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Sridhar A, Khan D, Moffett RC. The impact of diabetes and obesity on fertility and the potential role of gut hormones as treatment. Diabet Med 2023; 40:e15230. [PMID: 37734917 DOI: 10.1111/dme.15230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 09/23/2023]
Abstract
AIMS Alongside its metabolic implications, obesity and associated diabetes impair female reproductive function, causing infertility and polycystic ovarian syndrome (PCOS). Recently, gut hormones and their receptors have been identified in various reproductive organs indicating their potential regulatory effects on reproductive function. This review aims to give an overview of their potential effects. METHODS This review focuses on literature that outlines modifications during obesity, diabetes and related infertility with an emphasis on gut hormones and their therapeutic potential. RESULTS Evidence suggests that bariatric surgery has positive effects on fertility and PCOS where major alterations in metabolism occurs through restoration of gut hormone levels. This is thought to be due to the indirect effect weight loss and regulation of blood glucose has on the hypothalamic-pituitary-ovarian and hypothalamic-pituitary-adrenal axis influencing reproduction. CONCLUSIONS Further research is required to elucidate the cellular mechanisms involved in the direct effects of gut hormone receptor activation on reproductive tissues. Current observations suggest a therapeutic role for gut hormones in infertility/PCOS associated with metabolic pathophysiology.
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Affiliation(s)
- Ananyaa Sridhar
- Biomedical Sciences Research Institute, School of Biomedical Sciences, Ulster University, Coleraine, UK
| | - Dawood Khan
- Biomedical Sciences Research Institute, School of Biomedical Sciences, Ulster University, Coleraine, UK
| | - R Charlotte Moffett
- Biomedical Sciences Research Institute, School of Biomedical Sciences, Ulster University, Coleraine, UK
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Concepción-Zavaleta MJ, Coronado-Arroyo JC, Quiroz-Aldave JE, Durand-Vásquez MDC, Ildefonso-Najarro SP, Rafael-Robles LDP, Concepción-Urteaga LA, Gamarra-Osorio ER, Suárez-Rojas J, Paz-Ibarra J. Endocrine factors associated with infertility in women: an updated review. Expert Rev Endocrinol Metab 2023; 18:399-417. [PMID: 37702309 DOI: 10.1080/17446651.2023.2256405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/09/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Infertility is defined as the inability to conceive after unprotected sexual intercourse for at least 12 consecutive months. Our objective is to present an updated narrative review on the endocrine causes of infertility in women. AREAS COVERED A comprehensive review was conducted using Scielo, Scopus, and EMBASE databases, comprising 245 articles. The pathophysiology of infertility in women was described, including endocrinopathies such as hypothalamic amenorrhea, hyperprolactinemia, polycystic ovary syndrome, primary ovarian insufficiency, obesity, thyroid dysfunction, and adrenal disorders. The diagnostic approach was outlined, emphasizing the necessity of hormonal studies and ovarian response assessments. Additionally, the treatment plan was presented, commencing with non-pharmacological interventions, encompassing the adoption of a Mediterranean diet, vitamin supplementation, moderate exercise, and maintaining a healthy weight. Subsequently, pharmacological treatment was discussed, focusing on the management of associated endocrine disorders and ovulatory dysfunction. EXPERT OPINION This comprehensive review highlights the impact of endocrine disorders on fertility in women, providing diagnostic and therapeutic algorithms. Despite remaining knowledge gaps that hinder more effective treatments, ongoing research and advancements show promise for improved fertility success rates within the next five years. Enhanced comprehension of the pathophysiology behind endocrine causes and the progress in genetic research will facilitate the delivery of personalized treatments, thus enhancing fertility rates.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - José Paz-Ibarra
- Department of Medicine, School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Perú
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Koysombat K, Abbara A, Dhillo WS. Current pharmacotherapy and future directions for neuroendocrine causes of female infertility. Expert Opin Pharmacother 2023; 24:37-47. [PMID: 35413212 DOI: 10.1080/14656566.2022.2064217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Infertility is recognized as a major global health issue, often associated with significant psychological distress for affected couples. Causes of female infertility include endocrine conditions leading to oligo/anovulation, in addition to structural causes such as tubal, uterine, or peritoneal disorders. Pharmacological treatments, targeting pathways in the hypothalamic-pituitary-ovarian axis, can improve rates of ovulation, conception, pregnancy, and birth. Some existing therapeutic options are hindered by limited efficacy or by a non-physiological mechanism, which can risk excessive stimulation and treatment-related adverse effects. Therefore, there is a continued need for novel therapies to improve care for patients suffering with infertility. AREAS COVERED In this review, the authors focus on endocrine causes of oligo/anovulation in women and on advances in assisted reproductive technology. Current pharmacological treatments and putative future therapeutic avenues in development to aid fertility in women are outlined. EXPERT OPINION A deeper understanding of the reproductive neuroendocrine network governing hypothalamic gonadotropin-releasing hormone release can offer novel therapeutic targets for the treatment of female subfertility, leading to improved clinical outcomes, less invasive routes of administration, and decreased treatment-related side-effects. The ultimate aim of development in female subfertility is to offer therapeutic interventions that are effective, reproducible, associated with minimal risks, and have an acceptable route of administration.
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Affiliation(s)
- Kanyada Koysombat
- Section of Endocrinology and Investigative Medicine, Imperial College London Hammersmith Hospital, London, UK
| | - Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London Hammersmith Hospital, London, UK
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London Hammersmith Hospital, London, UK
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Secomandi L, Borghesan M, Velarde M, Demaria M. The role of cellular senescence in female reproductive aging and the potential for senotherapeutic interventions. Hum Reprod Update 2022; 28:172-189. [PMID: 34918084 PMCID: PMC8888999 DOI: 10.1093/humupd/dmab038] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/28/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Advanced maternal age is associated with decreased oocyte quantity and quality as well as uterine and placental dysfunctions. These changes lead to infertility, pregnancy complications and birth defects in the offspring. As the mean age of giving birth is increasing worldwide, prevention of age-associated infertility and pregnancy complications, along with the more frequent use of ART, become extremely important. Currently, significant research is being conducted to unravel the mechanisms underlying female reproductive aging. Among the potential mechanisms involved, recent evidence has suggested a contributing role for cellular senescence, a cellular state of irreversible growth arrest characterized by a hypersecretory and pro-inflammatory phenotype. Elucidating the role of senescence in female reproductive aging holds the potential for developing novel and less invasive therapeutic measures to prevent or even reverse female reproductive aging and increase offspring wellbeing. OBJECTIVE AND RATIONALE The review will summarize the positive and negative implications of cellular senescence in the pathophysiology of the female reproductive organs during aging and critically explore the use of novel senotherapeutics aiming to reverse and/or eliminate their detrimental effects. The focus will be on major senescence mechanisms of the ovaries, the uterus, and the placenta, as well as the potential and risks of using senotherapies that have been discovered in recent years. SEARCH METHODS Data for this review were identified by searches of MEDLINE, PubMed and Google Scholar. References from relevant articles using the search terms 'Cellular Senescence', 'Aging', 'Gestational age', 'Maternal Age', 'Anti-aging', 'Uterus', 'Pregnancy', 'Fertility', 'Infertility', 'Reproduction', 'Implant', 'Senolytic', 'Senostatic', 'Senotherapy' and 'Senotherapeutic' where selected. A total of 182 articles published in English between 2005 and 2020 were included, 27 of which focus on potential senotherapies for reproductive aging. Exclusion criteria were inclusion of the terms 'male' and 'plants'. OUTCOMES Aging is a major determinant of reproductive wellbeing. Cellular senescence is a basic aging mechanism, which can be exploited for therapeutic interventions. Within the last decade, several new strategies for the development and repurposing of drugs targeting senescent cells have emerged, such as modulators of the anti-inflammatory response, oxidative stress, DNA damage, and mitochondria and protein dysfunctions. Several studies of female reproductive aging and senotherapies have been discussed that show promising results for future interventions. WIDER IMPLICATIONS In most countries of the Organization for Economic Co-operation and Development, the average age at which women give birth is above 30 years. Currently, in countries such as the Netherlands, Australia, Spain, Finland, Germany and the UK, birth rates among 30- to 34-year-olds are now higher than in any other age groups. This review will provide new knowledge and scientific advancement on the senescence mechanisms during female reproductive aging, and benefit fundamental and clinical scientists and professionals in the areas of reproduction, cancer, immunobiology and fibrosis.
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Affiliation(s)
- Laura Secomandi
- European Research Institute for the Biology of Ageing (ERIBA), University Medical Center Groningen (UMCG), 9713AV Groningen, The Netherlands
| | - Michela Borghesan
- European Research Institute for the Biology of Ageing (ERIBA), University Medical Center Groningen (UMCG), 9713AV Groningen, The Netherlands
| | - Michael Velarde
- Institute of Biology, College of Science, University of the Philippines Diliman, Quezon City, PH 1101, Philippines
| | - Marco Demaria
- European Research Institute for the Biology of Ageing (ERIBA), University Medical Center Groningen (UMCG), 9713AV Groningen, The Netherlands
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Zehravi M, Maqbool M, Ara I. Polycystic ovary syndrome and infertility: an update. Int J Adolesc Med Health 2021; 34:1-9. [PMID: 34293835 DOI: 10.1515/ijamh-2021-0073] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/02/2021] [Indexed: 01/29/2023]
Abstract
Polycystic ovarian syndrome is the most well-known endocrine condition among women of this generation (PCOS). Symptoms of hyperandrogenism, irregular menstrual periods, and insulin resistance are all traits associated with PCOS. In women with PCOS, the chance of having problems including infertility, insulin resistance, and type 2 diabetes increases. The PCOS board hopes to reduce body weight and insulin levels, restore fertility, control excessive hair growth on the body or scalp, re-establish the regular feminine cycle, and avoid misunderstandings. Insulin sensitizers have been one of the most common metabolic modulators, but their effectiveness has been sporadic. Insulin resistance, followed by thiazolidinediones, is central to the pathophysiology of PCOS, with metformin having nearly similar efficacy. In the management of PCOS, statins and incretins are newer therapies with obvious metabolic targets. Vitamin D, acarbose, and myoinositol are just a few of the reciprocal and optional clinical treatments that have been proved to be useful in the treatment of PCOS. The number of viable methods for dealing with PCOS-related infertility has increased as well. Despite the fact that clomiphene citrate (CC) has long been the gold standard for ovulation induction in the event of ovulatory infertility, aromatase inhibitors can induce ovulation with results that are nearly identical to or better than those reported with CC, aromatase inhibitors can cause ovulation with results that are nearly identical to or better than those reported with CC. Ovarian incitement conventions that intelligently utilize gonadotropins, gonadotropin-delivering hormone rivals, the approach of ovarian boring, and assisted conceptive advancements with in vitro oocyte development indicate an expanding level of therapeutic progress.
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Affiliation(s)
- Mehrukh Zehravi
- Department of Clinical Pharmacy Girls Section, Prince Sattam Bin Abdul Aziz University Alkharj, Saudia Arabia
| | - Mudasir Maqbool
- Department of Pharmaceutical Sciences, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Irfat Ara
- Regional Research Institute of Unani Medicine, Srinagar, Jammu and Kashmir, India
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Feng L, Lin XF, Wan ZH, Hu D, Du YK. Efficacy of metformin on pregnancy complications in women with polycystic ovary syndrome: a meta-analysis. Gynecol Endocrinol 2015; 31:833-9. [PMID: 26440203 DOI: 10.3109/09513590.2015.1041906] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of metformin administration throughout pregnancy on pregnancy-related complications in women with polycystic ovary syndrome (PCOS). STUDY DESIGN MEDLINE and ScienceDirect were searched to retrieve relevant trials. The endpoint was the incidence of complications of pregnancy, gestational diabetes mellitus (GDM), pre-eclampsia (PE), miscarriage and premature birth included. RESULTS Five studies with 502 PCOS patients with metformin administration throughout pregnancy and 427 controls who used metformin just to get conception were included in our meta-analysis. In study group, a significantly lower change of emerging miscarriage and premature birth was observed, the pooled relative risk (RR) was 0.32 (95% confidence interval (CI): 0.19-0.56) for miscarriage and 0.40 (95%CI: 0.18-0.91) for premature birth. No significant difference was demonstrated in emerging GDM and PE. CONCLUSIONS Metformin therapy throughout pregnancy can reduce the RR of miscarriage and premature birth incidence in PCOS patients with no serious side effects.
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Affiliation(s)
- Li Feng
- a School of Public Health, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , The People's Republic of China
| | - Xiao-Fang Lin
- a School of Public Health, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , The People's Republic of China
| | - Zhi-Hua Wan
- a School of Public Health, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , The People's Republic of China
| | - Dan Hu
- a School of Public Health, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , The People's Republic of China
| | - Yu-Kai Du
- a School of Public Health, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , The People's Republic of China
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Codner E, Iñíguez G, López P, Mujica V, Eyzaguirre FC, Asenjo S, Torrealba I, Cassorla F. Metformin for the treatment of hyperandrogenism in adolescents with type 1 diabetes mellitus. Horm Res Paediatr 2014; 80:343-9. [PMID: 24280743 DOI: 10.1159/000355513] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 09/03/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A high prevalence of hyperandrogenism has been reported in women with type 1 diabetes (T1D). Metformin has been used as a therapeutic agent in patients with polycystic ovarian syndrome and in T1D patients without hyperandrogenism. This study sought to determine the effect of metformin on hyperandrogenism and ovarian function in adolescents with T1D. METHODS We recruited 24 girls with T1D. The participants had hyperandrogenism and displayed suboptimal metabolic control. The patients were enrolled in a randomized, double-blind, placebo-controlled trial. One group received metformin (850 mg bid) and the other group received a placebo. Treatment was administered for 9 months. Ovulation, steroids and gonadotropin levels were evaluated. RESULTS Metformin treatment was associated with decreases in testosterone, free androgen index, androstenedione, 17-OH progesterone and estradiol levels. The girls who were treated with placebo showed stable steroid, gonadotropin and sex hormone-binding globulin levels during the analysis. No differences were observed in the Ferriman-Gallwey scores, ovulation rates, HbA1c levels or daily insulin doses of the girls treated with metformin compared with the placebo group. CONCLUSION Treating hyperandrogenic T1D adolescents with metformin significantly decreased the serum androgens compared to the placebo, but metformin therapy did not significantly affect clinical parameters, such as hirsutism, ovulation and metabolic control.
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Affiliation(s)
- Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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9
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Bruyneel A, Catteau-Jonard S, Decanter C, Clouqueur E, Tomaszewski C, Subtil D, Dewailly D, Robin G. [Polycystic ovary syndrome: what are the obstetrical risks?]. ACTA ACUST UNITED AC 2014; 42:104-111. [PMID: 24485279 DOI: 10.1016/j.gyobfe.2014.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 01/08/2014] [Indexed: 11/25/2022]
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age and the leading cause of female infertility. This condition is frequently associated with significant metabolic disorders, including obesity and hyperinsulinemia. Therefore, it seems essential to focus on the pregnancy of these patients and possible obstetric complications. Many studies suggest an increase in the risk of obstetric pathology: early miscarriage, gestational hypertension, preeclampsia, gestational diabetes mellitus diagnosed during early pregnancy, prematurity, low birthweight or macrosomia, neonatal complications and cesarean sections. However, it is difficult to conclude clearly about it, because of the heterogeneity of definition of PCOS in different studies. In addition, many confounding factors inherent in PCOS including obesity are not always taken into account and generate a problem of interpretation. However it seems possible to conclude that PCOS does not increase the risk of placental abruption, HELLP syndrome, liver disease, postpartum hemorrhage, late miscarriage and stillbirth.
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Affiliation(s)
- A Bruyneel
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - S Catteau-Jonard
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - C Decanter
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - E Clouqueur
- Service de pathologie maternelle et fœtale, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - C Tomaszewski
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - D Subtil
- Service de pathologie maternelle et fœtale, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - D Dewailly
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - G Robin
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, centre hospitalier régional et universitaire de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France.
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Zheng J, Shan PF, Gu W. The efficacy of metformin in pregnant women with polycystic ovary syndrome: a meta-analysis of clinical trials. J Endocrinol Invest 2013; 36:797-802. [PMID: 23580001 DOI: 10.3275/8932] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The role of metformin in the treatment of pregnant women with polycystic ovary syndrome (PCOS) is controversial. Therefore, we evaluated whether the use of metformin during pregnancy in women with PCOS could reduce pregnancy-related complications. RESEARCH DESIGN AND METHODS MEDLINE was searched to retrieve relevant trials. In addition, reviews and reference lists of the retrieved articles were scanned for further appropriate studies. The primary outcome measure was the incidence of complications of pregnancy, which included early pregnancy loss (EPL), gestational diabetes (GDM), pre-eclampsia (PE), and pre-term delivery (PD). RESULTS In total, eight studies with 1106 patients were included. The pooled odds ratio (OR) (95% confidence interval) of outcome for pregnant women with PCOS prescribed metformin were 0.32 (0.19-0.55) for EPL, 0.37 (0.25-0.56) for GDM, 0.53 (0.30-0.95) for PE and 0.30 (0.13-0.68) for PD. CONCLUSIONS Metformin therapy throughout pregnancy decreased the OR of EPL, GDM, PE, and PD in pregnant PCOS women with no serious detrimental side effects.
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Affiliation(s)
- J Zheng
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital ZheJiang University College of Medicine, Hangzhou, 88 Jiefang Rd, Zhejiang 310009, P.R. China
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Use of clomiphene citrate in infertile women: a committee opinion. Fertil Steril 2013; 100:341-8. [PMID: 23809505 DOI: 10.1016/j.fertnstert.2013.05.033] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
Abstract
This committee opinion describes the use of clomiphene citrate, including indications, use, monitoring, and side effects. There is also a discussion of adjuvants and alternatives to clomiphene citrate therapy.
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Affiliation(s)
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- American Society for Reproductive Medicine, Birmingham, Alabama 35216, USA.
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Xiao J, Chen S, Zhang C, Chang S. The effectiveness of metformin ovulation induction treatment in patients with PCOS: a systematic review and meta-analysis. Gynecol Endocrinol 2012; 28:956-60. [PMID: 22808990 DOI: 10.3109/09513590.2012.705368] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate of metformin effectiveness of ovulation induction treatment in polycystic ovary syndrome (PCOS) women. METHODS Eight databases and nine related journals were searched for randomized controlled trails (RCTs) on the comparison between metformin and clomiphene citrate used for PCOS women. Meta analysis was performed after quality assessment. RESULTS Ovulation rate in metformin group compared with clomiphene citrate group was lower with a significant difference [OR = 0.48 (0.26-0.87), p = 0.01]; no significant difference was found for pregnancy rate [OR = 0.94 (0.26-3.43)], miscarriage rate [OR = 0.63 (0.06-6.47)] between two groups. Compared with the combination of metformin and clomiphene citrate group, pregnancy rate in metformin group was significantly lower [Peto OR = 1.56 (1.16-2.08), p = 0.003], but there was no significant difference in the two groups about ovulation rate [OR = 1.52 (0.95-2.45)], miscarriage rate [Peto OR = 1.40 (0.79-2.48)]. CONCLUSIONS Compared with clomiphene citrate, metformin used for ovulation induction treatment in PCOS women, can promote ovulation induction and pregnancy rate, the effect of the combination treatment is better than that of a single drug use.
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Affiliation(s)
- Jinsong Xiao
- Unit for Human Reproduction, Taihe Hospital of Hubei University of Medicine, Shiyan, Hubei, China.
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Clomiphene citrate versus letrozole: molecular analysis of the endometrium in women with polycystic ovary syndrome. Fertil Steril 2011; 96:1051-6. [PMID: 21851939 DOI: 10.1016/j.fertnstert.2011.07.1092] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 07/09/2011] [Accepted: 07/11/2011] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To compare the effect of clomiphene citrate (CC) and letrozole on endometrial receptivity in women with polycystic ovary syndrome (PCOS). DESIGN A randomized controlled trial. SETTING University teaching hospital. PATIENT(S) Ten anovulatory women with PCOS and 5 fertile ovulatory women. INTERVENTION(S) Patients received 2.5 mg of letrozole on cycle days 3-7 (5 patients, 1 cycle) or 50 mg of CC on cycle days 5-9 (5 patients, 1 cycle). MAIN OUTCOME MEASURE(S) Serum estrogen (E) and progesterone (P) endometrial protein and messenger RNA (mRNA) expression of leukemia inhibitory factor (LIF), dickkhopf homolog 1 (DKK-1), fibroblast growth factor 22 (FGF-22), and endometrial mRNA expression of LIF/GP130 receptor (LIFR). RESULT(S) No statistically significant differences were observed between groups compared with fertile ovulatory women when serum E and P were examined, or between body mass index (BMI), and cycle day at time of biopsy. Letrozole increased mRNA expression of LIF, DKK1, LIFR, and FGF-22, whereas CC only increased endometrial mRNA expression of LIF. Letrozole mRNA expression directly translated into increased protein expression of like genes in the endometrium. The CC protein expression of DKK-1 was significantly decreased compared with controls. CONCLUSION(S) Letrozole positively influences a number of markers of endometrial receptivity compared with CC.
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The role of continuing metformin therapy during pregnancy in the reduction of gestational diabetes and improving pregnancy outcomes in women with polycystic ovary syndrome. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2011. [DOI: 10.1016/j.mefs.2011.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bhathena RK. Insulin resistance and the long-term consequences of polycystic ovary syndrome. J OBSTET GYNAECOL 2011; 31:105-10. [PMID: 21281021 DOI: 10.3109/01443615.2010.539722] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In a significant number of women with the polycystic ovary syndrome there is impaired insulin metabolism with hypersecretion of insulin. Insulin resistance is defined as a diminution in the glucose response to a given amount of insulin. Insulin resistance has been implicated in the pathogenesis of many aspects of the syndrome. Hyperinsulinaemia leads to increased production of androgens resulting in anovulatory infertility. Women and particularly obese women with insulin resistance and the polycystic ovary syndrome have an increased risk of developing gestational diabetes and also type 2 diabetes and cardiovascular disease in later life. The women should be counselled about long-term health risks, and obese women with the polycystic ovary syndrome should be periodically screened. Lifestyle modification to reduce weight in obese women and treatment with insulin-sensitising drugs such as metformin in women with glucose intolerance result in the improvement of some metabolic abnormalities and hyperandrogenic disorders with the consequent restoration of normal menstrual and ovulatory function in a significant number of women with polycystic ovaries.
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Affiliation(s)
- R K Bhathena
- Department of Obstetrics and Gynaecology, Petit Parsee General and Masina Hospitals, Bombay, India.
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Atiomo W, Sinha A. The role of metformin in the treatment of infertile women with polycystic ovary syndrome. ACTA ACUST UNITED AC 2011. [DOI: 10.1576/toag.6.3.145.26996] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abu Hashim H, Shokeir T, Badawy A. RETRACTED: Letrozole versus combined metformin and clomiphene citrate for ovulation induction in clomiphene-resistant women with polycystic ovary syndrome: a randomized controlled trial. Fertil Steril 2010; 94:1405-1409. [PMID: 19732888 DOI: 10.1016/j.fertnstert.2009.07.985] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 07/11/2009] [Accepted: 07/14/2009] [Indexed: 11/28/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the ASRM Publications Committee. Several reports of randomized clinical trials were recently the subject of an investigation conducted by the publications committee of the ASRM. The committee reviewed concerns related to the validity of data reported in those reports. The committee noted significant duplication of data reported in this manuscript with data reported in another report (PMID 17686479; https://doi.org/10.1016/j.fertnstert.2007.05.010) pertaining to a different study group that could not be explained. As we cannot vouch for the validity of the data, we have issued a retraction of this paper.
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Affiliation(s)
- Hatem Abu Hashim
- Departments of Obstetrics & Gynecology, Mansoura University, Mansoura, Egypt.
| | - Tarek Shokeir
- Departments of Obstetrics & Gynecology, Mansoura University, Mansoura, Egypt
| | - Ahmed Badawy
- Departments of Obstetrics & Gynecology, Mansoura University, Mansoura, Egypt
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Iavazzo C, Vitoratos N. Polycystic ovarian syndrome and pregnancy outcome. Arch Gynecol Obstet 2010; 282:235-9. [DOI: 10.1007/s00404-010-1495-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 04/21/2010] [Indexed: 11/28/2022]
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Turner MJ, Walsh J, Byrne KM, Murphy C, Langan H, Farah N. Outcome of clinical pregnancies after ovulation induction using metformin. J OBSTET GYNAECOL 2009; 26:233-5. [PMID: 16698631 DOI: 10.1080/01443610600555295] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The objective of this study was to review the first 50 clinical pregnancies of women with polycystic ovarian syndrome (PCOS) who had ovulation induced either with metformin alone, or in combination with clomifene. The study was confined to women with PCOS attending our infertility service. A register of clinical pregnancies was maintained of women who conceived after metformin therapy. The metformin was continued throughout the first trimester. The outcome of pregnancy was determined by individual chart review. Of the 50 women, 21 conceived with a combination of clomifene and metformin, and 29 with metformin alone. Seven women had a first trimester loss and 43 had a live birth. There were no perinatal deaths, no neonatal seizures and no congenital malformations. There were also no multiple pregnancies. The overall caesarean rate was 37%, and none of the babies had an Apgar score less than 7, at 5 min. This study found no evidence of any adverse clinical effects when metformin is continued in the first trimester of women with PCOS following ovulation induction. There was also no evidence of an increase in the rate of miscarriage or multiple pregnancy.
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Affiliation(s)
- M J Turner
- Coombe Women's Hospital, Dublin, Ireland.
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Abstract
PURPOSE To review the diagnosis and management of gestational diabetes. EPIDEMIOLOGY In the United States, approximately 2 to 5% of all pregnant women have gestational diabetes. Those women with a family history of type 2 diabetes mellitus, Asian or native American race, Latina ethnicity or obesity are at higher risk for developing gestational diabetes. CONCLUSION Women with gestational diabetes who are treated appropriately can achieve good outcomes in the majority of pregnancies. Frequent blood glucose monitoring, nutrition counseling and frequent physician contact allow for individualized care to achieve optimal outcomes. Such treatment includes diet, exercise and insulin. The use of oral hypoglycemic agents is controversial and there is some concern about worse maternal and neonatal outcomes as compared to treatment with insulin. Evolving technologies promise to provide more therapeutic options.
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Affiliation(s)
- Y W Cheng
- Department of Obstetrics and Gynecology, University of California, San Francisco, CA 94143, USA
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Woodson SA. Fetal demise: what were the contributing factors? Nurs Womens Health 2007; 11:405-19. [PMID: 17883758 DOI: 10.1111/j.1751-486x.2007.00206.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sue A Woodson
- Charlottesville Gynecology Specialists, Charlottesville, VA, USA
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Casson IF. Management of Type 2 diabetes and pregnancy. WOMEN'S HEALTH (LONDON, ENGLAND) 2007; 3:593-602. [PMID: 19804036 DOI: 10.2217/17455057.3.5.593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Pregnancy complicated by diabetes presents risks for the mother and her baby and a challenge to those responsible for their care. Type 2 diabetes now represents a significant and rapidly increasing proportion of pregestational diabetes. Outcomes of pregnancies complicated by Type 2 diabetes are certainly no better and sometimes worse than for Type 1 diabetes. Perinatal mortality, stillbirths and congenital anomalies are increased between two- and fourfold. Women with Type 2 diabetes and who are of child-bearing age merit special attention for contraception and prepregnancy care. This review considers the implications for women with Type 2 diabetes before, during and after pregnancy.
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Affiliation(s)
- Ian F Casson
- University Hospital Aintree, Aintree Hospitals NHS Foundation Trust, Lower Lane, Fazakerley, Liverpool, L9 7AL, UK.
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Moll E, van der Veen F, van Wely M. The role of metformin in polycystic ovary syndrome: a systematic review. Hum Reprod Update 2007; 13:527-37. [PMID: 17767003 DOI: 10.1093/humupd/dmm026] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This meta-analysis evaluated the effectiveness of metformin in subfertile women with polycystic ovary syndrome (PCOS). Only randomized trials investigating the effectiveness of metformin and PCOS definition consistent with the Rotterdam consensus criteria, were eligible. Primary outcome was live birth rate. A literature search identified 27 trials. In therapy naïve women, we found no evidence of a difference in live birth rate when comparing metformin with clomifene citrate (CC) [relative risks (RR) 0.73; 95% confidence interval (CI) 0.51-1.1] or comparing metformin plus CC with CC (RR 1.0; 95% CI 0.82-1.3). In CC-resistant women, metformin plus CC led to higher live birth rates than CC alone (RR 6.4; 95% CI 1.2-35); metformin also led to higher live birth rates than laparoscopic ovarian drilling (LOD) (RR 1.6; 95% CI 1.1-2.5). We found no evidence for a positive effect of metformin on live birth when added to LOD (RR 1.3; 95% CI 0.39-4.0) or FSH (RR 1.6; 95% CI 0.95-2.9), or when co-administered in IVF (RR 1.5; 95% CI 0.92-2.5). In IVF, metformin led to fewer cases of ovarian hyperstimulation syndrome (OHSS) (RR 0.33; 95% CI 0.13-0.80). This meta-analysis demonstrates that CC is still first choice therapy for women with therapy naïve PCOS. In CC-resistant women, the combination of CC plus metformin is the preferred treatment option before starting with LOD or FSH. At present, there is no evidence of an improvement in live birth when adding metformin to LOD or FSH. In IVF, metformin leads to a reduced risk of OHSS.
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Affiliation(s)
- Etelka Moll
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, PO Box 22700, 1100 DE, Amsterdam, The Netherlands.
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Torre A, Fernandez H. Le syndrome des ovaires polykystiques (SOPK). ACTA ACUST UNITED AC 2007; 36:423-46. [PMID: 17540511 DOI: 10.1016/j.jgyn.2007.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 02/15/2007] [Accepted: 04/06/2007] [Indexed: 01/04/2023]
Abstract
Polycystic ovaries syndrome (PCOS) is one of the most common female hormonal disorders. Its multiple components--reproductive, metabolic, neoplasic and cardiovascular--have a major impact on the public health. Androgen excess and resistance to insulin, probably from genetic origin, are responsible for most of the clinical symptomatology. Resistance to insulin seems to be accompanied by a greater risk of glucose intolerance, type 2 diabetes, lipidic anomalies and can involve the development of cardiovascular diseases. In addition, sleep apnea syndrome is more progressively described in PCOS. Infertility, menses disorders and hirsutism often push these patients to consult their physician. A better understanding of the physiopathological mechanisms led to the emergence of new therapeutic options increasing the sensitivity to insulin. Besides the pregnancy wishes, cares aim to attenuate the marks of the hyper-androgenism (hormonal treatment and cosmetic) and to correct cardiovascular, respiratory and gynaecological risk factors. In case of infertility by anovulation, cares must be performed by trained experts to minimize the risk of ovarian hyper-stimulation syndrome and multiple pregnancies. A gradation from loose weight to clomiphene citrate ovulation induction, ovarian drilling, low dose gonadotropin, in vitro fertilisation, or in vitro maturation of oocytes should bring back good reproduction potential.
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Affiliation(s)
- A Torre
- Université Paris-Sud, UMR-S0782, Service de gynécologie-obstétrique et de médecine de la reproduction, hôpital Antoine-Béclère, APHP, 157, rue de la Porte-de-Trivaux, 92141 Clamart cedex, France
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Abstract
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women, associated with a characteristic ovarian appearance at ultrasound scan, hyperandrogenism, and ovulatory disorders. The pathogenesis appears to be mainly related to reduced insulin sensitivity in peripheral tissues, leading to hyperinsulinaemia. There is a wide variation in the severity of PCOS symptoms. Women with PCOS are believed to be predisposed to a variety of complications in pregnancy. We present a summary of the evidence surrounding these claims and discuss the weaknesses of the available to date studies.
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Affiliation(s)
- D Siassakos
- Department of Obstetrics and Gynaecology, Fertility clinic, Cotswold Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
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Mastorakos G, Lambrinoudaki I, Creatsas G. Polycystic ovary syndrome in adolescents: current and future treatment options. Paediatr Drugs 2007; 8:311-8. [PMID: 17037948 DOI: 10.2165/00148581-200608050-00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a very common disorder affecting 5-10% of women of reproductive age. The pivotal endocrine abnormalities of this syndrome are insulin resistance and ovarian and, to a lesser degree, adrenal hypersensitivity to hormonal stimulation. PCOS may manifest itself as early as the first decade of life by premature pubarche or menarche. Oligoamenorrhea in the first postpubarchal years, although very common, may be an early symptom of PCOS, especially in overweight girls with hirsutism or acne. Girls with low birth weight as well as a family history of diabetes mellitus or premature cardiovascular disease are at high risk for developing PCOS. Circulating bioavailable testosterone levels are usually elevated, while total testosterone may be normal due to low levels of sex hormone-binding globulin. The typical sonographic appearance of PCOS ovaries consists of high ovarian volume (>10 mL) and the presence of 12 or more follicles in each ovary measuring 2-9 mm in diameter. However, this finding is not specific, since it may occur in >20% of healthy girls. The therapeutic goals in adolescents with PCOS is first to restore bodyweight and menses and to reduce the signs of hyperandrogenism. The reduction of bodyweight in this young age group may require the collaboration of the pediatrician, dietitian, and psychotherapist. The adolescent should be urged to adopt a healthy lifestyle with the aim to maintain a normal body mass index throughout adolescence and adult life. The choice of medical therapy depends on the clinical presentation. Oral contraceptives are a good option when acne and hirsutism are the principal complaints. Adolescents with isolated cycle irregularity may be placed on a cyclical progestin regimen to induce withdrawal bleeding. Metformin, by decreasing insulin resistance, alleviates many of the hormonal disturbances and restores menses in a considerable proportion of patients. It may be used alone or in combination with oral contraceptives. Independently of medical treatment, restoration and maintenance of bodyweight within normal range is of paramount importance.
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Affiliation(s)
- George Mastorakos
- Second Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece.
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Neveu N, Granger L, St-Michel P, Lavoie HB. Comparison of clomiphene citrate, metformin, or the combination of both for first-line ovulation induction and achievement of pregnancy in 154 women with polycystic ovary syndrome. Fertil Steril 2007; 87:113-20. [PMID: 17081535 DOI: 10.1016/j.fertnstert.2006.05.069] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 05/31/2006] [Accepted: 05/31/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine which first-line medication is more effective in polycystic ovary syndrome (PCOS) patients for ovulation induction and pregnancy achievement and to verify whether any patient characteristic is associated with a better response to therapy. DESIGN Observational comparative study. SETTING Fertility clinic. PATIENT(S) One hundred fifty-four infertile women with oligomenorrhea and hyperandrogenism. INTERVENTION(S) Group 1 (56 patients) received clomiphene citrate (CC) 50 mg from days 5-9 of the cycle. Group 2 (57 patients) received 500 mg of metformin 3 times a day. Group 3 (41 patients) received both medications. MAIN OUTCOME MEASURE(S) Ovulation and pregnancy. RESULT(S) Patients receiving metformin alone had an increased ovulation rate compared with those receiving CC alone (75.4% vs. 50%). Patients on metformin had similar ovulation rates compared with those in the combination group (75.4% vs. 63.4%). Pregnancy rates were equivalent in the 3 groups. Response to metformin was independent of body weight and dose. Finally, nonsmoking predicted better ovulatory response overall as well as lower fasting glucose for CC and lower androgens for metformin. CONCLUSION(S) Metformin is better for ovulation induction than CC alone and equivalent for pregnancy achievement. We suggest that metformin can be used first for ovulation induction in patients with PCOS regardless of their weight and insulin levels because of its efficacy and known safety profile.
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Abstract
PURPOSE OF REVIEW This review discusses the endocrinological aspects of recurrent miscarriage based on the literature from January 2004 to January 2005, elaborating on the advances in the field and their impact on diagnosis and management. RECENT FINDINGS Endometrial luteal phase defect is associated with recurrent miscarriage. Fifty years have passed since the diagnostic criteria for dating the endometrial biopsy was established by Noyes et al. This has been the gold standard and last year its accuracy and clinical utility were critically analysed. A Cochrane review has shown a small but statistically significant difference in the live birth rate in the subgroup of women in which progestogen was used to prevent recurrent miscarriage. Endocannabinoids and fatty acid amide hydrolase have been found to have a potential role in signalling for implantation and maintenance of pregnancy. SUMMARY Abnormal secretory endometrial changes may adversely affect the early pregnancy outcome. Other dating techniques using biochemical and molecular markers of endometrial function may prove useful in predicting outcome. Use of progestogens with or without estrogens for prevention of recurrent miscarriage needs to be investigated further in larger randomized controlled trials. The role of endocannabinoids and agents modulating their receptors are potentially very exciting areas to be explored further.
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Affiliation(s)
- Neelam Potdar
- Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester Royal Infirmary, Leicester, UK
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Moll E, Bossuyt PMM, Korevaar JC, Lambalk CB, van der Veen F. Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of ovulation in women with newly diagnosed polycystic ovary syndrome: randomised double blind clinical trial. BMJ 2006; 332:1485. [PMID: 16769748 PMCID: PMC1482338 DOI: 10.1136/bmj.38867.631551.55] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the effectiveness of clomifene citrate plus metformin and clomifene citrate plus placebo in women with newly diagnosed polycystic ovary syndrome. DESIGN Randomised clinical trial. SETTING Multicentre trial in 20 Dutch hospitals. PARTICIPANTS 228 women with polycystic ovary syndrome. INTERVENTIONS Clomifene citrate plus metformin or clomifene citrate plus placebo. MAIN OUTCOME MEASURE The primary outcome measure was ovulation. Secondary outcome measures were ongoing pregnancy, spontaneous abortion, and clomifene resistance. RESULTS 111 women were allocated to clomifene citrate plus metformin (metformin group) and 114 women were allocated to clomifene citrate plus placebo (placebo group). The ovulation rate in the metformin group was 64% compared with 72% in the placebo group, a non-significant difference (risk difference - 8%, 95% confidence interval - 20% to 4%). There were no significant differences in either rate of ongoing pregnancy (40% v 46%; - 6%, - 20% to 7%) or rate of spontaneous abortion (12% v 11%; 1%, - 7% to 10%). A significantly larger proportion of women in the metformin group discontinued treatment because of side effects (16% v 5%; 11%, 5% to 16%). CONCLUSION Metformin is not an effective addition to clomifene citrate as the primary method of inducing ovulation in women with polycystic ovary syndrome. TRIAL REGISTRATION Current Controlled Trials ISRCTN55906981 [controlled-trials.com].
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Affiliation(s)
- Etelka Moll
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, PO Box 22700, 1100 DE, Amsterdam, Netherlands.
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Abstract
The prevalence of Type 2 diabetes in women of childbearing age continues to grow as the incidence of Type 2 diabetes increases. Recent evidence shows that treatment of gestational diabetes ensures the best possible outcome for pregnancy complicated by gestational diabetes. Metformin is a logical treatment in these circumstances but there has always been concern about its safety for the fetus, particularly as it crosses the placenta and it may increase the risk of teratogenesis. Although evidence is accumulating that metformin is useful and has a role in polycystic ovary syndrome, a condition of insulin resistance, it is not yet accepted as treatment for Type 2 diabetes in pregnancy and gestational diabetes. Observational data supports the use of metformin in Type 2 diabetes in pregnancy and its role in gestational diabetes is currently under investigation. Metformin may become an important treatment for women with either gestational or Type 2 diabetes in pregnancy and indeed may have additional important benefits for women, including reducing insulin resistance, body weight and long-term risk of diabetes. There is a need for a randomized controlled trial in women with Type 2 diabetes in pregnancy with long-term follow-up of both mothers and children. Until then the best advice remains that optimized glycaemic control prior to conception and during pregnancy is the most important intervention for best possible pregnancy outcome.
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Affiliation(s)
- G Hawthorne
- Newcastle Diabetes Centre, Newcastle General Hospital, Newcastle upon Tyne, UK.
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Abstract
AIMS To review pregnancy outcomes in women with Type 2 diabetes (Type 2 DM), comparing women treated with those not treated with metformin. METHODS Data were collected by case-note review for all pregnancies in women with Type 2 DM over a 6-year period (1998-2003) at the National Women's Hospital. Two hundred and fourteen pregnancies were included, metformin was taken in 93 pregnancies and continued until delivery in 32; the remaining 121 pregnancies comprised the control group. The principal outcome measures were preeclampsia, perinatal loss and neonatal morbidity. RESULTS Baseline characteristics differed between groups: women in the metformin group had greater mean (SD) body mass index [35.5(7.6) vs. 33.5(6.6) kg/m2, P < 0.05], more chronic hypertension (19% vs. 7%, P < 0.05) and higher mean (SD) first trimester glycated haemoglobin (HbA1c) levels [8.3(1.9)% vs. 7.5(1.7)%, P < 0.005]. There was no difference between metformin and control groups, respectively, in the rate of preeclampsia (13% vs. 14%, P = 0.84), perinatal loss (3% vs. 2%, P = 0.65) or neonatal morbidity, including rate of prematurity (23% vs. 22%, P = 0.7), admission to the neonatal unit (40% vs. 48%, P = 0.27), respiratory distress (9% vs. 18%, P = 0.07) and treatment with intravenous dextrose (20% vs. 31%, P = 0.08). CONCLUSIONS Pregnant women with Type 2 DM who were treated with metformin had more risk factors for adverse pregnancy outcomes, but no differences in outcomes were seen compared with women not taking metformin. We need randomized trials to address potential benefits of metformin treatment in this population that may be masked by current practice.
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Sohrabvand F, Ansari S, Bagheri M. Efficacy of combined metformin–letrozole in comparison with metformin–clomiphene citrate in clomiphene-resistant infertile women with polycystic ovarian disease. Hum Reprod 2006; 21:1432-5. [PMID: 16478764 DOI: 10.1093/humrep/del020] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Adding metformin to clomiphene citrate in clomiphene-resistant polycystic ovary syndrome (PCOS) patients increases ovulatory response. However, because of anti-estrogenic effects of clomiphene it may be associated with lower pregnancy rate, offsetting the ovulation rate benefit. Letrozole is an aromatase inhibitor which induces ovulation without anti-estrogenic effects. METHODS Infertile women with PCOS were randomly divided into metformin-letrozole (29 patients) and metformin-clomiphene groups (30 patients). After an initial 6-8 weeks of metformin, they received either letrozole (2.5 mg) or clomiphene (100 mg) from day 3-7 of their menstrual cycle. Estradiol (E2) levels, number of follicles, pregnancy rates and endometrial thickness were measured on the day of HCG administration. RESULTS Mean total E2 and E2 per mature follicle were significantly higher in clomiphene group without a difference in mean number of mature follicles >18 mm and ovulation rate. Endometrial thickness was significantly higher in letrozole group. The pregnancy rate in letrozole group (10 patients, 34.50%) as compared with clomiphene group (5 patients, 16.67%) did not show significant difference, whereas full-term pregnancies were higher in letrozole group [10 patients (34.50%) versus 3 patients (10%)]. CONCLUSION In clomiphene-resistant PCOS patients, the combination of letrozole and metformin leads to higher full-term pregnancies.
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Affiliation(s)
- F Sohrabvand
- Department of Infertility & IVF, Vali-e-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Checa MA, Requena A, Salvador C, Tur R, Callejo J, Espinós JJ, Fábregues F, Herrero J. Insulin-sensitizing agents: use in pregnancy and as therapy in polycystic ovary syndrome. Hum Reprod Update 2005; 11:375-90. [PMID: 15878899 DOI: 10.1093/humupd/dmi015] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Treatment with insulin-sensitizing agents is a relatively recent therapeutic strategy in women with polycystic ovary syndrome (PCOS) and insulin resistance. The key areas addressed in this review include PCOS and the development of type 2 diabetes mellitus and gestational diabetes, as well as the use of insulin-sensitizing agents, particularly metformin, in the management of infertility in obese and non-obese PCOS women. Treatment with metformin in PCOS women undergoing IVF and the use of metformin during gestation will be discussed. The challenge for the health care professional should be the appropriate utilization of pharmacotherapies to improve insulin sensitivity and lower circulating insulin levels resulting in beneficial changes in PCOS phenotype. Further research into the potential role of other insulin-sensitizing agents, such as pioglitazone and rosiglitazone, in the treatment of infertile women with PCOS is needed.
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Affiliation(s)
- M A Checa
- Department of Obstetrics and Gynecology, Hospital Universitari del Mar, Universitat Autónoma de Barcelona, Barcelona, Spain.
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Al-Fadhli R, Tulandi T. Laparoscopic treatment of polycystic ovaries: is its place diminishing? Curr Opin Obstet Gynecol 2004; 16:295-8. [PMID: 15232482 DOI: 10.1097/01.gco.0000136495.56958.1a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a critical discussion on the place of laparoscopic ovarian drilling and medical treatment with metformin for polycystic ovary syndrome. RECENT FINDINGS Laparoscopic ovarian drilling remains popular. It is associated with an ovulation rate of approximately 80% and a pregnancy rate of 50-60% within 1 year of the procedure. The technique results in a decrease in ovarian stromal blood flow. An increasing amount of data, however, suggests that treatment with metformin is equally as effective. The use of metformin in pregnancy appears to be safe; it decreases the miscarriage rate and possibly the incidence of gestational diabetes. SUMMARY Laparoscopic ovarian drilling and metformin improve ovulatory dysfunction and pregnancy rate to a similar extent. The advantages of metformin continue beyond conception. It reduces the miscarriage rate and also decreases the likelihood of developing gestational diabetes. A randomized trial comparing the effects of metformin and laparoscopic ovarian drilling in women with polycystic ovary syndrome is recommended.
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Affiliation(s)
- Raedah Al-Fadhli
- Department of Obstetrics and Gynecology, McGill University, Canada
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Use of clomiphene citrate in women. Fertil Steril 2004; 82 Suppl 1:S90-6. [PMID: 15363701 DOI: 10.1016/j.fertnstert.2004.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2003] [Revised: 06/20/2003] [Accepted: 06/20/2003] [Indexed: 11/28/2022]
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van Wely M, Bayram N, van der Veen F, Bossuyt P. Reply to: Are laparoscopic ovarian diathermy and gonadotropin administration the only therapeutic second-steps in clomiphene-citrate resistant women with polycystic ovary syndrome? Hum Reprod 2004. [DOI: 10.1093/humrep/deh469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Meenakumari KJ, Agarwal S, Krishna A, Pandey LK. Effects of metformin treatment on luteal phase progesterone concentration in polycystic ovary syndrome. Braz J Med Biol Res 2004; 37:1637-44. [PMID: 15517078 DOI: 10.1590/s0100-879x2004001100007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The causes of luteal phase progesterone deficiency in polycystic ovary syndrome (PCOS) are not known. To determine the possible involvement of hyperinsulinemia in luteal phase progesterone deficiency in women with PCOS, we examined the relationship between progesterone, luteinizing hormone (LH) and insulin during the luteal phase and studied the effect of metformin on luteal progesterone levels in PCOS. Patients with PCOS (19 women aged 18-35 years) were treated with metformin (500 mg three times daily) for 4 weeks prior to the test cycle and throughout the study period, and submitted to ovulation induction with clomiphene citrate. Blood samples were collected from control (N = 5, same age range as PCOS women) and PCOS women during the late follicular (one sample) and luteal (3 samples) phases and LH, insulin and progesterone concentrations were determined. Results were analyzed by one-way analysis of variance (ANOVA), Duncan's test and Karl Pearson's coefficient of correlation (r). The endocrine study showed low progesterone level (4.9 ng/ml) during luteal phase in the PCOS women as compared with control (21.6 ng/ml). A significant negative correlation was observed between insulin and progesterone (r = -0.60; P < 0.01) and between progesterone and LH (r = -0.56; P < 0.05) concentrations, and a positive correlation (r = 0.83; P < 0.001) was observed between LH and insulin. The study further demonstrated a significant enhancement in luteal progesterone concentration (16.97 ng/ml) in PCOS women treated with metformin. The results suggest that hyperinsulinemia/insulin resistance may be responsible for low progesterone levels during the luteal phase in PCOS. The luteal progesterone level may be enhanced in PCOS by decreasing insulin secretion with metformin.
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Affiliation(s)
- K J Meenakumari
- Department of Zoology, Banaras Hindu University, Varanasi, India
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Norman RJ, Wang JX, Hague W. Should we continue or stop insulin sensitizing drugs during pregnancy? Curr Opin Obstet Gynecol 2004; 16:245-50. [PMID: 15129054 DOI: 10.1097/00001703-200406000-00007] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The use of insulin sensitizing drugs such as metformin in polycystic ovary syndrome has been increasingly popular and validated by systematic reviews. There has also been an interest in the use of metformin for gestational diabetes. However, administration of metformin to prevent miscarriage is controversial and widespread use of this drug in early pregnancy requires investigation. RECENT FINDINGS There are claims that miscarriage and gestational diabetes are more common in polycystic ovary syndrome and that use of insulin sensitizers improves outcomes dramatically. This review suggests there is no evidence for increased risk of miscarriage solely due to polycystic ovary syndrome and that there are insufficient data for promoting therapy with metformin. There is some reason for use of metformin in mid-pregnancy for gestational diabetes but better evidence from randomized controlled trials is urgently needed. SUMMARY The use of metformin in early pregnancy for reducing the risk of miscarriage should be avoided outside of the context of properly designed prospective randomized trials. Safety in early pregnancy appears to be reassuring but not completely proven. The use of metformin in mid-pregnancy for gestational diabetes appears more logical but also needs adequate trials before general use is advocated.
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Affiliation(s)
- Robert J Norman
- Reproductive Medicine Unit, Department of Obstetrics and Gynaecology, University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.
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Glueck CJ, Bornovali S, Pranikoff J, Goldenberg N, Dharashivkar S, Wang P. Metformin, pre-eclampsia, and pregnancy outcomes in women with polycystic ovary syndrome. Diabet Med 2004; 21:829-36. [PMID: 15270785 DOI: 10.1111/j.1464-5491.2004.01251.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS Was metformin during pregnancy in women with polycystic ovary syndrome (PCOS) associated with pre-eclampsia, and was it safe for mother and neonate? METHODS In the current study, pre-eclampsia and other pregnancy outcomes were prospectively studied in 90 women with PCOS who conceived on metformin 1.5-2.55 g/day, and had > or = 1 live birth (97 pregnancies, 100 live births) compared with 252 healthy women (not known to have PCOS) with > or = 1 live birth, consecutively delivered in a community obstetrics practice. RESULTS Women with PCOS were older than controls (33 +/- 5 vs. 29 +/- 6 years, P < 0.0001), more likely to be > 35 years old at conception (23 vs. 13%, P = 0.028), much heavier (93 +/- 23 vs. 72 +/- 18 kg, P < 0.0001, BMI 33.8 +/- 7.8 kg/m2 vs. 25.6 +/- 5.9, P < 0.0001), and more likely to be Caucasian (97 vs. 90%, P = 0.05), but there were similar numbers with preconception Type 2 diabetes mellitus [2/90 (2.2%) vs. 1/252 (0.4%), P = 0.17]. Pre-eclampsia in PCOS (5/97 pregnancies, 5.2%), did not differ (P = 0.5) from controls (9/252, 3.6%), nor did it differ (P = 1.0) in PCOS vs. control primigravidas [2/45 (4.4%) vs. 4/91 (4.4%)]. Development of gestational diabetes in PCOS did not differ from controls [9/95 pregnancies (9.5%) vs. 40/251 (15.9%), P = 0.12]. Of the 100 live births to 90 women with PCOS, there were no major birth defects. Mean +/- sd birth weight of the 80 live births > or = 37 weeks gestation in women with PCOS (3414 +/- 486 g) did not differ from controls' 206 live births > or = 37 weeks (3481 +/- 555 g), P = 0.34, nor did the percentage of > or = 37 week gestation neonates > or = 4000 g (12.5 vs. 17.5%, P = 0.3) or > or = 4500 g (1.3 vs. 2.9%, P = 0.7). CONCLUSIONS Metformin is not associated with pre-eclampsia in pregnancy in women with PCOS, and appears to be safe for mother and fetus.
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Affiliation(s)
- C J Glueck
- Cholesterol Center, Jewish Hospital, Cincinnati, OH 45229, USA.
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Abstract
UNLABELLED Pregnancies in diabetic women are associated with increased risk of spontaneous abortion, congenital malformations, preeclampsia, preterm labor, macrosomia, shoulder dystocia, and cesarean section. Advances in antepartum cares and strict adherence to dietary and insulin regimens have been shown to significantly reduce the rate of maternal morbidity as well as perinatal morbidity and mortality. Historically, reports of potential fetal teratogenicity and hypoglycemic effects on the fetus contraindicated the use of oral hypoglycemic agents in pregnancies complicated with either type II diabetes mellitus (DM) or gestational diabetes mellitus (GDM). Recently, physicians increasingly prescribe newer generations of oral hypoglycemic agents to treat GDM and type II DM to pregnant patients. This review addresses the safety, current recommendations, and controversies surrounding use of the available oral hypoglycemic agents during pregnancy. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES After completion of this article, the reader should be able to describe the mechanisms of actions of the various oral hypoglycemic agents, to list the known side effects of these agents, and to summarize the data on the use of these agents during pregnancy.
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Affiliation(s)
- Nam D Tran
- Department of Obstetrics and Gynecology, University of California-San Francisco, San Francisco, California, USA
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McCarthy EA, Walker SP, McLachlan K, Boyle J, Permezel M. Metformin in obstetric and gynecologic practice: a review. Obstet Gynecol Surv 2004; 59:118-27. [PMID: 14752300 DOI: 10.1097/01.ogx.0000109224.52893.b8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Metformin is a common treatment for women who have insulin resistance manifesting as type 2 diabetes or polycystic ovarian syndrome (PCOS). With an increasing number of these patients conceiving, it is expected that the use of metformin in and around the time of pregnancy will increase. This article reassesses the mechanisms, safety, and clinical experience of metformin use in obstetrics and gynecology. Metformin is an attractive therapeutic option because administration is simple, hypoglycemia rare, and weight loss promoted. There is a large volume of research supporting the use of metformin treatment in diabetes mellitus, androgenization, anovulation, infertility, and recurrent miscarriage. Although metformin is known to cross the placenta, there is, as yet, no evidence of teratogenicity. Metformin has an array of complex actions, accounting for the varied clinical roles, many of which are still to be fully evaluated. Much research is still needed.
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Affiliation(s)
- Elizabeth A McCarthy
- University of Melbourne, Department of Obstetrics and Gynaecology, Mercy Hospital for Women, East Melbourne, Australia.
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van Dam EWCM, Roelfsema F, Veldhuis JD, Hogendoorn S, Westenberg J, Helmerhorst FM, Frölich M, Krans HMJ, Meinders AE, Pijl H. Retention of estradiol negative feedback relationship to LH predicts ovulation in response to caloric restriction and weight loss in obese patients with polycystic ovary syndrome. Am J Physiol Endocrinol Metab 2004; 286:E615-20. [PMID: 14678951 DOI: 10.1152/ajpendo.00377.2003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The present study tests the hypothesis that specific endocrine, metabolic, and anthropometric features distinguish obese women with polycystic ovary syndrome (PCOS) who resume ovulation in response to calorie restriction and weight loss from those who do not. Fifteen obese (body mass index 39 +/- 7 kg/m(2)) hyperandrogenemic oligoovulatory patients undertook a very low calorie diet (VLCD), wherein each lost > or =10% of body weight over a mean of 6.25 mo. Body fat distribution was quantitated by magnetic resonance imaging. Hormones were measured in the morning at baseline, after 1 wk of VLCD, and after 10% weight loss. To monitor LH release, blood was sampled for 24 h at 10-min intervals before intervention and after 7 days of VLCD. Responders were defined a priori as individuals exhibiting two or more ovulatory cycles in the course of intervention, as corroborated by serum progesterone concentrations > or =18 nmol/l followed by vaginal bleeding. At baseline, responders had a higher sex hormone-binding globulin (SHBG) concentration but were otherwise indistinguishable from nonresponders. Body weight, the size of body fat depots, and plasma insulin levels declined to a similar extent in responders and nonresponders. Also, SHBG increased, and the free testosterone index decreased comparably. However, responders exhibited a significant decline of circulating estradiol concentrations (from 191 +/- 82 to 158 +/- 77 pmol/l, means +/- SD, P = 0.037) and a concurrent increase in LH secretion (from 104 +/- 42 to 140 +/- 5 U.l(-1).day(-1), P = 0.006) in response to 7 days of VLCD, whereas neither parameter changed significantly in nonresponders. We infer that evidence of retention of estradiol-dependent negative feedback on LH secretion may forecast follicle maturation and ovulation in obese patients with PCOS under dietary restriction.
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Affiliation(s)
- Eveline W C M van Dam
- Department of General Internal Medicine, Leiden University Medical Center, C1-R39, 2300 RC Leiden, The Netherlands
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Abstract
The goal of an integrative science of women's health is bringing together childbearing with women's health during the lifespan. Enhancing a woman's ability to conceive and maintain a pregnancy is influenced by decisions made well before the beginning of a pregnancy. Identifying ovulatory disorders makes it possible to intervene early in a young woman's childbearing years. Gynecologic charting typically used in natural family planning provides information to the woman and to the healthcare provider that is useful for diagnosis. If young women have a better understanding of fertility and menstrual cycle function, they are in a stronger position to make informed decisions about how they wish to manage their reproductive and sexual health. It may be possible to educate the young woman in health habits that will lead to a healthy pregnancy when she chooses and/or to treat the cause of the ovulatory disorder. This article focuses on polycystic ovary syndrome and hypothalamic dysfunction which can cause menstrual cycle abnormalities in which gynecologic charting is useful in young women.
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Affiliation(s)
- Mary Lee Barron
- Family Nurse Practitioner Program, Nursing Center for Fertility Education, Saint Louis University, 3525 Caroline Mall, St. Louis, MO 63104, USA.
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Abstract
Polycystic ovarian syndrome (PCOS) affects 4% to 12% of women of reproductive age. The lack of well-defined diagnostic criteria makes identification of this common disease confusing to many clinicians. Also, with the varied manifestations of the disorder a patient may present to any one of several providers: an internist, family practitioner, nurse practitioner, pediatrician, gynecologist, dermatologist, or endocrinologist. Furthermore, the most distressing aspect of PCOS for any given patient may change over time, from hirsutism as a teenager to infertility as a young adult--potentially requiring several different providers along the way. It is important, therefore, that those caring for these patients understand not only the management issues pertinent to their specialty, but also appreciate the other potential health risks in these women. Recent insights into the pathophysiology of PCOS have shown insulin resistance to play a substantial role and as such have brought the long-term issues of type 2 diabetes mellitus and its resultant increased risk of coronary artery disease to the forefront. No longer can irregular menses and/or hirsutism be thought of as benign nuisances. This review will focus on the two most confusing aspects of PCOS for the practicing provider--diagnosis/differential diagnosis and treatment options. Special attention is given to the role of insulin resistance and the potential utility of insulin sensitizers in management. The benefit and utmost importance of lifestyle modification for the long-term health of these women is stressed as well. It is hoped that some clarity in this regard will allow more women to not only be diagnosed and managed properly for their presenting symptoms (hirsutism, irregular menses, etc.), but also to be educated and managed for the continuing health risk of insulin resistance throughout their lives.
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Affiliation(s)
- Michael T Sheehan
- Department of Endocrinology, Marshfield Clinic-Wausau Center, Wausau, Wisconsin 54401, USA.
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Tsilchorozidou T, Prelevic GM. The role of metformin in the management of polycystic ovary syndrome. Curr Opin Obstet Gynecol 2003; 15:483-8. [PMID: 14624214 DOI: 10.1097/00001703-200312000-00005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a critical summary of recent studies on the clinical effects of metformin in polycystic ovary syndrome. RECENT FINDINGS After the recognition that hyperinsulinaemia is a fundamental disturbance in polycystic ovary syndrome, a novel and promising form of therapy in the form of insulin-sensitizing drugs has been introduced. Among these, metformin is the most widely used. This therapeutic intervention has been shown to exert beneficial effects on the endocrine and metabolic disturbances that characterize the syndrome and, more recently, to improve the reproductive outcome in women with polycystic ovary syndrome. With rapid progress in this area, metformin use has also been extended to the management of lean polycystic ovary syndrome patients. SUMMARY Although most studies are nonrandomized trials, current data provide a rationale for metformin as first-line management for women with polycystic ovary syndrome, alone or in combination with conventional treatments. Controversy still exists, however, regarding the mechanisms by which metformin exerts its beneficial effects in polycystic ovary syndrome.
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Affiliation(s)
- Tasoula Tsilchorozidou
- Department of Medicine, Royal Free and University College London Medical School, The Middlesex Hospital, UK
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Glueck CJ, Wang P, Bornovali S, Goldenberg N, Sieve L. Polycystic ovary syndrome, the G1691A factor V Leiden mutation, and plasminogen activator inhibitor activity: associations with recurrent pregnancy loss. Metabolism 2003; 52:1627-32. [PMID: 14669168 DOI: 10.1016/j.metabol.2003.06.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Our specific aim was to assess associations of thrombophilia, hypofibrinolysis, and polycystic ovary syndrome (PCOS) with recurrent pregnancy loss (RPL) (>/=3 consecutive pregnancy losses < 20 weeks gestation). Prospective studies were performed in 33 Caucasian women referred for diagnosis and treatment of PCOS who were subsequently found to have RPL and in 16 Caucasian women referred for diagnosis and treatment of RPL, who did not have PCOS. Cases (PCOS-RPL, RPL without PCOS) were compared with controls (116 healthy Caucasian females) for the G1691A Factor V Leiden, G20210A prothrombin, C677T methylenetetrahydrofolate reductase (MTHFR), plasminogen activator inhibitor 4G/5G, and platelet glycoprotein PL A1A2 gene mutations. Cases were compared with controls (44 healthy adult Caucasian females) for serologic coagulation tests including homocysteine, proteins C, S, free S, antithrombin III, anticardiolipin antibodies IgG and IgM, dilute Russel's viper venom time, activated partial thromboplastin time, Factor VIII, Factor XI, lipoprotein (Lp)(a), and plasminogen activator inhibitor activity (PAI-Fx). The 33 Caucasian women with PCOS subsequently found to have RPL were 10% of a cohort of 322 Caucasian women who had >/= 1 previous pregnancy and had been referred for diagnosis and therapy of PCOS over a 4.3-year period. The Factor V Leiden G1691 mutation was present in 6 of 33 women (18%) with PCOS-RPL and in 3 of 16 women with RPL without PCOS (19%) versus 2 of 116 (1.7%) female controls, Fisher's P (p(f)) =.0016, p(f) =.013. The 33 PCOS-RPL cases also differed from the 44 female controls for high PAI-Fx (>21.1 U/mL), 38% versus 8%, p(f) =. 004. The thrombophilic G1691A Factor V Leiden mutation is associated with RPL in women with and without PCOS; hypofibrinolysis (high PAI-Fx) is also associated with RPL in women with PCOS.
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