EXPERT ANALYSIS FROM THE ANNUAL INTERNAL MEDICINE PROGRAM
ESTES PARK, COLO. (FRONTLINE MEDICAL NEWS) – The sweet spot for intervention in polycystic ovary syndrome occurs early: in the adolescent who doesn’t yet desire pregnancy and who is just starting to experience the classic PCOS progressive weight gain.
“The obstetricians don’t want to see these patients when they’re already 220 lb and they’re trying to induce ovulation. It’s our job to pick them up in their adolescence. You want to clamp the hormones – suppress the androgens – so that things will be better down the road,” Dr. Margaret E. Wierman urged at a conference on internal medicine sponsored by the University of Colorado.
Aggressive treatment at this stage will reduce the risk of a host of potential health problems later. In addition to infertility issues, these include increased long-term risks of diabetes, hypertension, dyslipidemia, metabolic syndrome, endometrial cancer, obstructive sleep apnea, and nonalcoholic fatty liver disease, noted Dr. Wierman, professor of medicine, ob.gyn., and physiology at the university and chief of endocrinology at the Denver VA Medical Center.
PCOS is by far the most common cause of hyperandrogenic anovulation. Indeed, 6%-8% of all women in their childbearing years have PCOS. The condition is defined by clinical and/or biochemical hyperandrogenism, oligomenorrhea or amenorrhea, and the presence of ovarian cysts or increased ovarian volume on ultrasound.
In the adolescent with PCOS who doesn’t desire pregnancy, Dr. Wierman takes a three-pronged treatment approach: regularize menses with a less androgenic oral contraceptive, such as one containing norethindrone, or by using cyclic progesterone; treat hirsutism with spironolactone at 50-100 mg once daily coupled with electrolysis for local control; and consider using short-acting metformin as an insulin-sensitizing agent.
The use of metformin in treating PCOS is controversial. It is off-label therapy. There have been no prospective, randomized, placebo-controlled, double-blind studies supporting this application of the drug. Nevertheless, Dr. Wierman is a believer.
“If you take these adolescent girls, especially as they’re beginning to start the weight gain, and you give them metformin, it will stop the weight gain, improve their androgen level and their insulin resistance, and it will help them when they’re ready to have kids later on. I use metformin, and I call it Antabuse for fat: You cheat, you pay. You have no side effects if you eat healthy. If you eat fatty foods, you will have nausea and diarrhea,” she explained.
The endocrinologist added that she finds metformin works best in the adolescent with PCOS who has a family history of diabetes, is gaining weight, but is not yet diabetic herself.
“And that’s based on clinical experience, no prospective studies,” Dr. Wierman emphasized.
She reported having no financial conflicts regarding her presentation.
