Patient Care Endocrinology & Cardiology - December 2007 - (Page 18)

I Polycystic ovary syndrome Article at a glance I I I I I I I I I In addition to reproductive implications (chronic anovulation, infertility, and pregnancy complications), women with polycystic ovary syndrome (PCOS) may experience long-term implications of metabolic and cardiovascular disease. The diagnostic evaluation of PCOS starts with a thorough menstrual and reproductive history, history of hyperandrogenism, signs, lifestyle, and family history of CVD and type 2 diabetes mellitus. The physical examination must document hirsutism and look for signs of insulin resistance and secondary causes of hyperandrogenism. Laboratory evaluation of PCOS is directed at assessing metabolic abnormalities and excluding secondary causes of hyperandrogenism. Evidence exists that women with PCOS have a 5- to 10-fold increased risk of developing type 2 diabetes compared to age- and weight-matched women. Monitoring women with PCOS for CVD risk factors (body mass index, waist circumference, BP, and LDL cholesterol and HDL cholesterol levels) is prudent from the time of diagnosis of PCOS. Pharmacotherapy is used to regulate menstrual function and treat infertility and hirsutism. Insulin sensitizers have been recently advocated for use in patients with PCOS to improve insulin sensitivity and menstrual regulation. Metformin is effective in achieving ovulation in women with PCOS. Oral contraceptive pills have been the traditional therapy for the long-term treatment of PCOS for women who prefer birth control. A trial of clomiphene seems to be most effective for ovulation induction. When PCOS is suspected, diagnostic evaluation starts with a thorough menstrual (chronic anovulation presented as oligomenorrhea, amenorrhea, or dysfunctional uterine bleeding) and reproductive history (infertility, early pregnancy loss, other pregnancy complications), history of hyperandrogenism signs, followed by lifestyle factors (smoking, diet, exercise), and family history of CVD and type 2 diabetes mellitus. It is especially relevant if family history is significant for premature CVD (men younger than 55 and women younger than 65) and if the CVD occurred in first-degree relatives. The physical exam must document hirsutism and look for signs of insulin resistance and secondary causes of hyperandrogenism such as Cushing’s syndrome as well as virilization suggesting androgen secreting tumors. Laboratory evaluation is aimed at evaluating metabolic abnormalities and excluding secondary causes of hyperandrogenism (see Table 2, page 20). Gynecologists guideline adopted the 1990 National Institutes of Health (NIH) consensus panel criteria for diagnosing PCOS: chronic anovulation and hyperandrogenism (established by hormone measurements or clinical findings such as acne or hirsutism) in women in whom secondary causes have been excluded (see Table 1, page 19).2 The NIH definition does not include insulin resistance and polycystic-appearing ovaries on ultrasonographic examination as diagnostic criteria.2 METABOLIC AND CARDIOVASCULAR IMPLICATIONS OF PCOS In addition to reproductive implications (chronic anovulation, infertility, and pregnancy complications), women with PCOS may experience the long-term implications of metabolic and cardiovascular disease. At least 30% and as many as 75% of women with PCOS are obese. Visceral adiposity has been associated with hyperandrogenism, insulin resistance, and dyslipidemia.5,6 Obesity and insulin resistance As key components of the metabolic syndrome, obesity and insulin resistance are associated with increased cardiovascular risks. Hyperinsulinemia directly stimulates both ovarian and adrenal androgen secretion and suppresses sex hormone-binding globulin synthesis in the liver, resulting in an increase in biologically active androgens. Excess of local ovarian androgen production augmented by hyperinsulinemia causes premature atresia and chronic anovulation and other clinical manifestations such as hirsutism. Evidence of decreased insulin sensitivity is seen in both lean and obese women with PCOS; but insulin resistance accompanied by compensatory hyperinsu- 18 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY www.patientcareonline.com http://www.patientcareonline.com

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Patient Care Endocrinology & Cardiology - December 2007 Research Digest Contents Medicine in the News Options for Managing Diabetes: Three Types of Basal Insulin Therapy Using the New AHA Guidelines for Preventing Coronary Heart Disease in Women Cardiovascular and Metabolic Implications of Polycystic Ovary Syndrome Case & Comment Classified Advertising Clinical Clips

Patient Care Endocrinology & Cardiology - December 2007

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