Pinpointing PCOS

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Discover why polycystic ovary syndrome is on the increase in the Middle East, the implications for women and the recommendations on how to treat it.

Polycystic Ovary Syndrome (PCOS) is a common problem that affects women starting in their teenage years or later in life. It is characterised by having irregular menstrual cycles and evidence that there is too much androgen in the body.

The excess androgen may be caused by abnormal levels of luteinising hormone, insulin or by overly active ovaries. Irregular periods may make it difficult to become pregnant, while extra testosterone can also cause problems with hair, skin, weight and insulin levels.

In the US, PCOS is estimated to affect almost 10% of women regardless of ethnic background. Its prevalence seems to be rising because of the current epidemic of obesity. At least 40% of women with PCOS are obese, and they are more insulin resistant than weight-matched women with normal ovaries.

As the rates of obesity and diabetes rise in the Middle East, it's a good idea for doctors to be on the alert for patients with PCOS. According to some estimates, about a third of the adults in the Middle East are obese and the prevalence of obesity in children is among the highest in the world.

There is no cure for PCOS, but there are many ways to manage its symptoms.

According to Dr Corrine Welt, an Assistant Professor at Harvard Medical School and an Assistant in Medicine at Massachusetts General Hospital in Boston, managing PCOS is important because, if left untreated, the condition can affect other parts of a woman's body.

Because PCOS is linked to obesity and insulin abnormalities, it may increase a woman's risk for heart disease, she explains. In addition, PCOS makes the lining of the uterus thicker because the menses are irregular, which can raise the risk of developing uterine cancer. Furthermore, women with PCOS often develop sleep apnoea, a potentially serious sleep disorder marked by one or more pauses in breathing or shallow breaths during sleep.

The cause of PCOS remains unclear, but it's thought that genetics plays a role. Researchers are getting closer and closer to understanding the mechanism, so this is an area to keep an eye on, Dr Welt says.

Other research suggests that PCOS is caused by an insulin imbalance. This finding is leading some doctors to take a broad-brush approach to prescribing the anti-diabetic drug metformin for all women with PCOS, observes Dr Welt. Metformin suppresses production of glucose in the liver and increases insulin sensitivity. Dr Welt says this agent is useful for women with PCOS, but not in every situation.

Who should take metformin?

"If someone is diabetic or has impaired glucose tolerance, metformin along with diet and weight loss may be used to lower insulin levels," says Dr Welt. Another group that may benefit are women who are trying to get pregnant because it can improve menstrual cycle regularity.

A 2003 systematic review and meta-analysis published in the October 25 British Medical Journal reported that metformin induces ovulation in women with PCOS, and is even more effective when combined with the fertility drug clomiphene citrate.

The authors, after pooling the results of 13 trials, including 543 women with PCOS, concluded that the choice of metformin as a first line agent "seems justified." But they noted that there is a shortage of data on long-term use, use in young women, and use during early pregnancy.

But this study is not the final word. More recently, a trial of 228 women with PCOS showed that when added to clomiphene, metformin did not induce ovulation or increase the odds of pregnancy. When the drug combination was given to infertile women with PCOS, the ovulation rate was just 64%, compared to 72% in women who received a placebo.

Moreover, there were no significant differences in the rates of ongoing pregnancy or spontaneous abortion, and many women in the metformin group stopped treatment because of its gastrointestinal side effects. The study appeared in the June 24, 2006 British Medical Journal.

The difference in the two studies may be related to the prevalence of obesity in the groups or ethnic differences between women in the studies.

Metformin is not the ideal treatment for women with irregular menstrual cycles or cosmetic concerns who are not trying to conceive, says Dr Welt. It's not as effective as other drugs in reducing excess hair or acne and does little to help regulate a woman's period.

For these women, a combination of birth control pills and anti-androgens is more effective. "Birth control pills work to regulate the menstrual cycle 100% of the time, whereas metformin works closer to 60-70% of the time," Dr Welt explains. In addition, birth control pills reduce excess hair and acne, and lower the risk of uterine cancer. Anti-androgens, such as spironolactone, also reduce the effects of male hormones on the skin and hair.

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