Patient Care Endocrinology & Cardiology - December 2007 - (Page 20)

I Polycystic ovary syndrome TABLE 2 Diagnostic evaluation of women with PCOS History Onset of various signs of hyperandrogenism, use of exogenous androgens Menstrual history Reproductive history Family history of diabetes and CVD Lifestyle factors (smoking, alcohol consumption, diet, exercise) Physical appearance Prolactin level (hyperprolactinemia) 17-Hydroxyprogesterone level (nonclassic congenital adrenal hyperplasia) Total testosterone or bioavailable or free testosterone levels (ovarian hyperandrogenism) 2-h oral glucose tolerance test (diabetes) Fasting lipid and lipoprotein levels (dyslipidemia) Optional tests to consider Body mass index (overweight, 25-30 kg/m2; obesity, 30 kg/m2) Waist-hip ratio (abnormal, 0.72) Signs of hyperandrogenism or insulin resistance: acne, acanthosis nigricans, androgenic alopecia, hirsutism Laboratory tests Thyroid-stimulating hormone level (thyroid disease) Pelvic ultrasound Gonadropin levels (to determine causes of amenorrhea) Fasting insulin level (in women with severe stigmata of insulin resistance and hyperandrogenism who are undergoing ovulation induction) 24-h urinary free cortisol tests (in women with stigmata of Cushing’s syndrome) Key: CVD, cardiovascular disease; PCOS, polycystic ovary syndrome. Source: Committee on Practice Bulletins-Gynecology, Practice Bulletin Number 41: Polycystic Ovary Syndrome, Obstetrics & Gynecology. 2002;100(6):1389-1402. opment of CVD.20,21 However, an explanation for the inconsistent published data about increased cardiovascular events in women with PCOS may be that the surrogate markers are not accurate in this syndrome. Reproductive concerns Women with PCOS generally present with menstrual disorders and frequently ask questions about their fertility and pregnancy prognosis. Approximately 4% to 6% of women with PCOS have hyperandrogenic chronic anovulation which raises the question about infertility, higher risk of endometrial hyperplasia, and endometrial cancer.22 With ovulation induction, there is an increased risk of ovarian hyperstimulation syndrome, pregnancy loss in the first trimester, and multiple pregnancies. The risk of pregnancy complications, such as hypertension and gestational diabetes, also is increased.23 PRACTICAL RECOMMENDATIONS A recent survey of women’s awareness, preventive action, and barriers to cardiovascular health has shown that approximately one-third of women underestimate their personal risk of CVD.24 Thus, de- spite the lack of epidemiologic data about the risk of CVD in PCOS, the physician’s role in evaluating early CVD risk factors and counseling women with PCOS remains substantial. New guidelines for prevention of CVD The 2007 update on guidelines for CVD prevention in women recommends classifying female patients according to “at high risk, at risk, or at optimal risk” (see “Using the new AHA guidelines for preventing coronary heart disease in women,” page 12).25 The guidelines consider that women with more than 1 major risk factor for CVD—including several risk factors common in PCOS such as obesity (especially central adiposity), metabolic syndrome, and dyslipidemia—may have a broad range of risk for CVD. The guidelines panel believes that a Framingham global risk score greater than a 20% risk of an event within 10 years could be used to identify a woman at high risk but that a lower score is not sufficient to ensure that an individual woman is at low risk.25 Based on the guidelines, monitoring for healthy levels of CVD risk factors (BMI, waist circumference, BP lipid levels) is warranted from the time of diagno, 20 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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