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February 6, 2005
Polycystic Ovarian Syndrome
This week, I met a 27 year old woman who was obese (BMI=40.9). Earlier in the year she had experienced periods that were irregular and lasted > 1 month. She was being treated with Metformin for "hard ovaries". She had been diagnosed with Polycystic Ovarian Syndrome (PCOS). Neither my preceptor nor I had heard of Metformin being used in the treatment of this disease. When we spoke to her gynecologist, he told us that Metformin has been used to increase fertility in women with PCOD as well as other beneficial effects.

A review article discusses the effects of clomiphene citrate (CC), which is the standard medication used to induce ovulation in infertile women. This article compares the effect of CC alone vs. CC and metformin and found that the combination lead to 3 to 4-fold higher rates of ovulation and pregnancy in women with PCOS. This review found that Metformin lead to a 50% increase in ovulation vs. placebo in women with PCOS. There are no studies which directly compare Metformin to CC. Metformin has a number of other beneficial effects on women with PCOS. Patients with PCOS tend to be hyperinsulinemic which leads to hyperandrogenemia. With Metformin, all of the patients became normoinsulinemic. LH decreased while FSH increased leading to spontaneous ovulation. Also HDL and total cholesterol decreased significantly and there was a mean weight loss of 4.7%. An advantage of using Metformin instead of CC is that Metformin favorably affects the metabolic profile of patients with PCOS and may lead to decrease in number of patients with PCOS who will develop Diabetes Mellitus type 2 and cardiovascular disease. CC does not have this effect and has several adverse effects associated with it. CC leads to increased numbers of multiple pregnancies, and in rare cases is associated with ovarian hyperstimulation syndrome. CC thickens the cervical mucus and may impede the passage of sperm. CC also has a negative effect on the endometrium because it is an anti-estrogen. Metformin does not hyperstimulate the ovaries but may exert its effect by decreasing Insulin levels, which leads to a decrease in Androgen levels. Currently some physicians are using Metformin as a primary therapy to induce ovulation in infertile women with PCOS. However, much literature still regards Metfomin as a secondary therapy to be used only when CC fails. It seems as though Metformin should be tried as an initial therapy because it can treat more aspects of PCOS as opposed to CC and it appears to be safer.

Posted At : 5:55 PM. | Link | Rotation 3 04-05 | Comments (3)

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Comments

Excellent post! I wonder why Metformin isn't a first line therapy with all the positive benefits. But what happens to the menstrual cycle women only taking Metformin. Are there other symptoms controlled as well as BCP's. Is metformin an option for women who aren't trying to get pregnant? Also, will taking Metformin reduce the risk of developing Type 2 DM for women with PCOS?

Posted By Erin Gates / Posted At 2/6/05 7:17 PM

very interesting. i never knew this. i wonder what is the correlation of DM and PCOS? also, what are some drawbacks of metformin in this population, espeically if they patient is not at risk of DM? interesting. great post

Posted By Fazila Lalani / Posted At 2/8/05 8:12 AM

Hi Patricia When I saw your post I said maybe PCOS is not that rare. Our patient came in for a PAP. It was her physical appearance that got us asking questions. She only mentioned Yasmin as the med she was taking. I though metformin was used only when patients presented with insulin resistance. There is another med used for pcos Diane35, see comments on my entry. Great job

Posted By Rachel Egbujor / Posted At 2/8/05 12:52 PM