Ethinyl estradiol-drospirenone vs ethinyl estradiol-drospirenone plus metformin in the treatment of lean women with polycystic ovary syndrome

Efficacy of Bariatric Surgery in the Treatment of Women With Obesity and Polycystic Ovary Syndrome

CONTEXT

The comparative effectiveness of drugs and surgical therapy for women with obesity and polycystic ovary syndrome (PCOS) has not been systematically compared.

OBJECTIVE

We aimed to determine the difference in efficacy between drug and bariatric surgery therapy for women with obesity and PCOS.

METHODS

This prospective nonrandomized trial enrolled 90 women aged 18 to 40 years with body mass index (BMI) ≥ 27.5 kg/m2 and waist circumference ≥ 85 cm and fulfilling the 2011 Chinese diagnostic criteria for PCOS; 81 subjects completed the study. In the drug group, patients were administered metformin and an oral contraceptive containing ethinyl-estradiol and cyproterone acetate for the first 6 months, and metformin alone for the second 6 months. In the surgical group, patients underwent laparoscopic sleeve gastrectomies. The follow-up period was 12 months. The main outcome was the complete remission of PCOS, requiring 6 consecutive regular menstruation cycles or spontaneous pregnancy.

RESULTS

Median BMI at endpoint was 30.1 kg/m2 in the drug group and 23.7 kg/m2 in the surgical group; complete remission rate was 15% and 78%, respectively. Except endpoint BMI, no difference was observed in free androgen index, ovarian morphology, homeostasis model assessment for insulin resistance, and total weight loss between remission and nonremission patients. Logistic regression analyses also revealed that the final BMI was the major factor influencing the remission of PCOS. The cutoff points for the final BMI were 27.5 kg/m2 for the drug group and 26 kg/m2 for the surgical group. Overall, nearly 95% of patients with an endpoint BMI below the cutoff values achieved complete remission.

CONCLUSION

Complete remission of PCOS in patients with obesity depends on the final BMI after weight loss. Thus, bariatric surgery should be prioritized for these patients.

The Pharmacogenetics of Metformin in Women with Polycystic Ovary Syndrome: A Randomized Trial

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder affecting women of reproductive age. PCOS is associated with obesity, dyslipidaemia and insulin resistance, and metformin treatment may improve such metabolic features. The effect of genetic variants in key metformin transporters, their transcriptional regulators or in metformin target genes on metformin response in women with PCOS is unclear. Associations between pharmacodynamic responses to metformin (changes in weight, lipid profile, insulin sensitivity evaluated by oral glucose tolerance testing) and polymorphisms in OCT1 (rs12208357 and rs72552763), HNF1A (rs1169288 and rs2464196), MATE1 (rs2289669 and rs2252281), MATE2-K (rs12943590) and ATM (rs11212617) were studied in 40 women with PCOS randomized to 12 months of treatment with metformin 1000 mg twice daily ± oral contraceptive pills (150 μg desogestrel + 30 μg ethinylestradiol). In the entire study population, treatment was associated with reduced weight (median weight change -2.4 kg, 25th-75th percentile -5.2 to 0.3 kg, p < 0.001) and increased triglycerides (0.2 mmol/L (0.0-0.6 mmol/L), p < 0.01) without significant changes in other lipid parameters or insulin sensitivity (insulin_AUC , glucose_AUC during OGTT). None of the evaluated polymorphisms significantly affected any treatment outcome. In conclusion, the genetic variants investigated were not crucial for the clinical response to metformin in PCOS.

Comparison of efficacy of metformin and oral contraceptive combination of ethinyl estradiol and drospirenone in polycystic ovary syndrome

OBJECTIVE

The 2013 Endocrine Society guidelines state that hormonal contraceptives should be used for treating both menstrual irregularity and hirsutism in patients with polycystic ovary syndrome (PCOS). Metformin should be reserved for the treatment of women presenting with only menstrual irregularity because it has limited benefits in treating hyperandrogenism associated with PCOS. A high prevalence of insulin resistance is noted among the South Asians, and these guidelines may not hold good for this population. Thus, this study was conducted to investigate and compare the effects of metformin and an oral contraceptive containing drospirenone on menstrual pattern, body mass index, serum testosterone levels, and dehydroepiandrosterone sulfate (DHEAS) levels at baseline to 6 months of therapy in the treatment groups.

MATERIAL AND METHODS

This was a prospective observational study that was conducted over a year in patients visiting the Endocrinology outpatient department at a tertiary care center in a south Indian city. Forty-six subjects diagnosed with PCOS as per the Rotterdam criteria were included. They received either metformin twice daily or an oral contraceptive containing drospirenone once daily as a monthly regimen for 6 months.

RESULTS

Metformin regularized menstrual cycles in 72% of patients who were followed up at 6 months. No significant difference was observed between the two treatment groups with respect to decreasing the body mass index, serum testosterone levels, and DHEAS levels (p=0.40, p=0.65, and p=0.22, respectively).

CONCLUSION

Metformin is effective in regularizing menstrual cycles, decreasing body mass index, and treating hyperandrogenism in Indian women diagnosed with PCOS.

A Combined Therapy with Myo-Inositol and D-Chiro-Inositol Improves Endocrine Parameters and Insulin Resistance in PCOS Young Overweight Women

Introduction. We evaluated the effects of a therapy that combines myo-inositol (MI) and D-chiro-inositol (DCI) in young overweight women affected by polycystic ovary syndrome (PCOS), characterized by oligo- or anovulation and hyperandrogenism, correlated to insulin resistance. Methods. We enrolled 46 patients affected by PCOS and, randomly, we assigned them to two groups, A and B, treated, respectively, with the association of MI plus DCI, in a 40 : 1 ratio, or with placebo (folic acid) for six months. Thus, we analyzed pretreatment and posttreatment FSH, LH, 17-beta-Estradiol, Sex Hormone Binding Globulin, androstenedione, free testosterone, dehydroepiandrosterone sulphate, HOMA index, and fasting glucose and insulin. Results. We recorded a statistically significant reduction of LH, free testosterone, fasting insulin, and HOMA index only in the group treated with the combined therapy of MI plus DCI; in the same patients, we observed a statistically significant increase of 17-beta-Estradiol levels. Conclusions. The combined therapy of MI plus DCI is effective in improving endocrine and metabolic parameters in young obese PCOS affected women.

Polycystic ovary syndrome: chemical pharmacotherapy

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the most common reproductive endocrine disease among women of childbearing age. The clinical features are heterogeneous and vary in intensity. Hirsutism, menstrual disorders and infertility are the most frequent conditions observed; however, long-term complications (dyslipidemia, hypertension, cardiovascular disease, type 2 diabetes mellitus, endometrial cancer) are also often described. Each disorder may be managed by tailored strategies, employing sequential or combined pharmacological and/or non-pharmacological treatment.

AREAS COVERED

The authors review the drugs used for PCOS management and discuss new approaches. A systematic MEDLINE search regarding the randomized controlled trials, retrospective and observational studies about medical treatments of PCOS, the Cochrane library for reviews and also search for registered trials on ClinicalTrials.gov is performed.

EXPERT OPINION

A uniform treatment for PCOS patients does not exist. Clinicians should perform an accurate evaluation of patients' characteristics, identifying the phenotypic target and, subsequently, the best-tailored treatment to manage one or more clinical issues. Lifestyle intervention should always be the first recommended approach unless other issues indicate that drug or hormonal interventions are superior.

Cardiovascular risk factors and events in women with androgen excess

Androgen excess (AE) was approximated to be present in 7% of the adult population of women. Polycystic ovary syndrome (PCOS) is the most prevalent among them, followed by idiopathic hirsutism (IH), congenital adrenal hyperplasia (CAH), hyperandrogenic insulin-resistant acanthosis nigricans (HAIRAN) syndrome, and androgen-secreting neoplasms (ASNs). Increased cardiovascular risk was implicated in women with AE. Serum testosterone independently increases risk for cardiovascular disease (CVD), and correlates even with indices of subclinical atherosclerosis in various populations of postmenopausal women. Hyperandrogenism in PCOS is closely related to the aggravation of abdominal obesity, and together with insulin resistance forming the metabolic core for the development of CVD. However, phenotypic variability of PCOS generates significant influence on the cardiometabolic risks. Numerous risk factors in PCOS lead to 5-7 times higher risk for CVD and over 2-fold higher risk for coronary heart disease and stroke. However, issue on the cardiometabolic risk in postmenopausal women with hyperandrogenic history is still challenging. There is a significant overlapping in the CVD characteristics of women with PCOS and variants of CAH. Relevant clinical data on the prevalence and cardiometabolic risk and events in women with IH, HAIRAN syndrome or ASNs are scarce. The effects of various oral contraceptives (OCs) and antiandrogenic compounds on metabolic profile are varying, and could be related to the selected populations and different therapy regiments mainly conducted in women with PCOS. It is assumed relation of OCs containing antiandrogenic progestins to the increased risk of cardiovascular and thromboembolic events.

Hyperinsulinaemic androgen excess in adolescent girls

Hyperinsulinaemic androgen excess is the most common cause of hirsutism, acne and menstrual irregularity in adolescent girls. Here, we propose that the disorder frequently originates from an absolute or relative excess of lipids in adipose tissue, and from associated changes in insulin sensitivity, gonadotropin secretion and ovarian androgen release. Girls from populations with genotypes attuned to nutritionally harsh conditions seem to be particularly vulnerable to the development of hyperinsulinaemic androgen excess in today's obesogenic environment. We propose that hirsutism, hyperandrogenaemia and menstrual irregularity (≥2 years after menarche) is used as a diagnostic triad for the disorder. No pharmacological therapy has been approved for girls with androgen excess; however, lifestyle intervention is essential to reduce adiposity. In girls without obesity who are not sexually active, insulin sensitization has more broadly normalizing effects than estradiol-progestogen combinations. The early recognition of girls at risk of developing hyperinsulinaemic androgen excess might enable prevention in childhood.

Body composition is improved during 12 months' treatment with metformin alone or combined with oral contraceptives compared with treatment with oral contraceptives in polycystic ovary syndrome

CONTEXT

Central obesity in polycystic ovary syndrome (PCOS) is associated with increased inflammatory markers and increased risk for type 2 diabetes.

OBJECTIVE

The objective of the study was to evaluate whether treatment with metformin (M) or M combined with oral contraceptive pills (OCPs) resulted in a more advantageous body composition than treatment with OCP alone.

SETTING

The study was conducted at an outpatient clinic.

PATIENTS AND INTERVENTIONS

This was a randomized, controlled clinical trial. Ninety patients with PCOS were randomized to 12 months' treatment with M (2 g/d), M + OCP (150 mg desogestrel+30 μg ethinylestradiol), or OCP. Whole-body dual-energy x-ray absorptiometry scans and clinical and hormonal evaluations were performed before and after the intervention period. A total of 65 of 90 patients completed the study.

MAIN OUTCOME MEASURES

Changes in weight at 6 and 12 months and changes in regional fat mass estimates at 12 months were measured.

RESULTS

Dropout rates between intervention groups were not significantly different. Treatment with M and M+OCP were superior to OCP regarding weight and regional fat mass. The median (quartiles) weight changes during 12 months of M, M+OCP, and OCP treatment were -3.0 (-10.3; 0.6), -1.9 (-4.9; 0.1), and 1.2 (-0.8; 3.0) kg, respectively, P < .05. Upper to lower fat mass ratio was unchanged. Changes in body composition were predicted by the type of medical intervention (M, M+OCP, or OCP) and not by body mass index at study inclusion. OCP and M+OCP were superior to M regarding reduction in free T levels.

CONCLUSIONS

M treatment alone or in combination with OCP was associated with weight loss and improved body composition compared with OCP, whereas free T levels decreased during M+OCP or OCP. Combined treatment with M+OCP should be considered as an alternative to treatment with OCP alone to avoid weight gain in PCOS.

Hormonal contraceptive choice for women with PCOS: a systematic review of randomized trials and observational studies

INTRODUCTION

This paper provides a critical review of the data concerning the effects of combined hormonal contraceptives (CHC) for polycystic ovary syndrome (PCOS). The aim is to determine the best treatment option for each PCOS phenotype.

STUDY DESIGN

A literature search of the PubMed database was conducted for randomized clinical trials (RCTs) and observational studies published in any language prior to October 2013. Hyperandrogenism (HA) is the essential diagnostic criterion for PCOS and is frequently associated with insulin resistance (IR) or obesity. The combinations of these criteria define the different PCOS phenotypes and establish the scale of metabolic and cardiovascular risks.

RESULTS AND CONCLUSIONS

19 RCTs and eight observational studies evaluated issues related to the current objectives. CHC represent an effective and safe treatment in women with any PCOS phenotype. In HA/PCOS patients, any CHC analyzed in this review can be used for symptom relief. For patients with metabolic risk, overweight or moderate IR that does not require metformin, a vaginal contraceptive ring appears to be preferred to oral EE/DRP. In these patients, the combination of CHC and myo-inositol may be more effective in controlling endocrine and metabolic profiles. However, further research is needed to define the optimal duration and to clarify the effects of treatment on long-term metabolic outcomes. Future research should also focus on new CHC.

Effects of drospirenone-ethinylestradiol and/or metformin on CD4(+)CD28(null) T lymphocytes frequency in women with hyperinsulinemia having polycystic ovary syndrome: a randomized clinical trial

OBJECTIVE

To evaluate the long-term effects of drospirenone (DRSP)/ethinylestradiol (EE) alone, metformin alone, and DRSP/EE-metformin on CD4(+)CD28(null) T lymphocytes frequency, a cardiovascular risk marker, in patients with hyperinsulinemic polycystic ovary syndrome (PCOS).

DESIGN

Randomized clinical trial.

INTERVENTIONS

Ninety three patients with hyperinsulinemic PCOS were age matched and body mass index matched and randomized to receive a 6 months daily treatment with DRSP (3 mg)/EE (0.03 mg), or metformin (1500 mg), or DRSP/EE combined with metformin.

MAIN OUTCOME MEASURES

CD4(+)CD28(null) T-cell frequencies.

RESULTS

The DRSP/EE and metformin groups did not show any significant change in the CD4(+)CD28(null) frequency compared to the baseline. Interestingly, a statistically significant decrease in CD4(+)CD28(null) frequency occurred after 6 months of DRSP/EE-metformin (median 3-1.5; P < .01). Of note, this statistically significant association was confirmed after adjusting for baseline values in DRSP/EE-metformin group by analysis of covariance (P < .05).

CONCLUSIONS

In women with hyperinsulinemic PCOS, combined therapy with DRSP/EE and metformin may reduce cardiovascular risk.