Sensitization to insulin in adolescent girls to normalize hirsutism, hyperandrogenism, oligomenorrhea, dyslipidemia, and hyperinsulinism after precocious pubarche

Effect of Aslagh Capsule, a Traditional Compound Herbal Product on Oligomenorrhea in Patients with Polycystic Ovary Syndrome: A Three-Arm, Open-label, Randomized, Controlled Trial

Background:

Oligomenorrhea is a common complaint in patients with polycystic ovary syndrome (PCOS). There are some useful medicinal recommendations such as Aslagh product (include fennel fruits, carrot seeds, chaste tree fruits) in Iranian traditional medicine for the treatment of oligomenorrhea in PCOS. Hence, the present investigation was designed to compare Aslagh capsule with metformin on the oligomenorrhea.

Materials and Methods:

One hundred fifty women aged between 18-43 years with oligomenorrhea due to PCOS were randomly divided into Aslagh, metformin, and Aslagh + metformin groups. The occurrence of menstrual bleeding was considered as the primary outcome. Menstrual cyclicity, duration, and volume of the bleeding were also evaluated.

Results:

Occurrence of menstrual bleeding was 87.2% in all patients, with no significant difference between the three groups (P> 0.05). Menstrual cyclicity significantly improved from baseline in Aslagh and Aslagh + metformin groups (P=0.02). Duration of menstrual bleeding was significantly higher in Aslagh group in the first and the second menstrual bleeding cycle compared to the other two groups (P<0.05). No significant change was observed in the volume of the bleeding after the intervention in any of the three groups. The occurrence of menstrual bleeding in Aslagh group was significantly (P=0.03) higher than the other two groups in the fourth month (drug-free period).

Conclusion:

Aslagh capsule showed beneficial effects similar to metformin in the treatment of oligomenorrhea in PCOS women and could be suggested for use as an alternative treatment in these patients.

Poly Cystic Ovarian Syndrome: An Updated Overview

Poly Cystic Ovarian Syndrome (PCOS) is one of the most common metabolic and reproductive disorders among women of reproductive age. Women suffering from PCOS present with a constellation of symptoms associated with menstrual dysfunction and androgen excess, which significantly impacts their quality of life. They may be at increased risk of multiple morbidities, including obesity, insulin resistance, type II diabetes mellitus, cardiovascular disease (CVD), infertility, cancer, and psychological disorders. This review summarizes what the literature has so far provided from guidelines to diagnosis of PCOS. It will also present a general overview about the morbidities associated with this disease, specifically with its more severe classic form. Finally, the review will stress on the various aspects of treatment and screening recommendations currently used in the management of this condition.

Hyperinsulinaemic androgen excess in adolescent girls

Hyperinsulinaemic androgen excess is the most common cause of hirsutism, acne and menstrual irregularity in adolescent girls. Here, we propose that the disorder frequently originates from an absolute or relative excess of lipids in adipose tissue, and from associated changes in insulin sensitivity, gonadotropin secretion and ovarian androgen release. Girls from populations with genotypes attuned to nutritionally harsh conditions seem to be particularly vulnerable to the development of hyperinsulinaemic androgen excess in today's obesogenic environment. We propose that hirsutism, hyperandrogenaemia and menstrual irregularity (≥2 years after menarche) is used as a diagnostic triad for the disorder. No pharmacological therapy has been approved for girls with androgen excess; however, lifestyle intervention is essential to reduce adiposity. In girls without obesity who are not sexually active, insulin sensitization has more broadly normalizing effects than estradiol-progestogen combinations. The early recognition of girls at risk of developing hyperinsulinaemic androgen excess might enable prevention in childhood.

Childhood obesity and its impact on the development of adolescent PCOS

Obesity exacerbates the reproductive and metabolic manifestations of polycystic ovary syndrome (PCOS). The symptoms of PCOS often begin in adolescence, and the rising prevalence of peripubertal obesity has prompted concern that the prevalence and severity of adolescent PCOS is increasing in parallel. Recent data have disclosed a high prevalence of hyperandrogenemia among peripubertal adolescents with obesity, suggesting that such girls are indeed at risk for developing PCOS. Obesity may impact the risk of PCOS via insulin resistance and compensatory hyperinsulinemia, which augments ovarian/adrenal androgen production and suppresses sex hormone-binding globulin (SHBG), thereby increasing androgen bioavailability. Altered luteinizing hormone (LH) secretion plays an important role in the pathophysiology of PCOS, and although obesity is generally associated with relative reductions of LH, higher LH appears to be the best predictor of increased free testosterone among peripubertal girls with obesity. Other potential mechanisms of obesity-associated hyperandrogenemia include enhanced androgen production in an expanded fat mass and potential effects of abnormal adipokine/cytokine levels. Adolescents with PCOS are at risk for comorbidities such as metabolic syndrome and impaired glucose tolerance, and concomitant obesity compounds these risks. For all of these reasons, weight loss represents an important therapeutic target in obese adolescents with PCOS.

Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for the diagnosis and treatment of polycystic ovary syndrome (PCOS).

PARTICIPANTS

An Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer developed the guideline.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize supporting evidence.

CONCLUSIONS

We suggest using the Rotterdam criteria for diagnosing PCOS (presence of two of the following criteria: androgen excess, ovulatory dysfunction, or polycystic ovaries). Establishing a diagnosis of PCOS is problematic in adolescents and menopausal women. Hyperandrogenism is central to the presentation in adolescents, whereas there is no consistent phenotype in postmenopausal women. Evaluation of women with PCOS should exclude alternate androgen-excess disorders and risk factors for endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease. Hormonal contraceptives are the first-line management for menstrual abnormalities and hirsutism/acne in PCOS. Clomiphene is currently the first-line therapy for infertility; metformin is beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but it has limited or no benefit in treating hirsutism, acne, or infertility. Hormonal contraceptives and metformin are the treatment options in adolescents with PCOS. The role of weight loss in improving PCOS status per se is uncertain, but lifestyle intervention is beneficial in overweight/obese patients for other health benefits. Thiazolidinediones have an unfavorable risk-benefit ratio overall, and statins require further study.

The effects of old, new and emerging medicines on metabolic aberrations in PCOS

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women of reproductive age that is associated with significant adverse short- and long-term health consequences. Multiple metabolic aberrations, such as insulin resistance (IR) and hyperinsulinaemia, high incidence of impaired glucose tolerance, visceral obesity, inflammation and endothelial dysfunction, hypertension and dyslipidemia are associated with the syndrome. Assessing the metabolic aberrations and their long term health impact in women with PCOS is challenging and becomes more important as therapeutic interventions currently available for the management of PCOS are not fully able to deal with all these consequences. Current therapeutic management of PCOS has incorporated new treatments resulting from the better understanding of the pathophysiology of the syndrome. The aim of this review is to summarize the effect of old, new and emerging therapies used in the management of PCOS, on the metabolic aberrations of PCOS.

State of the Art Review: Emerging Therapies: The Use of Insulin Sensitizers in the Treatment of Adolescents with Polycystic Ovary Syndrome (PCOS)

PCOS, a heterogeneous disorder characterized by cystic ovarian morphology, androgen excess, and/or irregular periods, emerges during or shortly after puberty. Peri- and post-pubertal obesity, insulin resistance and consequent hyperinsulinemia are highly prevalent co-morbidities of PCOS and promote an ongoing state of excess androgen. Given the relationship of insulin to androgen excess, reduction of insulin secretion and/or improvement of its action at target tissues offer the possibility of improving the physical stigmata of androgen excess by correction of the reproductive dysfunction and preventing metabolic derangements from becoming entrenched. While lifestyle changes that concentrate on behavioral, dietary and exercise regimens should be considered as first line therapy for weight reduction and normalization of insulin levels in adolescents with PCOS, several therapeutic options are available and in wide use, including oral contraceptives, metformin, thiazolidenediones and spironolactone. Overwhelmingly, the data on the safety and efficacy of these medications derive from the adult PCOS literature. Despite the paucity of randomized control trials to adequately evaluate these modalities in adolescents, their use, particularly that of metformin, has gained popularity in the pediatric endocrine community. In this article, we present an overview of the use of insulin sensitizing medications in PCOS and review both the adult and (where available) adolescent literature, focusing specifically on the use of metformin in both mono- and combination therapy.

Sex hormone-binding globulin, oligomenorrhea, polycystic ovary syndrome, and childhood insulin at age 14 years predict metabolic syndrome and class III obesity at age 24 years

OBJECTIVE

We hypothesized that oligomenorrhea (menstrual cyclicity ≥42 days), hyperandrogenism, low levels of sex hormone-binding globulin (SHBG), childhood insulin, and metabolic syndrome (MetS) at age 14 years would predict MetS and class III obesity (body mass index ≥40 kg/m(2)) at age 24 years.

STUDY DESIGN

In this prospective study of schoolgirls, at age 14 years, the girls were categorized as regularly cycling (n = 375), oligomenorrheic (n = 18), or oligomenorrhea plus biochemical hyperandrogenism (polycystic ovary syndrome [PCOS]; n = 12), together designated PCOS.

RESULTS

Significant explanatory variables for MetS at age 24 years included childhood insulin, MetS, and PCOS category (all positive) and SHBG (negative) at age 14 years. Using categorical data, top decile of childhood insulin, MetS at age 14, bottom decile of SHBG, and PCOS category were significant positive predictors for MetS at age 24. SHBG (negative), black race (positive), and oligomenorrhea (positive) were significant explanatory variables for class III obesity at age 24. Using categorical data, black race, MetS at age 14, bottom decile of SHBG, PCOS category, and top decile of childhood insulin were positive explanatory variables for class III obesity at age 24 years.

CONCLUSIONS

Oligomenorrhea, PCOS (a subcohort of oligomenorrhea), hyperandrogenism, low SHBG, MetS, and childhood insulin at age 14 years may represent a critical, reversible pathway for the development of MetS and class III obesity in young adulthood.

Effect of metformin therapy on 2-h post-glucose insulin levels in patients of polycystic ovarian syndrome

AIMS:

To evaluate if 2-h post glucose insulin level is an effective tool to monitor insulin resistance in response to metformin therapy, in infertile women with polycystic ovarian syndrome (PCOS).

SETTINGS AND DESIGN:

This prospective observational study was carried out in a tertiary care infertility clinic.

MATERIALS AND METHODS:

40 women with PCOS were categorized as having insulin resistance if fasting or 2-h post glucose insulin levels were >25 or >41μU/ml respectively. Post glucose insulin was compared before and after six months of metformin therapy along with other clinical, hormonal and metabolic parameters by using McNemar and the Student’s t-test.

RESULTS:

Fasting insulin was elevated in 4 (10%) and post-load insulin in 34 (85%) patients; after metformin therapy respective values were 2 (5%) and 16 (40%). Metformin therapy reduced post glucose insulin levels (P<0.001), improved the regularity of periods (P<0.001) and resulted in reduction of LH levels (P<0.001), total testosterone (P<0.001) and mean Body mass index (BMI) (P=0.047). Metformin therapy did not alter waist-hip ratio and fasting insulin levels.

CONCLUSION:

2-h post glucose insulin level is an effective tool to monitor insulin resistance in PCOS patients and improves significantly after metformin therapy, similar to improvements observed in clinical, hormonal and metabolic parameters.

Clinical features, investigations and management of adolescents with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is defined as chronic anovulation with evidence of hyperandrogenism, after the exclusion of secondary causes. It is commonly linked to obesity and the presence of the metabolic syndrome.

OBJECTIVES

To review the clinical features and medical assessment of adolescents referred for PCOS to gynecology or endocrinology services at The Hospital for Sick Children (Toronto, Ontario).

METHODS

A chart review was conducted of all adolescents with PCOS referred during a one-year period. Measures included clinical findings, investigations and management.

RESULTS

Forty-one adolescent girls, with a mean age +/- SD of 14.7+/-1.5 years, were reviewed. Common presenting complaints were menstrual irregularities in 35 of 41 girls (85%) and hirsutism in 28 of 41 girls (68%), with 32 of 41 adolescents (78%) having more than one complaint. The majority (31 of 38 [82%]) were overweight or obese. Features associated with the metabolic syndrome (hypertension, dyslipidemia, insulin resistance and obesity) were identified in some adolescents, but were not consistently assessed. Blood pressure was assessed in 38 adolescents, fasting plasma glucose in 27, triglycerides in 22 and cholesterol in 21. Only four of 28 adolescents (15%) who underwent pelvic ultrasound demonstrated ovarian cysts. Investigations and management differed somewhat between endocrinologists and gynecologists. Most adolescents (34 of 41 [83%]) received pharmacological treatment: oral contraceptive pill (21 of 34 [62%]); intermittent medroxyprogesterone acetate to induce withdrawal bleeding (nine of 34 [26%]); metformin (two of 34 [6%]); or oral contraceptive pill and antiandrogen (two of 34 [6%]).

CONCLUSIONS

Adolescents with PCOS are at risk of developing metabolic abnormalities. Polycystic ovaries were not a consistent finding. The most commonly prescribed treatment was the oral contraceptive pill. Greater attention should be placed on screening adolescents with PCOS for diabetes, hypertension and dyslipidemia, allowing for earlier identification and management of potentially modifiable cardiovascular risk factors.

Ramifications of adolescent menstrual cycles ≥42 days in young adults

OBJECTIVE

To determine to what degree annual reports from ages 14 to 19 years of menstrual cycles ≥42 days would be associated with increased body mass index (BMI), waist circumference, glucose, insulin, and homeostasis model assessment insulin resistance (HOMA-IR) at ages 14-25 years.

DESIGN

Prospective 11-year follow-up from ages 14 to 25 years.

SETTING

Urban-suburban schools, post-high school.

PATIENT(S)

A total of 370 schoolgirls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

BMI, waist, insulin, glucose, HOMA-IR.

RESULT(S)

From ages 14 to 19 years, 269 girls had 0/6 annual reports of menstrual cycles ≥42 days, 74 had 1, 19 had 2, and 8 had ≥3. Among these four categories, girls with ≥3 annual reports had highest free T and DHEAS at age 14, highest BMI and waist at ages 14, 19, and 25, highest insulin at age 25, and highest glucose and HOMA-IR at age 24 years. The number of annual reports of menstrual cycles ≥42 days was positively related to change in BMI and waist and inversely with change in high-density lipoprotein cholesterol from ages 14 to 25 years.

CONCLUSION(S)

Three or more annual reports of menstrual cycles ≥42 days during ages 14-19 are associated with high BMI, waist circumference, insulin, glucose, and HOMA-IR at ages 14-25 years.

Assessing and treating insulin resistance in women with polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is a highly prevalent hormonal and metabolic disorder among reproductive aged women worldwide. Women with PCOS have widely varying phenotypes and seek medical care for differing reasons. In addition to concern for menstrual cycle function, ovulation, hirsutism and acne, many PCOS women have abnormal glucose metabolism. While diabetes mellitus and impaired glucose tolerance are easily diagnosed, the diagnosis of and concern for insulin resistance as a precursor disorder is underappreciated. Insulin resistance may be the first important marker of metabolic disease in PCOS women at risk for metabolic syndrome and coronary artery disease.

A single nucleotide polymorphism in STK11 influences insulin sensitivity and metformin efficacy in hyperinsulinemic girls with androgen excess

OBJECTIVE

Serine-threonine kinase STK11 catalyzes the AMP-activated protein kinase complex. We tested the hypothesis that a gene variant in STK11 contributes to variation in insulin sensitivity and metformin efficacy.

RESEARCH DESIGN AND METHODS

We studied the effects of a single nucleotide polymorphism (SNP) (rs8111699) in STK11 on endocrine-metabolic and body composition indexes before and after 1 year of metformin in 85 hyperinsulinemic girls with androgen excess, representing a continuum from prepuberal girls with a combined history of low birth weight and precocious pubarche over to postmenarchial girls with hyperinsulinemic ovarian hyperandrogenism. Metformin was dosed at 425 mg/day in younger girls and 850 mg/day in older girls. STK11 rs8111699 was genotyped. Endocrine-metabolic features were assessed in the fasting state; body composition was estimated by absorptiometry.

RESULTS

Genotype effects were similar in younger and older girls. At baseline, the mutated G allele in STK11 rs8111699 was associated with higher insulin and IGF-I levels (both P < 0.005). The response to metformin differed by STK11 genotype: GG homozygotes (n = 24) had robust metabolic improvements, GC heterozygotes (n = 38) had intermediate responses, and CC homozygotes (n = 23) had almost no response. Such differences were found for 1-year changes in body composition, circulating insulin, IGF-I, free androgen index, and lipids (all P < 0.005).

CONCLUSIONS

In hyperinsulinemic girls with androgen excess, the STK11 rs8111699 SNP influences insulin sensitivity and metformin efficacy, so that the girls with the least favorable endocrine-metabolic profile improve most with metformin therapy.

Interventional studies for polycystic ovarian syndrome in children and adolescents

Polycystic ovarian syndrome (PCOS) is characterized by chronic anovulation, clinical and/or biochemical hyperandrogenism, which can be associated with altered insulin action. Symptoms usually begin around menarche, but onset after puberty may also occur as a result of environmental modifiers such as weight gain. The consequences of PCOS extend beyond the reproductive axis; there is a substantial risk for development of metabolic and cardiovascular abnormalities similar to the metabolic syndrome. Currently, the treatment is targeted to the patient's primary complaint such as hirsutism, restoration of regular menses or pregnancy. Pharmacological agents available for the treatment of hirsutism include androgen suppressors and peripheral androgen blockers. Recently, our understanding of the role of insulin resistance has led to the use of insulin-sensitizing medications as first-choice therapy. In conjunction with weight reduction and exercise, a pharmacologic reduction in insulin levels by either metformin or thiazolidinediones ameliorates both hyperinsulinemia and hyperandrogenism.

The role of insulin-sensitizing agents in the treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) represents a heterogeneous spectrum of disorders, mainly characterized by chronic oligoanovulation and hyperandrogenism. Although not included in the diagnostic criteria, insulin resistance is recognized as a fundamental pathogenetic factor of the syndrome. Thus, the use of insulin-sensitizing drugs, such as metformin and thiazolidinediones, has been proposed for PCOS treatment. These agents are unique because they exert both metabolic and endocrine/ovarian beneficial effects. In this review the results of up-to-date clinical studies and meta-analyses on the possible gynaecological actions of insulin sensitizers are discussed. It has been shown that, as well as favourable metabolic influences, such as improvement in glucose, lipid and proinflammatory profiles, these agents also exert beneficial endocrine and ovarian effects, including amelioration of reproductive abnormalities, restoration of ovulation and menstrual cycles, increase in pregnancy rates and reduction of androgen production. Therefore, current data support the use of insulin sensitizers, along with lifestyle measures and/or other agents, in women with PCOS, especially in the presence of insulin- or clomifene-resistance.

Identification and treatment of metabolic complications in pediatric obesity

Metabolic consequences of obesity including insulin resistance, type 2 diabetes mellitus, hyperlipidemia, hypertension, polycystic ovarian syndrome, and non-alcoholic fatty liver infiltration are rapidly emerging in the pediatric population. Identifying effective strategies for identifying and treating these obesity related comorbidities in children are crucial to the prevention of future cardiovascular disease and poor health outcomes.This review discusses the pathophysiologic connections between obesity, metabolic disease and cardiovascular risk. Current evidence and recommendations for screening and treatment for the metabolic consequences of pediatric obesity are reviewed.

Clinical spectrum of premature pubarche: links to metabolic syndrome and ovarian hyperandrogenism

Premature pubarche-defined as the appearance of pubic hair before age 8 years in girls and 9 years in boys-has been traditionally considered a benign entity. However, recent evidence supports the notion that premature pubarche in girls may be a forerunner of the metabolic syndrome, and may precede the development of clinical ovarian androgen excess in adolescence. This sequence seems to occur more frequently when premature pubarche was preceded by reduced fetal growth and followed by excessive postnatal catch-up in height and particularly in weight; hyperinsulinemia appears to be a key factor in the development of this sequence of events. In girls with premature pubarche and a history of a low birth weight, puberty tends to start earlier and to have a faster course, so that final height may be moderately reduced. In these girls, metformin therapy may reverse the progression to clinical ovarian hyperandrogenism, normalize body composition and excess visceral fat, and delay pubertal progression without attenuating linear growth and bone mineralization, suggesting that adult height may be improved. Long-term follow-up of these patients is needed to fully determine the ultimate effects of insulin sensitization as well as the maintenance of these benefits after discontinuation of therapy.

Periconception window: advising the pregnancy-planning couple

OBJECTIVE

To discuss the importance of the periconceptional window with regard to being a critical window of exposure. To review the empirical data related to healthy periconceptional behaviors.

DESIGN

Literature review.

CONCLUSION(S)

Human reproduction is a couple-dependent process. Recent literature has highlighted that the periconceptional time period is a critical window of exposure that can impact growth and development. In advising the pregnancy-planning couple, it is of paramount importance that couples have knowledge of the timing of the fertile window to ensure that intercourse occurs on days with the maximum probability of pregnancy. Many women adopt healthier lifestyles while trying to conceive, often quitting smoking, eating healthier or taking vitamins. However, there is a lack of empirical data from prospective studies regarding which environmental exposures or behaviors are or are not safe. Noticeably absent are data regarding the effect of male partners' exposures or behaviors on couple fecundity and fertility. As we improve our ability to pinpoint the timing of conception, we should be able to better advise couples planning pregnancy.

Persisting benefits 12-18 months after discontinuation of pubertal metformin therapy in low birthweight girls

BACKGROUND

Discontinuation of metformin therapy, if started beyond menarche in adolescents or young women with hyperinsulinaemia following low birthweight, is rapidly followed by rebound deteriorations in body fat, insulin resistance and blood lipid profile.

OBJECTIVE

We hypothesized that early commencement of metformin and its continuation throughout puberty might have more persisting benefits.

PATIENTS AND MEASUREMENTS

We followed up on a previously reported randomized study cohort at 12 months and 18 months after treatment discontinuation, including body composition by absorptiometry, fasting insulin, glucose and blood lipids. In that open-labelled, prospective study, 22 low birthweight girls with early normal puberty (Stage 2 breast development at age 8-9 years) were randomized to remain untreated (N = 12] or to receive metformin (850 mg/day; N = 10) for 36 months (between time -36 months to 0 month).

RESULTS

The significant improvements previously reported at the end of the 36-month active treatment period in per cent body fat, abdominal fat mass, fasting insulin sensitivity, high density lipoprotein (HDL) cholesterol and triglyceride levels all persisted at follow-up 12 months after treatment discontinuation. Further anthropometry at 18 months off therapy confirmed the persistence of benefits in height, body mass index (BMI) and waist circumference in the previously metformin-exposed girls.

CONCLUSION

In low birth weight girls with early normal onset of puberty, metformin treatment for 3 years across puberty resulted in auxological, endocrine and metabolic benefits that persisted for at least 1 year after metformin withdrawal. Further follow-up and longer-term studies are needed to explore the possibility that insulin sensitization therapy during puberty might reprogramme predisposition to metabolic disease.

Current approaches to the diagnosis and treatment of polycystic ovarian syndrome in youth

Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in reproductive-age women. It often presents during late adolescence but in some cases certain features are evident even before menarche. PCOS is a spectrum of disorders with any combination of oligo/anovulation, clinical and/or biochemical evidence of androgen excess, obesity, insulin resistance and polycystic ovaries on ultrasound. The pathogenesis is unknown; however, it is a complex multigenetic disorder where disordered gonadotropin release, dysregulation of steroidogenesis, hyperinsulinism and insulin resistance play a role. The diagnosis is based on a typical physical exam (acne, hirsutism, obesity, and acanthosis nigricans) and laboratory evidence of hyperandrogenism, such as elevated free testosterone, androstenedione and dehydroepiandrosterone sulfate (DHEAS), decreased sex hormone-binding globulin (SHBG) and increased luteinizing hormone (LH). An ovarian ultrasound may detect the multiple cysts. Secondary causes of PCOS need to be excluded. There are several classes of medications correcting different parameters of PCOS that can be used alone or in combination. Oral contraceptive therapy is used to reduce androgen and LH levels with resultant improvement in acne and hirsutism, and the induction of regular menses. Antiandrogens are usually required for a substantial improvement in hirsutism score. Insulin sensitizers such as metformin are a new class of drugs utilized in treatment of PCOS. By improving insulin sensitivity and decreasing insulin levels, they improve the unfavorable metabolic profile of patients with PCOS. Metformin also helps to increase SHBG, decrease androgen levels and induce ovulation. Despite all the available medications, life-style changes are the mainstay of therapy as weight loss and exercise improve all parameters of PCOS without the potential side effects of medication.

Polycystic ovary syndrome in adolescents: current and future treatment options

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.

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.