TREATING INSULIN RESISTANCE
Weight loss is one of the simplest, yet most effective, ways to manage insulin abnormalities, menstrual irregularities, and other PCOS symptoms. For weight-loss strategies, see Chapter 11.
Insulin-lowering drugs are another option. This class of drugs includes the diabetes drug metformin (Glucophage). Metformin has been receiving a lot of media attention and has been brilliantly effective for some women with PCOS.
In preliminary studies,7 metformin helped restore normal menstrual cycles in approximately 50 per cent of women with PCOS. Blood androgen (male hormone) levels sometimes also decrease, but there may not be much improvement in excess hair growth or acne. And metformin doesn’t provide contraception. In fact, it might stimulate ovulation – great if you do want to conceive, not so great if you don’t!
Metformin may also help with weight loss, though it’s not a weight-loss drug. Some studies8 have shown that women with PCOS on a low-calorie diet lose more weight when metformin is added. But to keep the weight off you need to stick to a healthy eating and exercise plan; otherwise it creeps back on.
There’s also been speculation that metformin might reduce the risk of early pregnancy loss and the development of gestational diabetes mellitus (diabetes during pregnancy) in women with PCOS. But experts don’t yet recommend its use in these situations until larger studies have been undertaken.
Metformin is available in three forms:
1 Generic Metformin Hcl
2 Glucophage (brand name)
3 Glucophage XR (brand name).
Glucophage is available in 500-mg, 850-mg or 1,000-mg tablets. The usual dose is 850–1,000mg twice daily. Your doctor will probably help you to build up to the appropriate dose gradually.
Side-effects can include diarrhoea and more frequent bowel movements – and some women feel this is why they’ve lost weight while they’ve been using it, and the reason why it’s all gone back on again once they’ve got used to the medication. But every case is individual and you’d work with your doctor to find the best dose for you.
The long-term safety and effectiveness of metformin and other experimental drugs for PCOS is still unknown.
‘My doctor agreed to start me on 500mg of Metformin twice daily, and we built up to 850mg, then 1,000mg. At this level I noticed a metallic taste in my mouth…I went back to the 850mg dose. I have started to lose weight and have had two periods in the last 31/2 months,
Janey, 32
FERTILITY TREATMENT
If you’re finding it hard to get pregnant your doctor will usually ask both you and your partner to have a thorough check-up. These exams may include tests of the fallopian tubes in the woman and a semen analysis in the man. If tests determine that the problem is lack of ovulation due to PCOS, three options are available. It’s important to know that all of these options work best for women who aren’t obese, and that even a modest amount of weight loss can make these treatments more effective.
CLOMIPHENE CITRATE
The first line of treatment is typically the fertility drug clomiphene citrate, which stimulates the ovaries to release one or more eggs. Clomiphene triggers ovulation in about 80 per cent of women with PCOS, and about 50 per cent of these women will actually become pregnant. In women taking clomiphene, ovulation can be confirmed by blood and urine tests or by measurement of body temperature. If the original dose of clomiphene does not trigger ovulation, the doctor may prescribe a higher dose.
Several studies9 have shown that the insulin-sensitizing drug, metformin, increases the effectiveness of clomiphene in producing ovulation. And another study10 suggested metformin may reduce the risk of miscarriage. So your specialist may prescribe it alongside clomiphene.
Although many women use metformin in their pursuit of a successful pregnancy, and early studies11 look promising, it’s important to point out that its safety for use during pregnancy has not been firmly established. Metformin does contribute to increased homocysteine levels, and increased homocysteine levels can increase the risk of miscarriage.
GONADOTROPIN THERAPY
A more aggressive medical treatment for PCOS-related infertility is with drugs called gonadotropins (LH and FSH). FSH is used without LH for women with PCOS, and is given as a daily injection for 7 to 10 days. These drugs trigger ovulation in almost all women with PCOS and lead to pregnancy in approximately 60 per cent. But these drugs are expensive; they can also overstimulate the ovaries and produce pregnancy with multiple foetuses because lots of eggs are ready to be fertilised at the same time.
OVARIAN SURGERY
Surgery is only used as a last measure for the treatment of infertility in women with PCOS, but can be effective in some women who do not respond to medical treatment.
Today, surgery is usually performed through a laparoscope (a thin, lighted tube). Instruments are inserted through the laparoscope and are used to damage the ovary mechanically or thermally (with heat or cold). This damage decreases androgen levels in the ovary and alters other hormone levels in the body, triggering the maturation and release of eggs.
Women with PCOS have an 80 to 87 per cent chance of becoming pregnant after laparoscopic surgery, and it usually reinstates normal menstrual cycles for at least several months afterwards. But it’s not without risks – it’s typically less effective in overweight women, and can lead to the formation of adhesions, wasting of the ovary, injury to surrounding tissues, and infection. Although the long-term effects of ovarian surgery are still being evaluated, studies suggest that the procedure may also lead to early menopause.
FUTURE RESEARCH
Research on PCOS and clinical trials addressing the best treatments are taking place in many countries around the world.
At the time of writing there’s currently a lot of research in the area of genetics as regards PCOS and the best way to treat it. Micro-rays are miniature chips that permit the screening of thousands and thousands of genes, and this type of research is simplifying the search for genes that have an impact on ovarian function, insulin resistance and PCOS.
With the increasing interest in hormonal therapies for prostate cancer it’s likely that novel treatments for the PCOS symptoms of hirsutism and acne will one day be found, such as a pure anti-androgen that has an effect only on the skin and doesn’t upset the menstrual cycle.
Preliminary research is also looking at the widely available anti-cholesterol drug simvastatin as a treatment for PCOS. Researchers at Yale University School of Medicine studied 48 women with PCOS. Levels of testosterone fell by an average of 18 per cent and cholesterol by 12 per cent in the women taking simvastatin. It also reduced hirsutism by 4 per cent and helped some women get rid of acne. Those who took part in the trial took twice the normal 10-mg dose usually recommended for cholesterol-lowering effect. More research needs to be done.
Several large-scale studies are underway to determine metformin’s safety and effectiveness for use in the long term and during pregnancy. Other studies are attempting, among other things, to determine why the ovaries are sensitive to insulin, what the most effective diet is for women with PCOS, and the impact of weight loss, diet and lifestyle on symptoms.
One other insulin-sensitizing medication, inositol,12 is showing particular promise. It will be a while before conclusions