PCOS AND HYPERINSULINSM
The most common endocrine cause of anovulation is polycystic ovary syndrome (PCOS). Typically, women with this problem present with infertility associated with scanty menstrual periods and cycles of more than 35 days. Most patients have some clinical or laboratory evidence for hyperandrogenism, and polycystic ovaries appear on ultrasonography. The familial association with diabetes mellitus (DM) is quite significant. As the risk for DM amongst PCOS women is increased several-fold, many of them become diagnosed with impaired glucose tolerance or insulin resistance. This disturbance in glucose metabolism is due to elevated baseline or stimulated insulin levels and may be a consequence of a genetic predisposition. The role of insulin as a growth factor is well established. Insulin stimulates the ovarian theca cells to produced increased amounts of androgens. Considering that androgens serve as precursors for estradiol synthesis, it is therefore unsurprising that estradiol levels become elevated. Hyperandrogenism also interferes locally with the normal process of folliculogenesis thus propounding the hormonal and fertility problems. Metformin is an insulin-sensitizing drug that is commonly used in the treatment of DM and serves to reduce insulin secretion. Its use is also associated with a normalization of the intraovarian paracrine milieu and is effective in PCOS. Despite the belief that metformin may not be totally effective in the management of fertility-related issues, it is quite logically an effective form of treatment that addresses the hormonal imbalance in patients with PCOS. Having said that, lifestyle changes remain in the forefront of combating abnormalities of glucose metabolism and associated metabolic problems.
see this powerpoint presentation on excess male hormones and their features in women
Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality of reproductive-age women. These patients usually present with infertility or menstrual disturbances, conditions caused by anovulation or oligoovulation. It has now become evident that there are deeper and more significant metabolic consequences to this syndrome than just the reproductive ones. Whereas this was previously strongly suspected, the most recent meeting of the PCOS Consensus Group confirmed the long-term consequences of the disorder*. After resolving the issues of menstrual abnormalities and hyperandrogenism, these patients need to be screened for metabolic abnormalities (lipid profile, glucose metabolism, hypertension), potential psychological problems, and the possibility of precancerous or cancerous changes. If the anovulatory cycles persist long enough, endometrial hyperplasia and even endometrial cancer may develop over time in otherwise healthy young women. Thus, PCOS is a multidisciplinary disorder and must be managed as such. * BC, Tarlatzis BC, Rebar RW, et al Consensus on Women's Health Aspects of Polycystic Ovary Syndrome (PCOS): The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012;97:28-38.e25