Patient Care Endocrinology & Cardiology - December 2007 - (Page 21)

Polycystic ovary syndrome I sis of PCOS. Routine screening for insulin resistance, however, is not recommended by the American Diabetes Association (ADA). But the ADA recommends screening all women with PCOS for type 2 diabetes and impaired glucose tolerance with fasting glucose levels followed by a 2-hour oral glucose tolerance test with a 75-g glucose load.26 If CVD risks are identified, it is a reasonable approach to counsel patients to follow the guidelines. Early risk factor awareness is especially important for initiating lifestyle modifications. Studies have shown that women who perceive themselves to be at high risk of heart disease were significantly more likely to see a health care provider compared with those who perceived themselves to be at moderate or low risk (93.4% versus 89.5% versus 85.5%, respectively). Women who had seen, heard, or read information about heart disease in the prior 12 months were significantly more likely to increase their physical activity, decrease their intake of unhealthy food, and lose weight.27 Lifestyle changes Weight reduction should be the cornerstone therapy for obese and overweight women with PCOS. Advise women with PCOS to seek a healthy weight through an appropriate balance of physical activity, caloric intake, and behavioral and weight management programs. The goal should be a BMI between 18.5 and 24.9 kg/m2 and a waist circumference of 35 inches or less.26 Changes in body weight (loss of as little as 5% of the initial weight) have been shown to improve metabolic and reproductive abnormalities in PCOS, ovulation, and pregnancy rates. While there is no evidence to recommend a particular dietary intervention, patients should be advised on portion sizes and caloric intake. Randomized trials of varying hypocaloric diets in women with PCOS have reported appropriate short-term weight loss (4-12 weeks).25 TREATMENT GOALS Pharmacotherapy is used to regulate menstrual function, infertility, and hirsutism. There is no evidence that primary treatment of women with PCOS prevents long-term medical complications. While insulin-sensitizing agents have been recently advocat- Drugs mentioned in this article Clomiphene (Clomid, Milophene, Serophene) Drospirenone/ ethinyl estradiol (YAZ) Flutamide (Eulexin) Medroxyprogesterone (Provera, Depo-Provera) Metformin (Glucophage) Pioglitazone (Actos) Spironolactone (Aldactone) ed for use in patients with PCOS to improve insulin sensitivity and menstrual regulation, their role in the primary or secondary prevention of CVD in women with PCOS remains unknown. Oral contraceptive pills (OCPs) have been the traditional therapy for the long-term treatment of PCOS for women who prefer birth control. Combined treatment with metformin (Glucophage) and lifestyle modifications has either shown or trended toward a greater weight loss than lifestyle and placebo.28 The use of metformin was associated with decreased levels of circulating androgens, better glucose tolerance, and improved ovulation rates. Metformin was found to be more effective than OCPs in reducing fasting insulin levels, improving glucose tolerance, and not increasing triglyceride levels.29 For patients with PCOS seeking cycle regulation but not pregnancy, oral contraceptives may remain better therapy because metformin does not normalize menses.30 In a randomized clinical trial (RCT) of 100 overweight women with PCOS, metformin and low- and high-dose OCP preparations have similar efficacy but different effects on insulin resistance and arterial function. The results suggest that a low-dose OCP preparation may be preferable if contraception is needed and that metformin should be considered for symptom management, particularly in women with metabolic and cardiovascular risk factors.28 Achieving ovulation A meta-analysis of 13 RCTs showed that metformin is effective in promoting ovulation in women with PCOS; for metformin versus placebo, the odds ratio (OR) is 3.88, confidence interval (CI), 2.25 to 6.69 and for metformin and clomiphene versus clomiphene alone the OR is 4.41; CI, 2.37 to 8.22.29 A meta-analysis of 7 RCTs showed that DECEMBER 2007 PATIENT CARE ENDOCRINOLOGY & CARDIOLOGY 21

Table of Contents Feed for the Digital Edition of Patient Care Endocrinology & Cardiology - December 2007

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

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.