  • What is polycystic ovarian syndrome? A proposal for a consensus on the definition and diagnosis of polycystic ovarian syndrome. (2002-01)
  • Polycystic ovary syndrome in adolescence and early adulthood. (2000-01)

PCOS Causes

Although a great deal is now known about the polycystic ovary syndrome, the exact cause has yet to be determined.

Polycystic ovary syndrome is probably an inherited condition. There has been one specific gene implicated and two others also seem to be involved. Premature balding in men is often a manifestation of the same gene that results in PCOS in women. It is believed that as the ovaries fail to ovulate, follicles are retained around the periphery in a necklace type pattern.

The hormone chemistry of polycystic ovaries is often deranged. This may result in period problems, particularly reduced or absent periods. Polycystic ovaries tend not to release their eggs regularly and, without treatment, there may be problems with fertility.

In recent years it has become recognised that many of the metabolic (body chemical) changes seen in PCOS may be related to insulin resistance.0301,
9901

Insulin   is produced by the pancreas, which is a gland found in the   abdomen. This gland has two functions, both related to the way   the body deals with food. It secretes enzymes (chemical   catalysts) into the small bowel allowing food to be broken down   into the basic components that can be absorbed. The pancreas   also secretes insulin into the blood stream. Insulin is a
hormone
that reduces the blood sugar level, mainly by converting sugar into fat. Diabetes occurs when the pancreas can no longer produced sufficient insulin to prevent the blood sugar level rising too high. It turns out that most women with PCOS are resistant to insulin. Hormones work like a key in a lock. Insulin resistance means that the insulin hormone receptors are defective and a stronger key is required. The result is an increased output of insulin and it is the higher levels of insulin that seems to result in the typical symptoms of PCOS. Women with PCOS are not diabetic and so there is no difference in their response to a glucose (sugar) load     (Figure 7.2).

image002

Figure Glucose Tolerance Test – Normal and PCOS women

Typically, women with PCOS require greater output of insulin from the pancreas to prevent their sugar rising too high (Figure 7.3).

 

Insulin Response - Normal and PCOS women

Figure Insulin Response to Glucose Load – Normal and PCOS
Related Medical Abstracts

It is becoming recognised that some patients have symptoms and blood chemistry (hormone levels) typical of polycystic ovary syndrome, although their ovaries do not have a typical PCO picture. The latest definition of PCOS allows for this.0401

Related Medical  Abstracts – Click on the paper title:-

  • Aging women with polycystic ovary syndrome who achieve regular menstrual cycles have a smaller follicle cohort than those who continue to have irregular cycles. (2003-01)
  • Age-related differences in features associated with polycystic ovary syndrome in normogonadotrophic oligo-amenorrhoeic infertile women of reproductive years. (2001-01)
  • Obesity, rather than menstrual cycle pattern or follicle cohort size, determines hyperinsulinaemia, dyslipidaemia and hypertension in ageing women with polycystic ovary syndrome. (2001-02)
  • Women with polycystic ovary syndrome gain regular menstrual cycles when ageing. (2000)  

How prevalent is polycystic ovary syndrome?

Polycystic ovary syndrome is one of the most common endocrine (hormone) disorders. Ultrasound examination provides an excellent window to look at ovarian structure. The ovaries are close to the top of the vagina and therefore transvaginal scanning shows of ovarian structure more clearly than transabdominal scanning.

In adult women, transvaginal scanning reveals an incidence of PCO in the order of 20%. About one in three with ultrasound evidence of PCO will have problems resulting in an incidence of 6-10%.

Before sexual activity has commenced ultrasound is performed by the transabdominal route. Evidence of PCO can be found in 6% of six year old girls and, by the age of ten, 18% of girls have evidence of PCO.

There is evidence that PCOS is more prevalent amongst those that are obese and in those with Type 1 diabetes or who have had gestational diabetes.

Related Medical  Abstracts – Click on the paper title:-

  • The prevalence of polycystic ovaries in Chinese women with a history of gestational diabetes mellitus. (2006-01)
  • Prevalence and characteristics of the polycystic ovary syndrome in overweight and obese women. (2006-02)
  • Prevalence of polycystic ovaries in women with self-reported symptoms of oligomenorrhoea and/or hirsutism: Northern Finland Birth Cohort 1966 Study. (2004-01)


For how long will I have polycystic ovary syndrome?

Unfortunately, PCOS is a problem that does not disappear. It is almost certainly an inherited r genetic condition. Just like the colour of your eyes, it cannot be changed.

Will polycystic ovary syndrome affect my general health?

There is a spectrum of severity ranging from a little irregularity of the menstrual cycle to troublesome excess body hair and anovulatory infertility. Early suggestions that PCOS is a cause of heart disease seems to have been unfounded. Obesity, however, is associated with heart problems and many women with PCOS are overweight. There is evidence that the long-term complications of PCOS are increased by the addition of obesity. If you have PCOS, you should make every effort to keep your weight down.

Between 20 and 40% of women found to have polycystic ovary syndrome will develop diabetes in later life. As PCOS is associated with anovulation, the endometrium may be subjected to long-term oestrogen without cyclical progesterone protection increasing the risk of endometrial cancer (endometrial cancer).

Related Medical  Abstracts – Click on the paper title:-

  • Polycystic ovary syndrome. Revised diagnostic criteria and long-term health consequences. (2005-01)
  • Polycystic ovary syndrome associated neoplasms (2005-02)information?
  • Polycystic ovary syndrome and gynecological cancers: is there a link? (2005-03)
  • Type 2 diabetes and the polycystic ovary syndrome. (2004-01)
  • Prevalence and predictors of coronary artery calcification in women with polycystic ovary syndrome. (2003-01)
  • Early endocrine, metabolic, and sonographic characteristics of polycystic ovary syndrome (PCOS): comparison between nonobese and obese adolescents. (2003-02)
  • Hyperinsulinemia in polycystic ovary syndrome correlates with increased cardiovascular risk independent of obesity. (2000)
  • Increased risk of non-insulin dependent diabetes mellitus, arterial hypertension and coronary artery disease in perimenopausal women with a history of the polycystic ovary syndrome. (2000)information?
  • Do polycystic-appearing ovaries affect the risk of cardiovascular disease among women with polycystic ovary syndrome?
  • (2000)information?
  • Long-term consequences of polycystic ovary syndrome: Results of a 31 year follow-up study. (2000).
  • Mortality of women with polycystic ovary syndrome at long-term follow-up.(1998)

What hormone changes are typical of polycystic ovary syndrome?

Blood tests to evaluate PCOS should be scheduled early in the menstrual cycle. Some prefer the third day of the cycle and others the eighth day.

Elevated LH (menstrual cycles) concentrations, seems to be the most common finding.

In a normal menstrual cycle, ovulation (egg release) occurs about fourteen days before the next period is due. An egg is released from a follicle within an ovary. Before egg release, the lining of the uterus (endometrium) thickens under the influence of the female hormone oestrogen – proliferative phase. After egg release, the follicle becomes a corpus luteum which secretes progesterone as well as oestrogen. The progesterone causes the endometrium to enter the secretory phase which would allow implantation of the early embryo if pregnancy occurs.

The androgenic hormones (steroid hormones) testosterone and androstenedione tend to be increased and these higher levels tend to be associated with decreased SHBG levels (SHBG).

Prolactin levels (menstrual cycles,hyperprolactinaemia) are often just above the normal range. As hormone levels fluctuate there may be merit in repeating the tests.  After food insulin levels rise higher than normal (PCOS cause;  Figure 7.3).

Related Medical  Abstracts – Click on the paper title:-

  • The role of inhibin in polycystic ovary syndrome. (2000)
  • Hyperinsulinaemia and polycystic ovary syndrome. (2000)

Increased levels of LH can be found in 40% of women with PCO. We know that raised LH levels are associated with difficulty conceiving and increased miscarriage rates.

Related Medical  Abstracts – Click on the paper title:-

  • The pathophysiology of polycystic ovary syndrome: trying to understand PCOS and its endocrinology. (2004-01)
  • Polycystic ovarian morphology with regular ovulatory cycles: insights into the pathophysiology of polycystic ovarian syndrome. (2004-03)
  • LH levels in women with polycystic ovarian syndrome: have modern assays made them irrelevant? (2003-01)

What is the significance of body weight in polycystic ovary syndrome?

PCOS encourages weight gain and fat has an adverse effect on the hormone balance leading to an escalating spiral of the problems.

PCOS and Pelvic Pain

PCOS is not considered to be a cause of pelvic pain. Sometimes there may be a slight dragging discomfort as the ovaries are heavier than normal.

Pelvic pain and PCO are both common and not surprisingly many patients with pelvic pain also have evidence of PCO. However, PCO does not seem to be a cause for pelvic pain.

Related Medical  Abstracts – Click on the paper title:-

  • Polycystic ovaries: A new ultrasonic classification. (1995)
  • Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion. (1990)

Are there concerns if I have absent or infrequent periods associated with my polycystic ovary syndrome?

Infrequent periods (infrequent periods) is a common symptom of polycystic ovary syndrome.

If you are a sexually active woman you may be anxious that you could be pregnant.

It must be stressed that PCOS associated with infrequent or absent periods only means that the chance of pregnancy is reduced, but this can by no means be considered as a guarantee against pregnancy. Family planning (family planning) is required.

Is Polycystic Ovary Syndrome a cause of   excess body hair – hirsutism?

PCOS is one of the more common reasons for women becoming hirsute   and this sign is in fact part of the definition of polycystic ovary   syndrome.

The biochemical changes associated with PCOS include increased levels of testosterone and reduced levels of SHBG which may result in increased male pattern hair distribution particularly on the moustache and beard areas of the face, the chest, back and lower abdomen. This may respond to medical treatments (hirsutism treatment).

Related Medical  Abstracts – Click on the paper title:-

  • Polycystic ovary syndrome: An endocrine and metabolic disease. (2001).

PCOS and amenorrhoea (absent periods)

If you are a sexually active woman you may be anxious that you could be pregnant. It must be stressed that PCOS associated with infrequent or absent periods only means that the chance of pregnancy is reduced, but this can by no means be considered as a guarantee against pregnancy.In the longer term, if the endometrium is being stimulated by oestrogen without the cyclical intervention of progesterone, there is a risk of the endometrium becoming hyperplastic (unduly thickened) and occasionally this could lead to malignant change (endometrial cancer). Cancer of the lining of the womb tends to be a problem around the age of fifty or sixty but can occur earlier. Twenty or thirty years ago, we would have investigated a woman with absent or infrequent periods and if no problem was found no treatment would have been recommended. Nowadays, we recommend checking that oestrogen levels are adequate and offer oestrogen with cyclical progestogen if the levels are persistently low.

 

How can the combined oral contraceptive pill treat the symptom of hirsutism associated with polycystic ovary syndrome?

The oestrogen in the combined oral contraceptive pill:

  • increases the oestrogen levels in the blood and this directly reduces hirsutism.
  • increases the SHBG levels and this reduces the amount of free androgen; the free androgen is largely responsible for  the symptom of hirsutism.
  • suppresses gonadotrophin (FSH and LH) from the pituitary. Reducing LH production results in lower levels of ovarian androgen production.

Hormone replacement therapy involves administration of oestrogen and there is some evidence that it may have a part to play in the management of hirsutism when the pill is not acceptable.

Cyproterone acetate is an anti-androgen; it competes at the receptor sites (hormones) with androgens and reduces their effects. Dianette (Schering) is a special combined oral contraceptive pill that contains 2mg cyproterone acetate.

Yasmin is a combined oral contraceptive pill with drosperinone as the progestogen. While many synthetic progestogens are derived from the male hormone, testosterone, drosperinone is derived from spironolactone and this most closely resembles and acts like the hormone progesterone made by your body.

 

Vaniqa and unwanted facial hair

Vaniqa is an enzyme inhibitor used topically to slow the growth of unwanted facial hair in women. It does not remove hair. Re-growth of unwanted hair can be dramatically slowed by the use of Vaniqa and in some cases, hair becomes so weak, it barely grows at all. The hairs that do grow after continued use of Vaniqa become considerably weakened which makes them finer and far less noticeable than coarse thick or dark hair often associated with unwanted facial hair in women.

Vaniqa is a cream that helps women to manage unwanted facial hair. It is the first cream that is clinically proven to slow the growth of unwanted facial hair in women. Vaniqa does not remove hair . Applying this fragrance-free cream twice a day, every day, does not replace your current method of removal. Instead, Vaniqa complements it, by slowing hair growth. You should continue to use your current method of hair removal or treatment. Vaniqa is a prescription drug for external use only.

How can polycystic ovary syndrome be treated?

 

If you are overweight, you should make every effort to lose weight. In addition to a calorie controlled diet, regular exercise is to be encouraged. Weight reduction improves the hormone balance, the chances of pregnancy when required and also the chance of a successful pregnancy outcome.

Traditionally, treatment has depended on your presenting problems. If your main concern is infrequent periods and you do not wish to conceive, cyclical hormone treatment such as the combined oral contraceptive pill, cyclical progestogen, or hormone replacement therapy may be indicated.

The combined pill can be used for treating some of the symptoms of PCOS including irregular cycles and hirsutism

If you want to start a family, treatment is directed towards encouraging your ovaries to release their eggs (ova) regularly (ovulation induction PCOS infertility treatment; ovulation induction).

PCOS is a common condition and the majority of affected women can be successfully treated by their family doctor or gynaecologist. If problems are not quickly resolved then a specialist reproductive endocrinologist should be considered to check that other conditions such as adrenal disorders have been excluded and to advise on all the treatment options.

Related Medical  Abstracts – Click on the paper title:-

  • Ovulation induction for polycystic ovary syndrome. (2000)

How does metformin help in the treatment of PCOS

Sadly, although for a few years following the introduction of metformin for PCOS in 1998, many of us believed that it was beneficial. Recent evidence, however, has been disappointing.

The Metformin PCOS Story:

In PCOS cause the recently discovered relationship between PCOS and insulin resistance has been presented. Metformin is a drug that increases sensitivity to insulin and it therefore reverses the insulin resistance of PCOS. Metformin has been used since the 1950s in the treatment of diabetes. There is accumulating evidence that metformin has a significant part to play in the treatment of PCOS, whether the symptoms are amenorrhoea (absent periods), oligomenorrhoea (infrequent periods), obesity, hirsutism (excessive hair production) or anovulation (failure to release eggs resulting in infertility). Metformin 500mg tablets are taken two or three times daily after meals. Although metformin has been available for more than forty years, its application for PCOS is new and it has yet to be licensed for this indication. We therefore provide metformin for PCOS only with informed consent. Some women may be initially troubled by bowel disturbance and flatulence but these problems improve after a couple of weeks. The tablets can be split and it is worth taking only half a tablet daily for a few days and gradually increasing the dose over two or three weeks. At this time there is no substitute for metformin as a drug to increase insulin sensitivity but there is a new class of insulin-sensitising agents due to be launched soon the thiazolidinedionesIt will be some years before the true value of metformin for patients with PCOS will be determined. Initial experience has shown that it is beneficial for women with hirsutism and absent or infrequent periods and infertility. It may assist in weight reduction. There is theoretical reason for optimism that metformin prescribed for women with PCOS will have several long-term benefits. It was suggested that metformin may reduce complications which may occur with ovulation stimulation particularly with gonadotrophin injections:

  • ovarian hyperstimulation syndrome ( OHSS).
  • miscarriages (recurrent miscarriage).
  • maturity onset diabetes.
  • endometrial cancer (endometrial cancer).
  • controlled trials (placebo & controlled trials) will be required to establish a clearer picture of the potential benefits.

 

 

A thirty-five year old woman had stopped seeing her periods (amenorrhoea) for a year and her weight had been increasing. Her only other problem was IBS (Q23.34). Her BMI was 38 (Q9.8) showing that her weight was 50% greater than it should have been. Ultrasound examination of her pelvis showed no abnormality and in particular there was no suggestion of polycystic ovaries. Her LH was 8.4 IU/l and FSH 4.8 IU/l which are normal readings and her thyroid tests and prolactin were normal. The testosterone was 3.2 nmol/l which is towards the upper level of normal but her SHBG was low at 14 nmol/l. Her fasting blood sugar was 4.8 mmol/l (normal) but her fasting insulin was 18.7 mU/L which is high. Metformin was commenced.

This case is an example of a patient presenting with two problems that can be associated with polycystic ovary syndrome namely amenorrhoea and obesity although the ultrasound was reported as showing normal ovaries. Her LH was not high and even her testosterone was just within the normal range. The low SHBG is a strong pointer to the diagnosis. Although the high fasting insulin in this case seems reassuring that metformin is likely to prove beneficial the value of insulin tests in clinical management remains to be determined.

Metformin and PCOS / Infertility

Research from 2007, has questioned the value of metformin for women with PCOS and infertility. In one study,0801 The ovulation rate was 23.7% in a metformin group, 59% in a CC group, and 68.4% in the combination treatment group. This was translated into a similar PR and live birth rate, which were higher in the CC and combination groups compared to the metformin group, although statistically the differences were not significant. There were no multiple pregnancies and the rate of spontaneous first trimester loss was similar to the general population. According to a recent concensus,0802 metformin use in PCOS should be restricted to women with glucose intolerance. Based on recent data available in the literature, the routine use of this drug in ovulation induction is not recommended.

Others provide a more optimistic evaluation on randomised controlled trials assessing the value of metformin in the management of PCOS associated infertility.  In PCOS patients with anovulatory infertility and not previously treated, the administration of metformin plus CC is not better than monotherapy (metformin alone or CC alone), whereas to date no specific recommendation can be given regarding the use of CC or metformin as first-step drug.0901

 

Related Medical  Abstracts – Click on the paper title:-

  • Clomiphene citrate, metformin or both as first-step approach in treating anovulatory infertility in patients with polycystic ovary syndrome (PCOS): a systematic review of head-to-head randomized controlled studies and meta-analysis.(2009-01)
  • Obesity, weight loss, and the polycystic ovary syndrome: effect of treatment with diet and orlistat for 24 weeks on insulin resistance and androgen  levels.(2008-03)
  • Metformin versus oral contraceptive pill in polycystic ovary syndrome: a Cochrane review. (2007-01)
  • Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome. (2007-02)
  • Polycystic ovary syndrome in adolescents: current and future treatment options. (2006-01)
  • Polycystic ovarian syndrome–prognosis and outcomes. (2006-02)
  • Treatment with flutamide, metformin, and their combination added to a hypocaloric diet in overweight-obese women with polycystic ovary syndrome: a randomized, 12-month, placebo-controlled study. (2006-03)
  • Metformin treatment is effective in obese teenage girls with PCOS. (2006-04)
  • The effect of metformin on fat distribution and the metabolic syndrome in women with polycystic ovary syndrome–a randomised, double-blind, placebo-controlled trial. (2006-05)
  • Metformin therapy improves coronary microvascular function in patients with polycystic ovary syndrome and insulin resistance. (2006-06)
  • Metformin treatment of polycystic ovary syndrome improves health-related quality-of-life, emotional distress and sexuality. (2006-07)
  • Prevention of diabetes and cardiovascular disease in women with PCOS: treatment with insulin sensitizers. (2006-08)
  • Insulin-sensitizing agents in polycystic ovary syndrome. (2006-09)
  • Indices of low-grade chronic inflammation in polycystic ovary syndrome and the beneficial effect of metformin. (2006-10)
  • Metformin-diet ameliorates coronary heart disease risk factors and facilitates resumption of regular menses in adolescents with polycystic ovary syndrome. (2006-11)
  • Lipids in polycystic ovary syndrome: role of hyperinsulinemia and effects of metformin. (2006-12)
  • Metformin versus rosiglitazone in the treatment of polycystic ovary syndrome. (2006-13)
  • Randomized placebo-controlled trial of metformin for adolescents with polycystic ovary syndrome. (2006-14)
  • Early effects of metformin in women with polycystic ovary syndrome: a prospective randomized, double-blind, placebo-controlled trial. (2006-15)
  • Metformin as treatment for overweight and obese adults: a systematic review. (2005-01)
  • Insulin resistance in polycystic ovarian disease. (2005-02)
  • Metformin and weight loss in obese women with polycystic ovary syndrome: comparison of doses. (2005-03)
  • Randomized controlled trial evaluating response to metformin versus standard therapy in the treatment of adolescents with polycystic ovary syndrome. (2005-04)
  • Polycystic ovarian syndrome: marked differences between endocrinologists and gynaecologists in diagnosis and management. (2005-05)
  • Combined use of metformin and ethinyl estradiol-cyproterone acetate in polycystic ovary syndrome. (2005-07)
  • Orlistat is as beneficial as metformin in the treatment of polycystic ovarian syndrome. (2005-08)
  • Women with polycystic ovary syndrome (PCOS) often undergo protracted treatment with metformin and are disinclined to stop: indications for a change in licensing arrangements? (2004-01)
  • Laparoscopic treatment of polycystic ovaries: is its place diminishing? (2004-02)
  • Should patients with polycystic ovarian syndrome be treated with metformin? A note of cautious optimism. (2002-01)
  • Continuing metformin throughout pregnancy in women with polycystic ovary syndrome appears to safely reduce first-trimester spontaneous abortion: A pilot study (2001)
  • Metformin-induced resumption of normal menses in 39 of 43 (91%) previously amenorrheic women with the polycystic ovary syndrome. (1999-01)
  • Metformin therapy improves the menstrual pattern with minimal endocrine and metabolic effects in women with polycystic ovary syndrome.? (1998-01)
  • Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. (1998-02)
  • Menstrual cyclicity after metformin therapy in polycystic ovary syndrome. (1997-01)
  • Use of metformin in the management of adolescents with polycystic ovary syndrome. (1997-02)
  • Can metformin reduce insulin resistance in polycystic ovary syndrome? (1996-01)

PCOS and metformin

Please see above– The recently discovered relationship between polycystic ovary syndrome and insulin resistance has been presented   above. Metformin is a drug that increases sensitivity to insulin and it therefore reverses the insulin resistance of PCOS. Metformin has been used since the 1950s in the treatment of diabetes and it is a remarkably safe drug.

There is accumulating evidence that metformin has a significant part to play in the treatment of PCOS, whether the symptoms are amenorrhoea (absent periods), oligomenorrhoea (infrequent periods), obesity, hirsutism (excessive hair production) or anovulation (failure to release eggs resulting in infertility). Metformin 500mg tablets are taken two or three times daily after meals. Although metformin has been available for more than forty years, its application for PCOS is new and it has yet to be licensed for this indication. We therefore provide metformin for PCOS only with informed consent (informed consent). Some women may be initially troubled by bowel disturbance and flatulence but these problems improve after a couple of weeks. The tablets can be split and it is worth taking only half a tablet daily for a few days and gradually increasing the dose over two or three weeks. At this time there is no substitute for metformin as a drug to increase insulin sensitivity but there is a new class of insulin-sensitising agents due to be launched soon the thiazolidine will be some years before the true value of metformin for patients with PCOS will be determined. Initial experience has shown that it is beneficial for women with hirsutism and absent or infrequent periods and infertility. It may assist in weight reduction. There is theoretical reason for optimism that metformin prescribed for women with PCOS will have several long-term benefits. It has been suggested that metformin may reduce complications which may occur with ovulation stimulation particularly with gonadotrophin injections:

  • ovarian hyperstimulation syndrome (OHSS).
  • miscarriages (recurrent miscarriage).
  • maturity onset diabetes.
  • endometrial cancer (endometrial cancer).
  • controlled trials (placebo & controlled trials)  will be required to establish a clearer  picture of the potential benefits.

Metformin has been used for many years by diabetic patients and there is no evidence that it causes such problems in pregnancy. Once pregnancy has been confirmed, there is no proven advantage in continuing treatment but there is some early infrequent periods the metformin until 20 weeks into the pregnancy and others continue the metformin throughout the pregnancy.

 

Related Medical  Abstracts – Click on the paper title:-

  • Neonatal outcome in polycystic ovarian syndrome patients treated with metformin during pregnancy. (2006-01)
  • Continuing metformin throughout pregnancy in women with polycystic ovary syndrome appears to safely reduce first-trimester spontaneous abortion: A pilot study. (2001)
  • Congenital malformations in offspring of diabetic women treated with oral hypoglycaemic agents during embryogenesis. (1994)

How should infertility associated with polycystic ovary syndrome be treated?

Please see – PCOS Infertility – Geeting Pregnant with PCOS

 

 

Treatment of Absent periods associated with PCOS

The combined oral contraceptive pill is often the most appropriate method for providing cycle control, assuming that conception is to be avoided. If oestrogen levels are satisfactory, regular withdrawal bleeds are likely to follow cyclical progestogen administration (Q5.12; Q 24.17). When the patient is a young teenager, parents often feel happy with this rather than knowing that their daughter has started a contraceptive agent. Another option is the use of a cyclical HRT (Q 28. 9). Metformin should also be considered.

Related Medical  Abstracts – Click on the paper title:-

  • Sensitization to insulin in adolescent girls to normalize hirsutism, hyperandrogenism, oligomenorrhea, dyslipidemia, and hyperinsulinism after precocious pubarche. (2000).?
  • Treatment of hirsutism, hyperandrogenism, oligomenorrhea, dyslipidemia, and hyperinsulinism in nonobese, adolescent girls: Effect of flutamide. (2000)

Absent or Infrequent Periods – Is Contraception   Necessary?

You can never rely on irregular periods as a symptom of anovulation (eggs not being released). The best advice is that you should not take unnecessary chances.

Related Medical  Abstracts – Click on the paper title:-

  • Contraceptive choices for women with endocrine complications. (1993)

Can PCOS be treated surgically?

The doctors who first described PCOS removed part of the ovaries (wedge resection), for microscopic examination. They observed that the menstrual cycle and fertility were often restored following these operations.

More recently, it has been shown that drilling tiny holes in the ovaries (ovarian drilling) at the time of laparoscopy, may improve their chemistry although it is too early to know how long this improvement will be sustained. Whilst ovarian drilling may have a part to play in PCOS patients with infertility, this treatment is not proven to have a definite place in treatment for hirsutism.

Ovarian drilling may result in spontaneous ovulation. Unlike ovulation stimulation, there is no increased risk of multiple pregnancy or ovarian hyperstimulation (enlargement of the ovaries with the possibility of other problems such as excess fluid in the abdominal cavity). We do not know why ovarian drilling works. For those patients who respond to ovarian drilling there appears to be a reduction in LH levels which suggests that the drilling must in some way alter the hormone feedback to the hypothalamus and pituitary possibly by the release of a factor not yet identified. Interestingly, in one study where four patients had drilling of just one ovary, there was evidence of ovulation from the other ovary in the first cycle after treatment in three of the patients.

One study has shown that the insulin response to sugar is not altered following ovarian drilling.

Related Medical  Abstracts – Click on the paper title:-

  • Effects of laparoscopic ovarian drilling on serum vascular endothelial growth factor and on insulin responses to the oral glucose tolerance test in women with polycystic ovary syndrome. (2000)
  • Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility (1998)

Support Groups

 

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

  • relating personal experiences,
  • listening to others’ experiences,
  • providing sympathetic understanding and
  • establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.
Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.
Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women’s health sites may help you (internet information). The following are more specialised relevant Web sites:-

http://www.verity-pcos.org.uk Verity and PCO Verity – The PCOS Self Help Group

New Bond House

124 New Bond Street

London

W1S 1DX

United Kingdom

 

Eflornithine HCl (Vaniqa – Vaniqa is pronounced ‘Vanika’) 13.9% cream is the first topical prescription treatment to be approved by the US FDA for the reduction of unwanted facial hair in women. It irreversibly inhibits ornithine decarboxylase (ODC), an enzyme that catalyzes the rate-limiting step for follicular polyamine synthesis, which is necessary for hair growth. In clinical trials eflornithine cream slowed the growth of unwanted facial hair in up to 60% of women. Improvement occurs gradually over a period of 4-8 weeks or longer. Most reported adverse reactions consisted of minor skin irritation.

This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist – Specialist Interests – Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women’s health questions in the patient information  and medical advice provided.

 

The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

David Viniker retired from active clinical practice in 2012. In 1999, he setup this website – www.2womenshealth.com – to provide detailed information many of his patients requested. The website attracts thousands of visitors every day from around the world. Website design and search engine optimization became hobbies that he plans to pursue in his retirement. If you would like advice on your website, please visit his website www.firstwebsitedesign.com or email him on david@firstwebsitedesign.com.
David has researched top positioning on Google for keywords. This can only be achieved if a webpage has sufficient Website Reputation to compete with the top pages for the target keyword. He writes articles on subjects that assist the websites and webpages of colleagues to attract link power that will move them up the Google rankings. For example he has recently written articles on solicitors in London and a magician in Kent.

No Comments

Post a Comment