Obesity and weight loss in polycystic ovary syndrome

Clinical Diagnostic Values of C1q/TNF-Related Protein-3 for Polycystic Ovary Syndrome Women with Insulin Resistance

Polycystic ovary syndrome (PCOS) is the most common disease caused by complex endocrine and metabolic abnormalities in women. Insulin resistance is considered an important pathophysiological factor in the pathogenesis of PCOS. Here we investigated the clinical values of C1q/TNF-related protein-3 (CTRP3) as predictive factor for insulin resistance. Our study included 200 patients with PCOS, among which 108 had insulin resistance. Serum CTRP3 levels were measured using enzyme-linked immunosorbent assay. Predictive values of CTRP3 for insulin resistance was analyzed using receiver operating characteristic (ROC) analysis. Correlations of CTRP3 to insulin levels, obesity measurements and blood lipid levels were determined using Spearman's correlation analysis. Our data suggested that PCOS patients with insulin resistance had a higher obesity, lower high-density lipoprotein cholesterol, higher total cholesterol, higher insulin levels and lower CTRP3 levels. CTRP3 had a high sensitivity (72.22%) and specificity (72.83%). CTRP3 significantly correlated to insulin levels, body mass index, waist-to-hip ratio, high-density lipoprotein, and total cholesterol levels. The predictive value of CTRP3 in PCOS patients with insulin resistance was supported by our data. Our findings suggest that CTRP3 is involved in the pathogenesis and insulin resistance of PCOS, which indicates its value as an indicator for the PCOS diagnosis.

Further delineation of familial polycystic ovary syndrome (PCOS) via whole-exome sequencing: PCOS-related rare FBN3 and FN1 gene variants are identified

AIM

To identify pathogenic rare coding Mendelian/high-effect size variant(s) by whole-exome sequencing in familial polycystic ovary syndrome (PCOS) patients to elucidate PCOS-related pathways.

METHODS

Twenty women and their affected available relatives diagnosed with PCOS according to Rotterdam criteria were recruited. Whole-exome sequencing on germ-line DNA from 31 PCOS probands and their affected relatives was performed. Whole-exome sequencing data were further evaluated by pathway and chemogenomics analyses. In-slico analysis of candidate variants were done by VarCards for functional predictions and VarSite for impact on three-dimensional (3D) structures in the candidate proteins.

RESULTS

Two heterozygous rare FBN3 missense variants in three patients, and one FN1 missense variant in one patient from three different PCOS families were identified.

CONCLUSION

We identified three novel FBN3 and FN1 variants for the first time in the literature and linked with PCOS. Further functional studies may identify causality of these newly discovered PCOS-related variants, and their role yet remains to be investigated. Our findings may improve our understanding of the biological pathways affected and identify new drug targets.

Postpartum weight retention in women with polycystic ovary syndrome

BACKGROUND

Compared with women without polycystic ovary syndrome, women with polycystic ovary syndrome have a higher prevalence of cardiometabolic risk factors. Postpartum weight retention has been shown to contribute to these risks in the general population, but little is known about postpartum weight retention among women with polycystic ovary syndrome.

OBJECTIVE

This study aimed to compare postpartum weight retention and peripartum weight trends between women with polycystic ovary syndrome and controls.

STUDY DESIGN

Data on live, full-term singleton deliveries from January 1, 2014, to January 1, 2019, in women with and without polycystic ovary syndrome were abstracted from the electronic medical record. Weights during the pregestational period, pregnancy, and up to 12 months postpartum were collected. The primary outcome was likelihood of high postpartum weight retention of ≥5 kg above pregestational weight at 12 months after delivery. Secondary outcomes included the prevalence of high weight retention at other postpartum time points (6 weeks, 3 months, 6 months), absolute postpartum weight retention, gestational weight gain, and excess weight gain above the Institute of Medicine guidelines for weight gain in pregnancy.

RESULTS

A total of 6333 women had the requisite weight information (pregestational, peak pregnancy, and at least 1 postpartum weight), including 429 (6.8%) with polycystic ovary syndrome. After adjusting for age, pregestational body mass index, race, gestational diabetes mellitus, and parity, women with polycystic ovary syndrome were less likely to be high weight retainers at 6 weeks after delivery (adjusted odds ratio, 0.71; P=.02). There was no difference in postpartum weight retention between groups at 3, 6, and 12 months after delivery. Overall, the prevalence of high weight retainers at 12 months after delivery was high in both groups (22.7% in polycystic ovary syndrome vs 29.2% in controls; P=.13), and there was no difference in absolute weight retention (1.69 kg in polycystic ovary syndrome vs 2.05 kg in controls; P=.25). Although women with polycystic ovary syndrome had a higher pregestational body mass index, they had lower gestational weight gain (median, 12.7 kg) than controls (median, 13.5 kg) (P=.01). These findings were driven by the group with obesity. The percentage of women who surpassed the Institute of Medicine guidelines for gestational weight gain based on the body mass index category was similar between groups (43.4% in polycystic ovary syndrome vs 47.3% in controls; P=.12). Overall, 18.5% of women with polycystic ovary syndrome and 23.4% of controls had a higher body mass index category at 12 months after delivery than before pregnancy.

CONCLUSION

Women with polycystic ovary syndrome had lower gestational weight gain and lower likelihood of high weight retention at 6 weeks after delivery but similar weight retention at 12 months after delivery compared with controls. Overall, the large proportion of women with high postpartum weight retention highlights the importance of the peripartum time period for weight management, particularly in this high-risk group predisposed to obesity and cardiometabolic disease.

Quality of life in adolescent girls with polycystic ovary syndrome

Quality of life (QoL) is an important aspect of health and well-being. QoL is reduced in women with polycystic ovary syndrome (PCOS), but there is limited data in adolescents. This review aimed to assess studies regarding the QoL of adolescent girls with PCOS. Five databases were searched for relevant studies. Studies were included if they were conducted in adolescent girls with PCOS, aged 12-22 years old, and used a questionnaire to measure QoL. The search identified a total of 254 studies, and after exclusions, 11 relevant studies were included in the review. Most studies had a relatively small sample size, but overall included a total of 512 adolescents with PCOS. In most cases, adolescent girls with PCOS have reduced QoL when compared to healthy girls, and PCOS symptoms/excess weight impact on their QoL. Further research is required due to limited data on QoL in adolescents with PCOS of normal weight.

Polycystic Ovary Syndrome: Menopause and Malignancy

Polycystic ovary syndrome (PCOS) has been extensively studied in reproductive-aged women. However, accumulating research shows that PCOS can have lifelong effects on multiple aspects of women's health. PCOS can affect the onset and course of menopause and cardiovascular health in perimenopausal and postmenopausal patients. Moreover, PCOS may increase a woman's risk for both gynecologic and nongynecologic malignancies. When treating older PCOS patients, physicians should be cognizant of the syndrome's long-term effects and consider the unique needs of these women.

Lipidomics reveals altered biosynthetic pathways of glycerophospholipids and cell signaling as biomarkers of the polycystic ovary syndrome

Purpose

In this work, a non-targeted approach was used to unravel changes in the plasma lipidome of PCOS patients. The aim is to offer new insights in PCOS patients strictly selected in order to avoid confounding factors such as dyslipemia, obesity, altered glucose/insulin metabolism, cardiovascular disease, or cancer.

Results

Multivariate statistics revealed a specific lipidomic signature for PCOS patients without associated pathologies. This signature implies changes, mainly by down-regulation, in glycerolipid, glycerophospholipid and sphingolipid metabolism suggesting an altered biosynthetic pathway of glycerophospholipids and cell signaling as second messengers in women with PCOS.

Conclusions

Our study confirms that a lipidomic approach discriminates a specific phenotype from PCOS women without associated pathologies from healthy controls.

Methods

In a cross-sectional pilot study, data were obtained from 34 subjects, allocated to one of two groups: a) lean, healthy controls (n = 20), b) PCOS patients (n = 14) with diagnosis based on hyperandrogenaemia, oligo-anovulation and abnormal ovaries with small follicular cysts. A detailed biochemical characterization was made and lipidomic profiling was performed via an untargeted approach using LC-ESI-QTOF MS/MS.

Nutritional management in women with polycystic ovary syndrome: A review study

Polycystic ovary syndrome (PCOS) is endocrine disorder in women of reproductive age, which leads to reproductive, hormonal and metabolic abnormalities. Due to the presence of insulin resistance, PCOS increases the risk of chronic diseases like type 2 diabetes, hypertension, lipid disorders, cardiovascular diseases and malignancies such as breast and endometrial cancer. The actual cause of this syndrome is unknown but environmental factors such as dietary habits play an important role in prevention and treatment and lifestyle modifications are the most important therapeutic strategies in these patients. The approach of the diet therapy in these patients must be to reach specific goals such as improving insulin resistance, metabolic and reproductive functions that will be possible through the design of low-calorie diet to achieve weight loss or maintaining a healthy weight, limit the intake of simple sugars and refined carbohydrates and intake foods with a low glycemic index, reduction of saturated and trans fatty acids and attention to possible deficiencies such as vitamin D, chromium and omega-3. Given the prevalence of overweight and obesity and insulin resistance, a relatively low reduction in weight, about 5%, can improve problems such as insulin resistance, high levels of androgens, reproductive system dysfunctions and fertility in these women.

A story of metformin-butyrate synergism to control various pathological conditions as a consequence of gut microbiome modification: Genesis of a wonder drug?

The most widely prescribed oral anti-diabetic agent today in the world today is a member of the biguanide class of drugs called metformin. Apart from its use in diabetes, it is currently being investigated for its potential use in many diseases such as cancer, cardiovascular diseases, Alzheimer's disease, obesity, comorbidities of diabetes such as retinopathy, nephropathy to name a few. Numerous in-vitro and in-vivo studies as well as clinical trials have been and are being conducted with a vast amount of literature being published every day. Numerous mechanisms for this drug have been proposed, but they have been unable to explain all the actions observed clinically. It is of interest that insulin has a stimulatory effect on cellular growth. Metformin sensitizes the insulin action but believed to be beneficial in cancer. Like -wise metformin is shown to have beneficial effects in opposite sets of pathological scenario looking from insulin sensitization point of view. This requires a comprehensive review of the disease conditions which are claimed to be affected by metformin therapy. Such a comprehensive review is presently lacking. In this review, we begin by examining the history of metformin before it became the most popular anti-diabetic medication today followed by a review of its relevant molecular mechanisms and important clinical trials in all areas where metformin has been studied and investigated till today. We also review novel mechanistic insight in metformin action in relation to microbiome and elaborate implications of such aspect in various disease states. Finally, we highlight the quandaries and suggest potential solutions which will help the researchers and physicians to channel their research and put this drug to better use.

Clinical characteristics in Taiwanese women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common hormonal endocrine disorders in women of reproductive age. It consists of a heterogeneous collection of signs and symptoms that together form a disorder spectrum. The diagnosis of PCOS is principally based on clinical and physical findings. The extent of metabolic abnormalities in women with PCOS varies with phenotype, body weight, age, and ethnicity. For general population, the prevalence of hyperandrogenism and oligomenorrhea decreases with age, while complications such as insulin resistance and other metabolic disturbances increase with age. Obese women with PCOS have a higher risk of developing oligomenorrhea, amenorrhea, hyperandrogenemia, insulin resistance, and lower luteinizing hormone (LH) to follicle stimulation hormone (FSH) ratios than non-obese women with PCOS. The LH to FSH ratio is a valuable diagnostic tool in evaluating Taiwanese women with PCOS, especially in the diagnosis of oligomenorrhea. Overweight/obesity is the major determinant of cardiovascular and metabolic disturbances in women of reproductive age.

Metabolic disorders in menopause

Metabolic disorders occurring in menopause, including dyslipidemia, disorders of carbohydrate metabolism (impaired glucose tolerance - IGT, type 2 diabetes mellitus - T2DM) or components of metabolic syndrome, constitute risk factors for cardiovascular disease in women. A key role could be played here by hyperinsulinemia, insulin resistance and visceral obesity, all contributing to dyslipidemia, oxidative stress, inflammation, alter coagulation and atherosclerosis observed during the menopausal period. Undiagnosed and untreated, metabolic disorders may adversely affect the length and quality of women's life. Prevention and treatment preceded by early diagnosis should be the main goal for the physicians involved in menopausal care. This article represents a short review of the current knowledge concerning metabolic disorders (e.g. obesity, polycystic ovary syndrome or thyroid diseases) in menopause, including the role of a tailored menopausal hormone therapy (HT). According to current data, HT is not recommend as a preventive strategy for metabolic disorders in menopause. Nevertheless, as part of a comprehensive strategy to prevent chronic diseases after menopause, menopausal hormone therapy, particularly estrogen therapy may be considered (after balancing benefits/risks and excluding women with absolute contraindications to this therapy). Life-style modifications, with moderate physical activity and healthy diet at the forefront, should be still the first choice recommendation for all patients with menopausal metabolic abnormalities.

Adiposopathy: how do diet, exercise and weight loss drug therapies improve metabolic disease in overweight patients?

An increase in bodyweight is generally associated with an increased risk of excessive fat-related metabolic diseases (EFRMD), including Type 2 diabetes mellitus, hypertension and dyslipidemia. However, not all patients who are overweight have EFRMD, and not all patients with EFRMD are significantly overweight. The adipocentric paradigm provides the basis for a unifying, pathophysiological process whereby fat gain in susceptible patients leads to fat dysfunction ('sick fat'), and wherein pathological abnormalities in fat function (adiposopathy) are more directly related to the onset of EFRMD than increases in fat mass (adiposity) alone. But just as worsening fat function worsens EFRMD, improved fat function improves EFRMD. Peroxisome proliferator-activated receptor-gamma agonists increase the recruitment, proliferation and differentiation of preadipocytes ('healthy fat') and cause apoptosis of hypertrophic and dysfunctional (including visceral) adipocytes resulting in improved fat function and improved metabolic parameters associated with EFRMD. Weight loss interventions, such as a hypocaloric diet and physical exercise, in addition to agents such as orlistat, sibutramine and cannabinoid receptor antagonists, may have favorable effects upon fat storage (lipogenesis and fat distribution), nutrient metabolism (such as free fatty acids), favorable effects upon adipose tissue factors involved in metabolic processes and inflammation, and enhanced 'cross-talk' with other major organ systems. In some cases, weight loss therapeutic agents may even affect metabolic parameters and adipocyte function independently of weight loss alone, suggesting that the benefit of these agents in improving EFRMD may go beyond their efficacy in weight reduction. This review describes how adiposopathy interventions may affect fat function, and thus improve EFRMD.

Changes in the PCOS phenotype with age

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder of reproductive-age women. The diagnosis of PCOS is mainly based on the following three components: (1) hyperandrogenism, (2) oligo-amenorrhea, and (3) the observation of polycystic ovaries on a sonogram. The comorbidities may include insulin resistance, type II diabetes mellitus, hypertension and cardiovascular disease. Importantly, the diagnostic criteria and complications related to PCOS are age-dependent. Androgen production in women may decrease because of ovarian aging or decreased production by the adrenal glands over time. The prevalence of hirsutism and acne decreases with age. Ovarian volume and follicle number also decrease with age, with the age-related decrease in follicle number seemingly greater than that of ovarian volume. Aging may also be associated with increased risk of insulin resistance and metabolic disturbances. Therefore, these age-related changes may affect the observed incidence and complications of PCOS. In adolescent patients, the criteria described above pose particular diagnostic problems because the characteristics of normal puberty often overlap with the signs and symptoms of PCOS. Hyperandrogenism and chronic anovulation are the primary disturbances in younger women with PCOS; whereas, obesity, insulin resistance, and metabolic disturbances are predominant in older women with PCOS. The deterioration of insulin resistance during the reproductive life of women with PCOS appears to be mainly attributable to the increase in obesity. Therefore, if body weight could be controlled properly, younger hyperandrogenic PCOS women might reduce their risk of insulin resistance and metabolic disturbances later in life.

Genetics of the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a highly complex endocrine disorder, characterized by hyperandrogenemia, menstrual irregularities and polycystic ovaries. A strong genetic component to the etiology of PCOS is evident. However, due to the genetic and phenotypic heterogeneity of PCOS and the lack of insufficiently large cohorts, studies to identify specific contributing genes to date have yielded only few conclusive results. In this review we discuss the current status of the genetic analysis of PCOS including the results of numerous association studies with candidate genes involved in TGF-β and insulin signaling, type 2 diabetes mellitus and obesity susceptibility. Furthermore, we address current challenges in genetic studies of PCOS, and the promise of new approaches, including genome-wide association studies and next-generation sequencing.

Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterised by infrequent or absent ovulation (anovulation), high levels of male hormones (hyperandrogenaemia) and high levels of insulin (hyperinsulinaemia secondary to increased insulin resistance). Hyperinsulinaemia is associated with an increase in cardiovascular risk and the development of diabetes mellitus. Insulin-sensitising agents such as metformin may be effective in treating the features of PCOS, including anovulation.

OBJECTIVES

To assess the effectiveness of insulin-sensitising drugs in improving reproductive outcomes and metabolic parameters for women with PCOS.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (October 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 3rd Quarter 2011), CINAHL (October 2011), MEDLINE (January 1966 to October 2011), and EMBASE (January 1985 to October 2011).

SELECTION CRITERIA

Randomised controlled trials of insulin sensitising drugs compared with either placebo, no treatment, or an ovulation induction agent for women with PCOS, menstrual disturbance and subfertility.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and trial quality, and extracted data.  

MAIN RESULTS

Forty-four trials (3992 women) were included for analysis, 38 of them using metformin and involving 3495 women.There was no evidence that metformin improved live birth rates, whether it was used alone (pooled OR 1.80, 95% CI 0.52 to 6.16, 3 trials, 115 women) or in combination with clomiphene (pooled OR 1.16, 95% CI 0.85 to 1.56, 7 trials, 907 women). However, clinical pregnancy rates were improved for metformin versus placebo (pooled OR 2.31, 95% CI 1.52 to 3.51, 8 trials, 707 women) and for metformin and clomiphene versus clomiphene alone (pooled OR 1.51, 95% CI 1.17 to 1.96, 11 trials, 1208 women). In the studies that compared metformin and clomiphene alone, there was evidence of an improved live birth rate (pooled OR 0.3, 95% CI 0.17 to 0.52, 2 trials, 500 women) and clinical pregnancy rate (pooled OR 0.34, 95% 0.21 to 0.55, 2 trials, 500 women) in the group of obese women who took clomiphene.Metformin was also associated with a significantly higher incidence of gastrointestinal disturbances than placebo (pooled OR 4.27, 95% CI 2.4 to 7.59, 5 trials, 318 women) but no serious adverse effects were reported.

AUTHORS' CONCLUSIONS

In agreement with the previous review, metformin was associated with improved clinical pregnancy but there was no evidence that metformin improves live birth rates whether it is used alone or in combination with clomiphene, or when compared with clomiphene. Therefore, the role of metformin in improving reproductive outcomes in women with PCOS appears to be limited.

Do women with PCOS have a unique predisposition to obesity?

Women with PCOS are often obese and there is debate in the literature regarding whether women are obese because of their PCOS status or if those who become obese are more predisposed to PCOS. There is support for a predisposition to obesity by some data indicating impaired metabolism in PCOS women compared to weight matched controls but this data is limited. Contrary data also exist that adiposity rates do not vary between women with PCOS and those without, and that differences in obesity rates between countries are more likely due to environmental and lifestyle factors. Until further data are available, lifestyle recommendations for weight reduction in women with PCOS should be similar to those for women without PCOS.

Obesity and insulin resistance in women with polycystic ovary syndrome

OBJECTIVE

To evaluate the impact of obesity and various phenotypes of polycystic ovary syndrome (PCOS) on the insulin sensitivity index (ISI) and insulin resistance (IR).

METHODS

ISI and IR from 273 women in four phenotypes of PCOS and control groups were evaluated retrospectively.

RESULTS

The ISI and the percentage of IR were not significantly different among discrete phenotypes of PCOS groups and normal controls. Obesity (OR = 14.0, 95% CI (Confidence Interval), 7.5-26.5) results in a higher risk for developing insulin resistance than hyperandrogenemia (OR = 2.1, 1.3-3.6), oligomenorrhea (OR = 1.8, 1.0-3.3) and polycystic ovary morphology (PCOM) (OR = 1.4, 0.8-2.7).

CONCLUSION

The ISI did not differ significantly among the various phenotypes of PCOS. In comparison with hyperandrogenemia, chronic anovulation, and PCOM, obesity was the dominant risk factor in determining insulin resistance in women with PCOS.

Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterised by anovulation, hyperandrogaenemia and insulin resistance. Hyperinsulinaemia is associated with an increase in cardiovascular risk and the development of diabetes mellitus. If insulin sensitising agents such as metformin are effective in treating features of PCOS, then they could have wider health benefits than just treating the symptoms of the syndrome.

OBJECTIVES

To assess the effectiveness of insulin sensitising drugs in improving reproductive outcomes and metabolic parameters for women with PCOS and menstrual disturbance.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group trials register (searched September 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library, third Quarter 2008), CINAHL (searched September 2008), MEDLINE (January 1966 to September 2008), and EMBASE (January 1985 to September 2008). All searches were rerun 13 August 2009 17 RCTs were located and await classification.

SELECTION CRITERIA

Randomised controlled trials which investigated the effect of insulin sensitising drugs compared with either placebo or no treatment, or compared with an ovulation induction agent.

DATA COLLECTION AND ANALYSIS

Thirty one trials (2537 women) were included for analysis, 27 of them using metformin and involving 2150 women.

MAIN RESULTS

There is no evidence that metformin improves live birth rates whether it is used alone (Pooled OR = 1.00, 95% CI 0.16 to 6.39) or in combination with clomiphene (Pooled OR = 1.48, 95% CI 1.12 to 1.95). However, clinical pregnancy rates are improved for metformin versus placebo (Pooled OR = OR 3.86, 95% C.I. 2.18 to 6.84) and for metformin and clomiphene versus clomiphene alone (Pooled OR =1.48, 95% C.I. 1.12 to 1.95) ). In the studies that compared metformin and clomiphene alone, there was no evidence of an improved live birth rate (OR= 0.67, 95% CI 0.44 to 1.02) but the pooled OR resulted in improved clinical pregnancy rate in in the clomiphene group (OR = 0.63 , 95% 0.43 to 0.92), although there was significant heterogeneity.There is also evidence that ovulation rates are improved with metformin in women with PCOS for metformin versus placebo (Pooled OR 2.12, 95% CI 1.50 to 3.0) and for metformin and clomiphene versus clomiphene alone (Pooled OR = 3.46, 95% CI 1.97 to 6.07).Metformin was also associated with a significantly higher incidence of gastrointestinal disturbance, but no serious adverse effects were reported.

AUTHORS' CONCLUSIONS

In agreement with the previous review, metformin is still of benefit in improving clinical pregnancy and ovulation rates. However, there is no evidence that metformin improves live birth rates whether it is used alone or in combination with clomiphene, or when compared with clomiphene. Therefore, the use of metformin in improving reproductive outcomes in women with PCOS appears to be limited.

Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterised by anovulation, hyperandrogaenemia and insulin resistance. Hyperinsulinaemia is associated with an increase in cardiovascular risk and the development of diabetes mellitus. If insulin sensitising agents such as metformin are effective in treating features of PCOS, then they could have wider health benefits than just treating the symptoms of the syndrome.

OBJECTIVES

To assess the effectiveness of insulin sensitising drugs in improving reproductive outcomes and metabolic parameters for women with PCOS and menstrual disturbance.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group trials register (searched September 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library, third Quarter 2008), CINAHL (searched September 2008), MEDLINE (January 1966 to September 2008), and EMBASE (January 1985 to September 2008). All searches were rerun 13 August 2009 17 RCTs were located and await classification.

SELECTION CRITERIA

Randomised controlled trials which investigated the effect of insulin sensitising drugs compared with either placebo or no treatment, or compared with an ovulation induction agent.

DATA COLLECTION AND ANALYSIS

Thirty one trials (2537 women) were included for analysis, 27 of them using metformin and involving 2150 women.

MAIN RESULTS

There is no evidence that metformin improves live birth rates whether it is used alone (Pooled OR = 1.00, 95% CI 0.16 to 6.39) or in combination with clomiphene (Pooled OR = 1.48, 95% CI 1.12 to 1.95). However, clinical pregnancy rates are improved for metformin versus placebo (Pooled OR = OR 3.86, 95% C.I. 2.18 to 6.84) and for metformin and clomiphene versus clomiphene alone (Pooled OR =1.48, 95% C.I. 1.12 to 1.95) ). In the studies that compared metformin and clomiphene alone, there was no evidence of an improved live birth rate (OR= 0.67, 95% CI 0.44 to 1.02) but the pooled OR resulted in improved clinical pregnancy rate in in the clomiphene group (OR = 0.63 , 95% 0.43 to 0.92), although there was significant heterogeneity.There is also evidence that ovulation rates are improved with metformin in women with PCOS for metformin versus placebo (Pooled OR 2.12, 95% CI 1.50 to 3.0) and for metformin and clomiphene versus clomiphene alone (Pooled OR = 3.46, 95% CI 1.97 to 6.07).Metformin was also associated with a significantly higher incidence of gastrointestinal disturbance, but no serious adverse effects were reported.

AUTHORS' CONCLUSIONS

In agreement with the previous review, metformin is still of benefit in improving clinical pregnancy and ovulation rates. However, there is no evidence that metformin improves live birth rates whether it is used alone or in combination with clomiphene, or when compared with clomiphene. Therefore, the use of metformin in improving reproductive outcomes in women with PCOS appears to be limited.

WITHDRAWN: Insulin-sensitising drugs for polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterised by anovulation, hyperandrogaenemia and insulin resistance. Hyperinsulinaemia is associated with an increase in cardiovascular risk and the development of diabetes mellitus. If insulin sensitising agents such as metformin are effective in treating features of PCOS, then they could have wider health benefits than just treating the symptoms of the syndrome.

OBJECTIVES

To assess the effectiveness of insulin sensitising drugs in improving clinical and biochemical features of PCOS.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group trials register (searched September 2008 ), the Cochrane Central Register of Controlled Trials (Cochrane Library, September 2008), MEDLINE (January 1966 to September 2008), and EMBASE (January 1985 to September 2008).

SELECTION CRITERIA

Randomised controlled trials which investigated the effect of insulin sensitising drugs compared with either placebo or no treatment, or compared with an ovulation induction agent.

DATA COLLECTION AND ANALYSIS

Thirty nine trials (3576 subjects) were included for analysis, 31 of them using metformin and involving 2625 participants.

MAIN RESULTS

Meta-analysis showed that metformin is effective in achieving ovulation in women with PCOS with odds ratios of 2.21(CI 1.57 to 3.10) for metformin versus placebo and 3.93(CI 2.32 to 6.65) for metformin and clomiphene versus clomiphene alone. An analysis of pregnancy rates suggests a significant treatment effect for metformin and clomiphene (OR 1.58, CI 1.20 to 2.07). Nevertheless, these benefits were not translated into live birth rates.Metformin has a significant effect in reducing fasting insulin levels (WMD -4.20 mIU/L, CI -7.68 to -0.73); however, the reduction was only significant in the non-obese group (BMI < 30 kg/m2). Treatment effect on serum testosterone concentration was observed; but the magnitude of the reduction was greater in the non-obese group compared with the obese group (WMD -1.79 versus. -0.30 nmol/L). Metformin has no effect on serum lipid profiles. Metformin was also associated with a significantly higher incidence of gastrointestinal disturbance, but no serious adverse effects were reported.

AUTHORS' CONCLUSIONS

In agreement with the previous review, metformin is still of benefit in improving ovulation and pregnancy rates. However, metformin does not improve live birth whether it is used alone or in combination with clomiphene. In addition, metformin has limited effect on metabolic parameters, especially in obese women with PCOS. Therefore, the use of metformin in improvement of reproductive outcomes or in reducing the risk of developing metabolic syndrome in women with PCOS appears to be limited.

Implementation of dietary and general lifestyle advice among women with polycystic ovarian syndrome

AIMS

Central obesity and insulin resistance are strongly implicated in the etiology of polycystic ovarian syndrome (PCOS) and their reduction is therefore a central treatment focus. Weight loss has been consistently successful in reducing insulin resistance and restoring ovulation and fertility in women with PCOS. The purpose of the current study is to investigate the general attitudes towards dieting and exercise in women with PCOS, together with the extent of implementation of the dietary and lifestyle advice that these women are given as part of their treatment. General knowledge of patients about their condition (PCOS) has also been assessed.

METHODS

Fifty three pre-menopausal women, over the age of 18 years, with a confirmed diagnosis of PCOS, were recruited from the Endocrinology Department, Middlesex Hospital, London. Subjects were interviewed individually using an interview-guided questionnaire.

RESULTS

Sixty four per cent of the subjects were overweight (BMI > 25 kg/m2) and 55% of those were obese (BMI > 30 kg/m2). All subjects identified the importance of weight control in the management of their condition. However, only nine out of the 35 overweight women had actually been referred to a dietician and only 22 reported taking moderate exercise at least once a week in order to improve their health. The main sources of information on weight management were the internet and their consultant endocrinologist, who they normally see only twice a year.

CONCLUSION

In spite of the fact that weight loss and weight maintenance are absolutely vital in the treatment of PCOS, our study has shown that the support given to PCOS patients to help reduce and control their weight is inadequate and needs to be improved.

Obesity, weight loss, and the polycystic ovary syndrome: effect of treatment with diet and orlistat for 24 weeks on insulin resistance and androgen levels

OBJECTIVE

To investigate the combined effect of diet and orlistat, for 24 weeks, on anthropometric features, hormonal parameters, and indices of insulin resistance in obese women with polycystic ovary syndrome (PCOS) and in obese women without the syndrome.

DESIGN

Prospective clinical study.

SETTING

Department of obstetrics and gynecology in a major university in Greece.

PATIENT(S)

Eighteen selected women with PCOS were matched for age and body mass index with 14 obese control women.

INTERVENTION(S)

Subjects were prescribed an energy-restricted diet, and orlistat (120 mg, 3 times per d) was administered to all subjects for 24 weeks.

MAIN OUTCOME MEASURE(S)

At baseline, week 12, and week 24, after an overnight fast, blood samples were collected, and serum levels of FSH, LH, PRL, T, Delta(4)A, DHEAS, 17 alpha-hydroxyprogesterone, sex hormone-binding globulin, glucose, and insulin were measured.

RESULT(S)

Testosterone levels were significantly decreased with treatment in women with PCOS; this decrease was attributed to the first trimester, whereas T levels did not change during the second 12-week period. In women with PCOS, insulin levels and HOMA-IR values were decreased during the first 12 weeks, whereas no significant change was observed during the second trimester.

CONCLUSION(S)

Orlistat administration, combined with diet, for 24 weeks, resulted in significant weight loss and improvement of insulin resistance in obese women, with or without PCOS. Moreover, T levels were significantly decreased in women with PCOS. There appears to be a trend during the first 12-week period for greater improvement of metabolic and hormonal parameters in women with PCOS.

Preoperative assessment and perioperative care of patients undergoing bariatric surgery

The prevalence of morbid obesity in the United States and worldwide is increasing at an alarming rate. The number of bariatric surgical procedures also has steadily increased during the past decade. This article reviews the published literature and current practice trends for preoperative workup and assessment of patients undergoing bariatric surgery.

ART: iatrogenic multiple pregnancy?

Assisted reproductive technologies (ART) are now widely accepted as effective treatment for most causes of infertility. With improving success rates, attention has turned to the problem of multiple pregnancies, which are associated with a poor perinatal outcome, maternal complications and significant financial consequences. The challenge is to reduce multigestational pregnancies while maintaining good treatment outcomes. Methods to prevent multiple pregnancy include restrictive use of ART in couples with a good chance of spontaneous pregnancy, cautious use of gonadotrophins, and increased use of natural-cycle intra-uterine insemination and elective single embryo transfer in in-vitro fertilization and intracytoplasmic sperm injection. The aim of this article is to review the contribution of fertility treatment to multiple pregnancies and strategies for reducing multiples in ART.

Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass

PURPOSE

Many women with polycystic ovarian syndrome (PCOS) are overweight. This study investigated the impact of weight loss surgery on the clinical manifestations of this disorder in morbidly obese women with PCOS-a major risk factor for the development of heart disease, stroke, and type II diabetes.

METHODS

We reviewed the outcomes of women diagnosed with PCOS who had undergone weight loss surgery at the University of Pittsburgh between July 1997 and November 2001. We evaluated the changes in menstrual cycles, hirsutism, infertility, and type II diabetes.

RESULTS

A total of 24 women with PCOS were included in the study. Their mean age was 34 +/- 9.7 years. The mean preoperative body weight was 306 +/- 44 lb, with a body mass index of 50 +/- 7.5. All patients were oligomenorrheic. Of the 24 patients, 23 were hirsute. All women underwent elective laparoscopic gastric bypass surgery. The mean follow-up period was 27.5 +/- 16 months. The mean excess weight loss at 1 year of follow-up was 56.7% +/- 21.2%. All women resumed normal menstrual cycles after a mean of 3.4 +/- 2.1 months postoperatively. Of the 23 women with hirsutism, 12 (52%) had complete resolution at a mean follow-up of 8 +/- 2.3 months, 6 (25%) had moderate resolution at a mean of 21 +/- 18 months, and 3 had minimal resolution at 34 +/- 14 months. Two women reported no change in their hirsutism at 32 +/- 7 months. Five women were able to conceive after surgery without the use of clomiphene.

CONCLUSION

Gastric bypass surgery and its consequent weight loss results in significant improvement of multiple clinical problems related to PCOS.

PCOS according to the Rotterdam consensus criteria: change in prevalence among WHO-II anovulation and association with metabolic factors

OBJECTIVE

The current report aims to compare the prevalence of polycystic ovary syndrome (PCOS) diagnosed according to the new Rotterdam criteria (Rott-PCOS) versus the previous criteria as formulated by the National Institutes of Health (NIH) (NIH-PCOS) in women with normogonadotropic (WHO-II) anovulation and assess the frequency of obesity and related factors determined in these women.

DESIGN

Cohort study based on large anovulation screening database.

SETTING

Two large tertiary referral centres for reproductive medicine.

POPULATION

WHO-II normogonadotropic, anovulatory, infertility cases.

METHODS

WHO-II cases were extracted from the screening database and classified according to both the Rotterdam and NIH criteria for PCOS. Within these two classes, the prevalence of obesity, hyperglycaemia and insulin resistance was assessed and compared and their relation to the difference in diagnostic criteria applied was analysed.

MAIN OUTCOME MEASURES

Prevalence of diagnosis PCOS in the WHO-II anovulation group. Prevalence of obesity, hyperglycaemia and insulin resistance in the two diagnostic classes.

RESULTS

The Rott-PCOS group appeared to be more than 1.5 times larger than the group classified as NIH-PCOS (91 versus 55% of the WHO-II cohort). Especially, women with ovarian dysfunction and polycystic ovaries at ultrasound scan, but without hyperandrogenism, were added to the PCOS diagnostic group. The Rott-PCOS exhibited a lower frequency of obesity, hyperglycaemia and insulin resistance compared with the NIH-PCOS group. Obese women in the Rott-PCOS group without androgen excess had a different metabolic profile compared with obese women in the NIH-PCOS group, with lower rates of hyperglycaemia and hyperinsulinism, despite comparable distributions of body weight.

CONCLUSION

The present findings indicate that with the new Rotterdam consensus criteria, oligo/anovulatory women with less severe metabolic derangement will be added to the heterogeneous group of women with PCOS.

Pediatric obesity and insulin resistance: chronic disease risk and implications for treatment and prevention beyond body weight modification

The study of childhood obesity has continued to grow exponentially in the past decade. This has been driven in part by the increasing prevalence of this problem and the widespread potential effects of increased obesity in childhood on lifelong chronic disease risk. The focus of this review is on recent findings regarding the link between obesity and disease risk during childhood and adolescence. We describe recent reports relating to type 2 diabetes in youth (2), prediabetes (69, 166), metabolic syndrome (33, 35), polycystic ovarian syndrome (77), and nonalcoholic fatty liver disease (58, 146), and the mediating role of insulin resistance in these conditions. In addition, we review the implications of this research for the design of more effective treatment and prevention strategies that focus more on the improvement of obesity-related metabolic abnormalities and chronic disease risk reduction than on the conventional energy balance approach that focuses on weight management.

Ovulation induction: a mini review

Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophic hypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Pulsatile GnRH has the same effectiveness as gonadotrophins and the advantage of the low multiple pregnancy rate. In polycystic ovary syndrome (PCOS), the first treatment choice is clomiphene citrate. With this drug, in properly selected patients, the cumulative pregnancy rate approaches that of normal women. Low-dose protocols of FSH are the second line of treatment, effective in inducing monofollicular development. Laparoscopic ovarian drilling can be an alternative but not as a first choice treatment in clomiphene-resistant patients. Other treatments, such as pulsatile GnRH and GnRH agonists, are hardly used today in PCOS. However, in obese women with PCOS, weight loss and exercise should be recommended as the first line of therapy. Newer agents including aromatase inhibitors and insulin sensitizers, although promising, need further evaluation.

Endocrine and metabolic effects of rosiglitazone in non-obese women with polycystic ovary disease

We hypothesized that the administration of rosiglitazone, an insulin-sensitizing agent of the thiazolidinedione class, would improve the ovulatory dysfunction, hirsutism, hyperandrogenemia, and hyperinsulinemia of polycystic ovary syndrome (PCOS) patients. Forty women with PCOS and impaired glucose tolerance test (IGT) were randomly assigned to the 8-month treatment with rosiglitazone at either 2 mg/day or 4 mg/day. We compared changes in ovulatory function, hirsutism, hormonal levels (total and free testosterone, estradiol, estrone, androstenedione, LH and FSH), and measures of glycemic parameters (fasting and post-challenge levels of glucose and insulin, HOMA-IR, hemoglobin A1c), between the study groups. The patients' baseline characteristics were similar across all treatment arms. Fifteen of 20 women in the 2 mg group and 19 of 20 women in the 4 mg group achieved normal glucose tolerance; 14 of 20 women in the 2 mg group and 17 of 20 women in the 4 mg group achieved ovulatory menses at the end of the study period. The decreases of free testosterone levels were better in the 4 mg group than the 2 mg rosiglitazone group (-1.89+/-0.35 pg/ml vs. -2.21+/-0.39 pg/ml; P<0.01). There were neither any serious adverse events nor any liver enzyme elevations in our study patients during the treatment period. This study demonstrated that rosiglitazone improves the ovulatory dysfunction, hirsutism, hyperandrogenemia, and insulin resistance of PCOS in a dose-related fashion, with minimal adverse effects. This drug may be a good choice for lifetime treatment of patients with PCOS, especially for the ones who failed to show satisfactory results in metformin therapy.

Understanding and managing disturbances in insulin metabolism and body weight in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common clinical and metabolic condition in women of reproductive age. It is associated with short-term reproductive and long-term metabolic dysfunction. Treatment has traditionally focused on fertility and hormonal therapy. However, general obesity, central obesity and insulin resistance are strongly implicated in its aetiology and improving these factors has proved highly successful in some clinical situations, reducing the need for costly assisted reproduction. A low-fat, high-carbohydrate diet is thought to improve insulin sensitivity, aid in weight loss and reduction of metabolic and reproductive symptoms and improve the long-term maintenance of a reduced weight. However, there has been recent community interest in adopting a protocol advocating a moderate increase in dietary protein for improving weight loss and PCOS symptoms. Altering the glycaemic index of the diet has also received considerable attention as a regime for promoting satiety and reducing metabolic risk factors for type 2 diabetes mellitus and cardiovascular disease. Exercise and other lifestyle changes are essential for altering the short- and long-term effects of PCOS. It is vital that the efficacy of these strategies is assessed so that accurate medical and dietetic advice can be given both to patients and to the health-care community.

Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome

Polycystic ovarian morphology is seen on ultrasound in approximately 22% of women. Polycystic ovary syndrome (PCOS) is a common and perplexing endocrine disorder of women in their reproductive years, with a prevalence of up to 10%. Clinical expression of the syndrome varies but commonly includes menstrual cycle disturbance, hyperandrogenism, insulin resistance and obesity. Recently, the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine (ESHRE/ASRM) achieved a new consensus regarding the definition of PCOS. This is now defined as the presence of any two of the following three criteria: (i) polycystic ovaries; (ii) oligo-/anovulation; and/or (iii) clinical or biochemical evidence of hyperandrogenism. This revised definition provides an international framework for the clinical assessment of PCOS and for future research and collaboration.

A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study

OBJECTIVE

To obtain data from a pilot randomized trial on the effect of metformin therapy and lifestyle modification on ovulation and androgen concentrations in women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized, placebo-controlled pilot trial.

SETTING

Academic medical center.

PATIENT(S)

Thirty-eight overweight or obese women with PCOS.

INTERVENTION(S)

All subjects were randomized to one of four 48-week interventions: metformin 850 mg two times per day, lifestyle modification plus metformin 850 mg two times per day, lifestyle modification plus placebo, or placebo alone.

MAIN OUTCOME MEASURE(S)

Recruitment, dropout, and compliance with a long-term lifestyle intervention in PCOS; preliminary estimates of treatment effect on ovulation, as measured by weekly urinary pregnanediol glucuronide, and on total T and free androgen index.

RESULT(S)

It was necessary to screen seven women to have one subject randomized. The dropout rate was 39%, with the majority of dropouts occurring within the first 24 weeks. Mean body mass index was >39 mg/kg(2). Modest weight reduction was found in all treatment groups, with the most significant reduction occurring with the combination of metformin and lifestyle intervention. Significant androgen reduction occurred in the combination group only. Ovulation rates did not differ significantly between groups. However, when data were analyzed by presence or absence of weight reduction in subjects, independent of treatment group, the estimated odds ratio for weight loss was 9.0 (95% confidence interval 1.2-64.7) with respect to regular ovulation. If weight loss occurred during metformin therapy, the odds ratio for regular ovulation was 16.2 (95% confidence interval 4.4-60.2).

CONCLUSION(S)

Key methodologic issues for a large-scale, randomized trial of lifestyle intervention in PCOS include minimizing early dropout from the lifestyle intervention and including a range of body mass index that is not skewed toward severe obesity. Weight reduction might play the most significant role in restoration of ovulation in obese women with PCOS.

Effects of obesity on women's reproduction and complications during pregnancy

Obesity is increasing rapidly among women all over the world, and more women in fertile ages become overweight and obese. Among all other problems, women who are obese have higher rates of amenorrhoea and infertility. Obese women have a higher risk of complications during pregnancy such as hypertensive diagnoses and gestational diabetes, and delivery complications such as higher rates of caesarean sections and prolonged time of delivery. The aim of this article is to review the consequences of being obese during the reproductive life of a woman.

Polycystic ovarian syndrome: diagnosis and management

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.

Body morphology and its impact on adolescent and pediatric gynecology, with a special emphasis on polycystic ovary syndrome

PURPOSE OF REVIEW

To provide the reader with a timely review of studies investigating the impact of body morphology and weight on pubertal maturation, impact of pubertal maturation on adult body morphology, and recent developments in the diagnosis and management of polycystic ovary syndrome.

RECENT FINDINGS

The temporal trends in age of onset of puberty and menarche, and prevalence of obesity, are presented. Timing of pubertal maturation and initial manifestations of puberty may impact adult adiposity and ponderosity, as well as predispose to conditions associated with adult morbidity. The polycystic ovary syndrome is the most common endocrinologic disorder, occurring in up to 10% of women. It is associated with insulin resistance, and substantial proportions of women with polycystic ovary syndrome, regardless of age or obesity status, have impaired glucose tolerance. Clinical and biochemical abnormalities seen in polycystic ovary syndrome may improve through utilization of insulin-sensitizing agents, although lifestyle changes provide more profound clinical improvements.

SUMMARY

We now understand better those factors associated with initiation of puberty, and pathophysiology of polycystic ovary syndrome. However, further longitudinal studies are needed.

Polycystic Ovary Syndrome in Adolescence

Polycystic ovary syndrome (PCOS) is a common disorder among reproductive-age women, yet the diagnosis may be overlooked during adolescence. Although the clinical and metabolic features are similar to those found in adult women, it can be difficult to distinguish the young woman with PCOS from a normal adolescent. Irregular menses, anovulatory cycles, and acne are not uncommon in adolescent women. Adolescents with a history of premature pubarche, a family history of PCOS, Caribbean-Hispanic and African-American ancestry, and/or obesity are at risk for PCOS and deserve close surveillance. The laboratory evaluation of the adolescent with suspected PCOS or hyperandrogenism should be individualized based on the history, symptoms, and examination findings. The cornerstone of management of PCOS in adolescence includes either a combination oral contraceptive or progestin. Consideration of insulin-sensitizing agents, antiandrogens, topical treatments for acne, and various treatments for hair removal are dependent on the patient's symptoms and concerns. Healthy eating, regular exercise, and for the overweight adolescent, weight reduction, are encouraged to reduce the risk of cardiovascular disease and type II diabetes mellitus. Numerous studies have shown that weight loss and exercise decrease androgen levels, improve insulin sensitivity, and lead to the resumption of ovulation. Although initial studies suggest that Metformin may be particularly useful for treating the PCOS adolescent with insulin resistance and obesity, additional studies are needed to determine the efficacy and long-term outcome. Management of the adolescent with PCOS is challenging and requires a supportive, multidisciplinary team approach for optimal results.

The polycystic ovary syndrome: what does insulin resistance have to do with it?

About half of infertility cases are attributable to female factors, of which anovulation is the leading cause. Most cases of anovulation are due to the polycystic ovarian syndrome (PCOS). Clinically PCOS, present in 5% of all women, consists of anovulation, acne, hirsutism, reversed LH-to-FSH ratio and often resistance to insulin. In some cases PCOS appears in familial clusters but its genetic cause is unknown. Several genes were suggested as possible culprits for PCOS but their involvement has not been proven. The central paradox regarding the role of insulin in PCOS is the high responsiveness to insulin by the ovary, as opposed to the resistance of the whole body. On the backdrop of knowledge of several paralogous genes for each of the participating proteins in the insulin signal transduction pathways, it is possible that different paralogues propagate the intracellular signal in the ovary as opposed to peripheral tissues. Studies by microarray techniques of the different gene expression profiles in the two ovarian cells and peripheral cells such as adipocytes could clarify whether the ovarian defect in PCOS is identical to the peripheral defect in insulin signal transduction, or whether serum insulin concentrations simply serve to reveal the ovarian defect.

The role of lifestyle modification in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine condition with reproductive and metabolic consequences, including anovulation, infertility and an increased prevalence of diabetes mellitus. Obesity, central obesity and insulin resistance are strongly implicated in its etiology and reduction of these risk factors should be a central treatment focus. Short-term weight loss has been consistently successful in reducing insulin resistance and restoring ovulation and fertility. However, problems arise with maintaining weight loss and precisely quantifying the associated long-term benefits of risk factor change. Although recent research indicates modest long-term lifestyle changes might reduce the extent of impaired glucose tolerance and delay the conversion to diabetes mellitus in the general population, this has not yet been examined in women with PCOS. Current conservative treatment should emphasize sustainable weight loss through dietary modification and exercise. Modifying additional lifestyle factors, including alcohol consumption, psychosocial stressors and smoking, are also crucial in long-term treatment of PCOS.

Clinical, endocrine and metabolic effects of metformin added to ethinyl estradiol-cyproterone acetate in non-obese women with polycystic ovarian syndrome: a randomized controlled study

BACKGROUND

Oral contraceptive pills (OC) are usually the first choice of treatment for polycystic ovarian syndrome (PCOS), when fertility is not desired. However, they do not improve, or may even further induce impairment of insulin sensitivity, which is already impaired in women with PCOS. In this prospective, randomized study, we analysed the additional benefits of adding metformin to the OC treatment in non-obese women with PCOS.

METHODS

After a baseline work-up including body mass index (BMI), waist:hip ratio (WHR), Ferriman-Gallwey score, ovarian volume, serum gonadotrophin, androgen and sex hormone-binding globulin (SHBG) levels, and fasting lipid, glucose and insulin levels, 40 non-obese women with PCOS were assigned either to the OC or to the OC + metformin treatment by computer-assisted randomization. At the end of the 4 month follow-up period, subjects were re-evaluated.

RESULTS

The two groups were similar at baseline. After treatment, women in the OC + metformin group had significant decreases in BMI and WHR, and a significant increase in insulin sensitivity, in contrast to those in the OC group, who had insignificant changes in these parameters. Adding metformin also caused significant improvements in serum androstenedione and SHBG levels compared with the OC treatment alone.

CONCLUSIONS

Adding metformin to the OC treatment may improve the insulin sensitivity, and may further suppress the hyperandrogenaemia in non-obese women with PCOS.