Polycystic Ovaries Syndrome and insulin resistance: how are these related?

Women who suffer from polycystic ovaries syndrome (PCOS) develop impaired insulin action points out an Italian review recently published on Current Pharmaceutical Design. Insulin is a hormone released by the pancreas. It regulates blood sugar levels by facilitating the transfer of glucose through the bloodstream into the cells, where glucose is used as the burning material for energy production. The importance of insulin is best recognized when considering the lack of this hormone and the relevant effect on blood sugar levels which rise excessively leading to diabetes mellitus.

In some cases (obesity, polycystic ovaries, diabetes predisposition, overproduction of cortisol etc.), although production and release of insulin is not negatively affected, its action in the cells is distorted. Thus, although insulin is present, glucose cannot be regulated as tissues resist against its action (insulin resistance). To deal with this situation, the body pushes the pancreas to produce excess amounts of insulin, leading to an increase of insulin levels in the blood that is 2 to 10 times above normal (hyperinsulinemia). This phenomenon is very common and seen in 20-26% of adult population in Europe and America.

A recent review of studies by the University of Verona confirmed that insulin resistance is a major health issue among young women with polycystic ovaries syndrome (PCOS). Dr Paolo Moghetti evaluated the evidence on the pathogenesis and treatment of impaired insulin action that is frequently diagnosed in women with PCOS.

He concluded that insulin resistance is a basic mechanism involved in PCOS pathogenesis as hyperinsulinemia is greatly associated with excess androgens seen in this gynaecological condition. Moreover, impaired insulin action is the key mechanism in metabolic disorders, also seen in these women and is a major aspect of the underlying medical significance of polycystic ovaries syndrome.

“The key question that comes up after any similar study on polycystic ovaries syndrome is the role of body weight and particularly the effect of excess body fat in women with polycystic ovaries syndrome. Furthermore, systemic studies have shown that obese women suffering from PCOS have insulin resistance and are facing a 20% risk of developing type ΙΙ Diabetes Mellitus (non-insulin dependent). However, patients who are not obese but have an increased body mass index (BMI>27) are also in great risk of developing the condition.

Lifestyle changes and/or a specific medication could have a positive contribution in management. Nevertheless, the therapeutic model that is each time selected must be personalized”, comments Dr Harry C. Hiniadis, Obstetrician –Gynaecologist specialised in IVF and Laparoscopy, associate in the IVF unit at MITERA Maternity Hospital (http://www.hiniadis.com/) He adds: “given this chance, we should point out that polycystic ovaries syndrome should not be confused with polycystic ovaries.

Now that ultrasound screening is part of the routine gynaecological monitoring, polycystic ovaries have become a very common finding. It is estimated that approximately 20% of women of reproductive age have polycystic ovaries but less than half of this population develop the biochemical and hormonal features that may set the diagnosis for polycystic ovaries syndrome.

Therefore, only 4-5% of the female reproductive population is diagnosed with PCOS. Moreover, studies concentrating on the symptom’s causes have brought forward the role of a particular gene, suggesting that the syndrome may be hereditary and passed down from a mother to a daughter”. According to Dr Hiniadis, to be able to reach an accurate diagnosis of the polycystic ovaries syndrome a doctor must take a detailed medical history of the patient and consider specific information such as obesity or tendency to easy body weight increase, heredity and most dominant features, such as abnormal menstrual cycle (absent, scanty or rare menstruation – amenorrhoea or oligomenorrea – at a rate of 20-50%), excess hair growth (65-70%), acne (25-35%) and alopecia (3-6%).

“A significant 20-75% of these women are facing infertility and in most cases, PCOS is diagnosed during investigation of infertility causes” adds Dr Hiniadis. Monitoring involves Transvaginal Ultrasound of the ovaries followed by patient hormonal profile screening (LH, FSH, Prolactine, Progesterone, DHEAS, SHBG etc.). “At the same we check the adrenal gland function to cross-out certain androgen-secreting ovarian tumours which, although rare, can imitate PCOS symptoms”, says the doctor.

Personalized treatment plan

For successful therapeutic management of polycystic ovaries syndrome, the gynaecologist should take into account all clinical, laboratory and screening data.

“Usually the doctor will first choose between a simple contraception pill or cyproterone acetate with progesterone to achieve a regular menstrual cycle and protect the endometrium. At the same time the patient is advised to introduce regular exercise and dieting to her lifestyle.

If necessary and indicated further to insulin/ glucose testing, then, based on the new data, the doctor may proceed with gradual administration of metformin, which is also prescribed for type-ΙΙ diabetes mellitus, with satisfactory results as to body weight control, excess hair growth, as well as ovulation.

Excess hair growth can also be managed with various other methods (laser, photolysis etc.), but the decision should be taken further to examination by a specialized Dermatologist.

The same applies for acne where simple treatment with antimicrobial agents and antibiotics can be replaced by a more specialized approach (spironolactone, chemical peeling etc.)” says Dr Harry Hiniadis.

As to the management of infertility secondary to polycystic ovaries syndrome, Dr Hiniadis explains that many patients have a positive reaction to ovulation induction with clomiphene citrate when combined with frequent ultrasound screening.

If this approach is not successful, other available options include intrauterine insemination or IVF. “Such attempts should always be made by specialized gynaecologists in recognized IVF centres as the patient is in high risk of developing OHSS (Ovarian Hyper Stimulation Syndrome)” points out Dr Hiniadis.

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