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Polycystic Ovary Syndrome and Diabetes

Polycystic ovary syndrome (PCOS), or Stein-Leventhal syndrome affects 5 to 10% of women of reproductive age and most don’t even know that they have it. The syndrome has been known for about seventy-five years and though doctors are still not very sure what causes it, it is one of the leading causes of infertility.

The ovaries are two small organs found on each side of the uterus. They contain follicles which are tiny cysts filled with liquid that holds eggs. Each month, several of these follicles start to mature but only one continues to grow, accumulating fluid. When the egg matures, the follicle ruptures to release the egg and this is called ovulation. The egg then travels through the fallopian tube for fertilization. In women with PCOS, the ovary does not make enough hormones to enable successful ovulation. The follicles may start to grow but do not mature properly. No dominant follicle successfully releases an egg. Some of the maturing follicles remain only as cysts, making the ovary “polycystic”. These cysts also produce an excess of male hormones (testosterone) which inhibits ovulation. When ovulation does not occur, the hormone progesterone is not made and so the woman’s menstrual cycle is either irregular or absent.

Women with PCOS often have the following symptoms: irregular or absent menses, numerous cysts in the ovaries (in many but not all cases), acne, excess hair on face and body (chest, stomach, back, thumbs or toes) with thinning of scalp hair and weight gain or obesity (usually carrying extra weight around the waist). Most of these women will also have high blood pressure and cholesterol, and diabetes. Thus, PCOS is no longer thought of as simply a disorder of infertility but a metabolic disorder which can put a woman at increased risk for heart disease.

PCOS is strongly linked to diabetes. In Asian women, the prevalence of diabetes in women with PCOS has been estimated to be 6.3%.’ In an unpublished study done in the Philippine General Hospital’ which enrolled 85 women with PCOS, 55% had impaired fasting glucose (fasting blood sugar >100 mg/dL), 4% had impaired glucose tolerance (two hour value on oral glucose tolerance test >140 mg/dL) and 9% had diabetes. These data demonstrate that diabetes is common in Filipino women with PCOS since the national prevalence of diabetes is only about 4%.3 This study estimates that a Filipino woman with PCOS has four to five times greater risk of developing diabetes as compared to normal women. The American Diabetes Association thus recommends that screening for diabetes be done even in asymptomatic women with PCOS.

Up until recently when the connection of PCOS to diabetes was recognized, it was not known why the ovaries of women with PCOS produced an excess of male hormones. Now, it is believed to be strongly associated with insulin resistance, the same underlying mechanism for diabetes. Insulin is the hormone responsible for bringing sugar or glucose in the blood stream into the cells of the body. The body must have the right amount of insulin to maintain appropriate glucose levels. When the cells become resistant to insulin, as can happen when a person is overweight or obese, the body is triggered to produce extremely high levels of insulin, despite which the glucose in the blood rises causing glucose intolerance and eventually diabetes. It is the excess insulin which is thought to be responsible for stimulating the ovaries to produce an excess of male hormones. Hence for women with PCOS and glucose intolerance, physicians often recommend diet, exercise and weight loss as these can improve insulin sensitivity.

The recognition that PCOS is a disorder of insulin resistance just like diabetes, has led to the thinking that drugs commonly used to treat insulin resistance in diabetes can be of benefit in PCOS. One such drug being used in women with PCOS and glucose intolerance is metformin, a drug used to combat insulin resistance in diabetes. Metformin has been shown to facilitate weight loss and reduce body hair. It reduces insulin resistance and male hormone levels in women with PCOS. Metformin has been used in combination with fertility drugs to restore ovulation for these women.

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