Patient Care Endocrinology & Cardiology - December 2007 - (Page 22)

I Polycystic ovary syndrome For patients with PCOS seeking cycle regulation but not pregnancy, oral contraceptives may remain better therapy because metformin does not normalize menses. metformin improves menstrual cyclicity;* on average, 1 additional ovulation is attained in every 5 months. Spontaneous ovulation and normal menstruation are achieved within 3 months of the start of therapy. With the use of metformin, ovulation is achieved in 46% of recipients compared with 24% in placebo groups. Metformin is a category B drug and not approved by the FDA for the treatment of obesity or for PCOS. In a limited study, when used during the first trimester, metformin has been shown to decrease miscarriage rates in women with PCOS.31 Side effects of metformin include anorexia and diarrhea, which improve in 50% of cases with continuation of medication, and rare cases of lactic acidosis in the presence of renal insufficiency. Thiazolidinediones also have been shown to improve ovulation rates in women with PCOS. The use of pioglitazone (Actos)* for 3 months increased normal regular cycles and ovulations over placebo (41.2% versus 5.6%; P .02).32 However, safety concerns are significant in this group of medications. OCPs have been shown to be more effective than insulin-sensitizing drugs in improving menstrual patterns and reducing serum androgen levels. They are also associated with significant increases in circulating triglyceride and HDL-C levels.33 However, no evidence suggests that more cardiovascular events occur with OCP use in women who have PCOS compared with the general population. There is insufficient evidence in favor of either metformin or an OCP in treating hirsutism or acne or in preventing the development of diabetes, heart disease, or endometrial cancer.34 The evidence equally supports the use of any oral contraceptive (OC). The estrogenic component of an *Unlabeled use. OC suppresses luteinizing hormone and reduces the free fraction of plasma testosterone through enhancing hepatic production of sex hormone-binding globulin and thus androgen production. However, the choice of an OC’s progesterone component is important because of the variable androgenic effects. Norgestimate and desogestrel, which are virtually nonandrogenic progestogens, potentially have more benefit for women with PCOS.35 The use of a progestin-based medication such as medroxyprogesterone acetate (depot or intermittent oral therapy) should be limited because of known weight gain and acne side effects.36 Ovulation induction For women with PCOS who desire to conceive, a trial of clomiphene seems to be most effective. Clomiphene has been shown to be successful in ovulation induction in 80% of cases. Clomiphene-induced conception rates approached 50% after 3 cycles and 75% within 9 cycles of treatment.33 Side effects of clomiphene include hot flashes, mood changes, (rarely) visual changes, as well as relatively high rate of multiple pregnancies. If ovulation induction is not successful, low-dose gonadotropins may be considered. These agents have a lower risk of ovarian hyperstimulation than high-dose gonadotropins. Surgical ovulation induction The benefit and role of surgical laparoscopic ovarian drilling by laser or diathermy (LOD) is to be determined. There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD compared to gonadotropin treatment.37 The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about the long-term effects of LOD on ovarian function.37 Hirsutism For patients not seeking fertility, hirsutism is the major concern. The combination of an antiandrogen (spironolactone* or flutamide*) and an ovarian suppression agent appears to be an effective approach to hirsutism in women with PCOS, although the best OCP or antiandrogen agent is unknown. I *Unlabeled use. 22 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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