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pcos and bcpsFrom: Janet (anonymous@obgyn.net)Thu, 4 Sep 2003 23:25:31 -0500 (CDT)
Just got this in an e-mail thought I would pass it along. from Medscape Ob/Gyn & Women's Health Question I have a patient with polycystic ovarian syndrome and metabolic syndrome who is being treated with metformin 500 mg/3 times per day, exercise, diet modification, and irbesartan 150 mg/day. Is it safe and effective to give her oral contraceptives (OCs)? Response from Peter Kovacs, MD, 07/01/2003 Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting up to 10% of reproductive-age women. It is diagnosed on the basis of hyperandrogenemia or clinical hyperandrogenism and oligoanovulation or anovulation. To establish the diagnosis, other endocrine problems (Cushing syndrome, congenital adrenal hyperplasia, adrenal tumor, hyperprolactinemia) need to be ruled out. The exact cause of the disease is not known, although more and more evidence points to a metabolic origin, namely insulin resistance. In most patients with PCOS, normoglycemia can only be maintained by increased insulin output. Insulin stimulates ovarian androgen production, and the resulting hyperandrogenemia leads to arrested follicular development. The clinical picture can vary. Some patients are obese; others are lean. Some patients display clinical evidence of hyperandrogenemia; others do not. Some patients have irregular cycles; others have amenorrhea. Therefore, the presenting complaint can be infertility, menstrual irregularity, or a cosmetic issue relating to hirsutism or acne. Obviously, treatment depends on the primary clinical issue. In recent years, serious long-term consequences of PCOS have been identified. Type 2 diabetes, cardiovascular disease, endothelial dysfunction, and dyslipidemia (elevated cholesterol, triglyceride levels) have been shown to occur more frequently among women with this endocrine problem. Treatment that is aimed at reducing circulating insulin levels often results in normalization of the menstrual cycles and could improve long-term outcome. Successful treatment with insulin-sensitizing drugs, such as metformin, introduces a new "problem": Those with restored menstrual function and ovulatory cycles will require effective contraception. OCs are effectively used by women with PCOS who require treatment to manage hirsutism or irregular cycles and can provide effective contraception at the same time. However, OC use has been associated with increased insulin resistance and increased risk for cardiovascular disease. This issue is further complicated by the availability of pills that contain progestins with various degrees of androgenicity. Newer pills contain fewer androgenic progestins, which may reduce their adverse effect. But it should be noted that these newer-generation pills have also been associated with increased risk for cardiovascular disease. So, do we lose the benefits of insulin-sensitizing drugs when we administer OCs to provide these patients with contraception? This is a very important question. The decision to start OCs should be based on whether any cardiovascular risk factors are present. Family history, hypertension, lipid levels, body weight, lifestyle, and ethnicity all need to be evaluated, in addition to whether insulin resistance is present. These factors need to be assessed before OCs are started and then reassessed at regular intervals. If the patient has a high baseline risk for cardiovascular disease, another form of contraception should probably be recommended (eg, barrier methods, intrauterine device, or sterilization once fertility is no longer desired). In addition to providing these women with contraception, the benefits of a healthy lifestyle (weight loss, exercise, healthy diet) should be emphasized. We need to accumulate more data on the safety of OCs in women with PCOS/insulin resistance.
-- Email always welcome Janet at JanetHeller@msn.com
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