Polycystic ovarian syndrome (PCOS) affects 4% to 12% of women of reproductive age.
hallmarks of the disease are hyperandrogenism and chronic anovulation
management not only toward treating infertility and improving the often troublesome hirsutism but also toward the long-term risks associated with IR.
Recent data suggest that women with PCOS are at increased risk for preterm labor, preeclampsia, and gestational diabetes, though the evidence for increased miscarriage rates is less certain (Legro , 2007)
Ideal design to get best Evidence
A randomised controlled trial (RCT) with large numbers and, ideally, three groups is needed:
women with PCOS taking medication,
women with PCOS taking no treatment
metformin vs. both clomiphene and combination therapy
Metformin is not an effective addition to clomifene citrate as the primary method of inducing ovulation in women with polycystic ovary syndrome
The live-birth rate was 22.5% (47 of 209 subjects) in the clomiphene group, 7.2% (15 of 208) in the metformin group, and 26.8% (56 of 209) in the combination-therapy group
(P<0.001 for metformin vs. both clomiphene and combination therapy; P=0.31 for clomiphene vs. combination therapy).
Clomid alone vs clomid + metformin
no significant differences in either rate of ongoing pregnancy (40% v 46%)
gastrointestinal side effects were more frequent with metformin arm
Addition of metformin to clomid is not recommended
based on good and consistent scientific evidence (Level A)
All women with polycystic ovary syndrome (PCOS) should be screened for glucose intolerance with a 2-hour glucose level after a 75-g fasting glucose challenge
All women with PCOS should be screened for dyslipidemia with a fasting lipoprotein profile, including total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride determinations.
LIFESTYLE MODIFICATION WEIGHT LOSS
A 3 to 6 month trial of aggressive lifestyle modification may be a prudent first step before considering medications.
However, many patients will have difficulty in achieving weight loss
Use of clomiphene citrate is appropriate because it effectively results in pregnancy in women with PCOS. (Hughes, 1997)
The following recommendations are based on limited or inconsistent scientific evidence (Level B)
Improvements in insulin sensitivity, by weight loss may favorably improve many risk factors for diabetes and cardiovascular disease in women with PCOS.
When using gonadotropins to induce ovulation, low-dose therapy is recommended because it offers a high rate of monofollicular development and a significantly lower risk of ovarian hyperstimulation in women with PCOS.
The clear benefit and role of surgical therapy in ovulation induction in women with PCOS is uncertain.
The following recommendations are based primarily on consensus and expert opinion (Level C)
Combining medical interventions may be the most effective way to treat hirsutism. Combined therapy with an ovarian suppression agent and an antiandrogen appears effective in treating hirsutism in women with PCOS. The best pill or antiandrogen is unknown.
The ideal choice of ablative procedures for long-term management of hirsutism in women with PCOS is unknown.
The effects of insulin-sensitizing agents on early pregnancy are unknown; metformin appears safe, but any additional effect at reducing pregnancy loss is uncertain
Side Effects of Medication
Progestins . Use of medroxyprogesterone acetate is associated with decreases in sex hormone binding globulin (SHBG). Progestin-only oral contraceptives are associated with high incidence of breakthrough bleeding.
Use of gonadotrophins can result in ovarian hyperstimulation syndrome
The most common adverse reactions of metformin are gastrointestinal symptoms (diarrhea, nausea, vomiting, abdominal bloating, flatulence, and anorexia).
Troglitazone had been associated with an increased risk of hepatotoxicity and was removed from the market.
Cosmetic management of hirsutism
Plucking can cause folliculitis, pigmentation, and scarring.
Electrolysis is tedious, its success is highly operator-dependent, and it may be impractical for treating large numbers of hairs.
Laser treatment is also operator-dependent and multiple treatments may be necessary
There are few data to support treatment during pregnancy with metformin in women with PCOS to prevent pregnancy loss or pregnancy complications. (Legro, 2007)
it may be time to take PCOS in pregnancy seriously