Ovulation induction for polycystic ovary syndrome. (2000)

ovarian hyperstimulation syndrome ( OHSS).  

miscarriages (recurrent miscarriage).  

maturity onset diabetes.

endometrial cancer(endometrial cancer).

controlled trials (placebo & controlled trials) will be required to establish a clearer picture of the potential benefits. 

A thirty-five year old woman had stopped seeing her periods (amenorrhoea) for a year and her weight had been increasing. Her only other problem was IBS (Q23.34). Her BMI was 38 (Q9.8) showing that her weight was 50% greater than it should have been. Ultrasound examination of her pelvis showed no abnormality and in particular there was no suggestion of polycystic ovaries. Her LH was 8.4 IU/l and FSH 4.8 IU/l which are normal readings and her thyroid tests and prolactin were normal. The testosterone was 3.2 nmol/l which is towards the upper level of normal but her SHBG was low at 14 nmol/l. Her fasting blood sugar was 4.8 mmol/l (normal) but her fasting insulin was 18.7 mU/L which is high. Metformin was commenced.

This case is an example of a patient presenting with two problems that can be associated with polycystic ovary syndrome namely amenorrhoea and obesity although the ultrasound was reported as showing normal ovaries. Her LH was not high and even her testosterone was just within the normal range. The low SHBG is a strong pointer to the diagnosis. Although the high fasting insulin in this case seems reassuring that metformin is likely to prove beneficial the value of insulin tests in clinical management remains to be determined.

Related Medical Abstracts - Click on the paper title:-

PCOS and metformin

Please see above- The recently discovered relationship between polycystic ovary syndrome and insulin resistance has been presented above. Metformin is a drug that increases sensitivity to insulin and it therefore reverses the insulin resistance of PCOS. Metformin has been used since the 1950s in the treatment of diabetes and it is a remarkably safe drug.

There is accumulating evidence that metformin has a significant part to play in the treatment of PCOS, whether the symptoms are amenorrhoea (absent periods), oligomenorrhoea (infrequent periods), obesity, hirsutism (excessive hair production) or anovulation (failure to release eggs resulting in infertility). Metformin 500mg tablets are taken two or three times daily after meals. Although metformin has been available for more than forty years, its application for PCOS is new and it has yet to be licensed for this indication. We therefore provide metformin for PCOS only with informed consent (informed consent). Some women may be initially troubled by bowel disturbance and flatulence but these problems improve after a couple of weeks. The tablets can be split Infrequent periods worth taking only half a tablet daily for a few days and gradually increasing the dose over two or three weeks. At this time there is no substitute for metformin as a drug to increase insulin sensitivity but there is a new class of insulin-sensitising agents due to be launched soon the thiazolidine will be some years before the true value of metformin for patients with PCOS will be determined. Initial experience has shown that it is beneficial for women with hirsutism and absent or infrequent periods and infertility. It may assist in weight reduction. There is theoretical reason for optimism that metformin prescribed for women with PCOS will have several long-term benefits. It has been suggested that metformin may reduce complications which may occur with ovulation stimulation particularly with gonadotrophin injections:

ovarian hyperstimulation syndrome (OHSS).  

miscarriages (recurrent miscarriage).  

maturity onset diabetes.

endometrial cancer (endometrial cancer).

controlled trials (placebo & controlled trials) will be required to establish a clearer picture of the potential benefits.

Metformin has been used for many years by diabetic patients and there is no evidence that it causes such problems in pregnancy. Once pregnancy has been confirmed, there is no proven advantage in continuing treatment but there is some early eInfrequent periodsinue the metformin until 20 weeks into the pregnancy and others continue the metformin throughout the pregnancy.

Related Medical Abstracts - Click on the paper title:-

How should infertility associated with polycystic ovary syndrome be treated?

PCOS is associated with ovulation problems (egg release) and therefore ovulation induction is often required. The ovaries will often respond to tablets; Tamoxifen (tamoxifen infertility) is thought to provide a good balance of hormone production although clomiphene (Clomid clomiphene citrate) may also prove to be effective.

Metformin has been shown to be effective in the treatment of polycystic ovary syndrome. For several years, many infertility specialists increasingly turned to metformin as first-line treatment for infertility associated with polycystic ovary syndrome. However, there is now evidence that clomiphene should be the first-line treatment and metformin added if pregnancy is not achieved.

If the ovaries do not respond to tablets more powerful agents (gonadotrophins e.g. Pergonal, Humegon or Metrodin gonadotrophins) given by injection will almost invariably prove to be successful. Increased levels of LH occur in 40% of women with PCOS and this seems to reduce the chance of conception and there is also an increased risk of miscarriage. LH levels can be suppressed by GnRH agonists (gonadotrophins) but disappointingly studies in these situations have shown no improvement.

Ovarian drilling (ovarian drilling) may have a part to play when ovulation stimulation proves difficult to achieve with drugs. Before commencing ovulation stimulation, it seems sensible to ensure reasonable male fertility by checking a semen analysis. Many authorities recommend testing Fallopian tube patency before commencing treatment. My own view is that if there is clear evidence of PCOS and anovulation, a few months of treatment before confirming tubal patency will save many women from an uncomfortable procedure.

Related Medical Abstracts - Click on the paper title:-

Treatment of Absent periods associated with PCOS

The combined oral contraceptive pill is often the most appropriate method for providing cycle control, assuming that conception is to be avoided. If oestrogen levels are satisfactory, regular withdrawal bleeds are likely to follow cyclical progestogen administration (Q5.12; Q 24.17). When the patient is a young teenager, parents often feel happy with this rather than knowing that their daughter has started a contraceptive agent. Another option is the use of a cyclical HRT (Q 28. 9). Metformin should also be considered.

Related Medical Abstracts - Click on the paper title:-

You can never rely on irregular periods as a symptom of anovulation (eggs not being released). The best advice is that you should not take unnecessary chances.

Related Medical Abstracts - Click on the paper title:-

Contraceptive choices for women with endocrine complications. (1993) 

Can PCOS be treated surgically?

The doctors who first described PCOS removed part of the ovaries (wedge resection), for microscopic examination. They observed that the menstrual cycle and fertility were often restored following these operations.

More recently, it has been shown that drilling tiny holes in the ovaries (ovarian drilling) at the time of laparoscopy, may improve their chemistry although it is too early to know how long this improvement will be sustained. Whilst ovarian drilling may have a part to play in PCOS patients with infertility, this treatment is not proven to have a definite place in treatment for hirsutism.

Ovarian drilling may result in spontaneous ovulation. Unlike ovulation stimulation, there is no increased risk of multiple pregnancy or ovarian hyperstimulation (enlargement of the ovaries with the possibility of other problems such as excess fluid in the abdominal cavity). We do not know why ovarian drilling works. For those patients who respond to ovarian drilling there appears to be a reduction in LH levels which suggests that the drilling must in some way alter the hormone feedback to the hypothalamus and pituitary possibly by the release of a factor not yet identified. Interestingly, in one study where four patients had drilling of just one ovary, there was evidence of ovulation from the other ovary in the first cycle after treatment in three of the patients.

One study has shown that the insulin response to sugar is not altered following ovarian drilling.

Related Medical Abstracts - Click on the paper title:-

Support Groups

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

• relating personal experiences,
• listening to others' experiences,
• providing sympathetic understanding and
• establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-

DISCLAIMER

The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

Thank you for your visiting us at 2womenshealth.com.

This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London.

I do hope that you find the answers to your questions in the patient information and medical advice provided. If you still have unanswered questions, please consider entering them into one of our forums and I will try to assist you.