Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorder in adolescent and adult women affecting 1 in 15 women worldwide and have important metabolic and reproductive implication.
The diagnosis of PCOS is challenging specially in adolescent as normal pubertal changes can mimic the signs of PCOS. The Rotterdam criteria are widely in use for diagnosis. These criteria require that patients have at least two of the following conditions: ovulatory dysfunction, androgen excess, and polycystic ovaries. It is also necessary to rule out other causes of androgen excess and ovulatory dysfunction before a diagnosis of PCOS is made.
The treatment approach varies according to the age of the patient, desire for pregnancy and the presenting symptoms.
The Endocrine Society guidelines for the treatment of adults with PCOS recommends using oral contraceptive pills (OCPs) to control symptoms of androgen excess, while reserving metformin for cases with impaired glucose tolerance or features of metabolic syndrome.
However, evidence is sparse to support the best first-line medication in adolescents with PCOS.
Investigators Dr. Reem A. Al Khalifah and colleagues of King Saud University in Saudi Arabia published a metaanalysis and systemic review of randomized, controlled trials (RCTs) to evaluate the use of metformin versus OCPs for the treatment of PCOS in adolescents ages 11 to 19 years in the Pediatrics, online April 28.
The team searched the literature through Ovid Medline, Ovid Embase, Cochrane Central Register of Controlled Trials, and gray literature resources, up to January 29, 2015. Only four RCTs met the inclusion and exclusion criteria’s amounting to 170 patients in total.
It was seen that OCP treatment resulted in improvement in menstrual irregularities with a modest improvement in the acne scores. On the other hand, metformin improved the BMI, decreased dysglycemia prevalence and improved total cholesterol and low-density lipoprotein levels. Both treatment modalities have a similar effect on hirsutism.
However, the evidence quality was very low, so "treatment choice should be guided by patient values and preferences, while balancing potential side effects" said Dr. Al Khalifah
But, as PCOS is a spectrum with many girls presenting with obesity and hairiness while others have normal body weight and just have menstrual irregularities. So, depending upon the symptoms, the treatment is tailored according to the patient need, with either OCP or metformin being the first line of treatment.
Concurrently, the importance of life style modification and statin is also stressed to provide long term cardiac protection in these patients.
References:
http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html#b
http://www.ncbi.nlm.nih.gov/pubmed/26280343
http://press.endocrine.org/doi/abs/10.1210/jc.2013-2350
The diagnosis of PCOS is challenging specially in adolescent as normal pubertal changes can mimic the signs of PCOS. The Rotterdam criteria are widely in use for diagnosis. These criteria require that patients have at least two of the following conditions: ovulatory dysfunction, androgen excess, and polycystic ovaries. It is also necessary to rule out other causes of androgen excess and ovulatory dysfunction before a diagnosis of PCOS is made.
The treatment approach varies according to the age of the patient, desire for pregnancy and the presenting symptoms.
The Endocrine Society guidelines for the treatment of adults with PCOS recommends using oral contraceptive pills (OCPs) to control symptoms of androgen excess, while reserving metformin for cases with impaired glucose tolerance or features of metabolic syndrome.
However, evidence is sparse to support the best first-line medication in adolescents with PCOS.
Investigators Dr. Reem A. Al Khalifah and colleagues of King Saud University in Saudi Arabia published a metaanalysis and systemic review of randomized, controlled trials (RCTs) to evaluate the use of metformin versus OCPs for the treatment of PCOS in adolescents ages 11 to 19 years in the Pediatrics, online April 28.
The team searched the literature through Ovid Medline, Ovid Embase, Cochrane Central Register of Controlled Trials, and gray literature resources, up to January 29, 2015. Only four RCTs met the inclusion and exclusion criteria’s amounting to 170 patients in total.
It was seen that OCP treatment resulted in improvement in menstrual irregularities with a modest improvement in the acne scores. On the other hand, metformin improved the BMI, decreased dysglycemia prevalence and improved total cholesterol and low-density lipoprotein levels. Both treatment modalities have a similar effect on hirsutism.
However, the evidence quality was very low, so "treatment choice should be guided by patient values and preferences, while balancing potential side effects" said Dr. Al Khalifah
But, as PCOS is a spectrum with many girls presenting with obesity and hairiness while others have normal body weight and just have menstrual irregularities. So, depending upon the symptoms, the treatment is tailored according to the patient need, with either OCP or metformin being the first line of treatment.
Concurrently, the importance of life style modification and statin is also stressed to provide long term cardiac protection in these patients.
References:
http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html#b
http://www.ncbi.nlm.nih.gov/pubmed/26280343
http://press.endocrine.org/doi/abs/10.1210/jc.2013-2350
Choice of OCP? How best to prevent endothelial damage if she does not engage in physical exercise?? Which OCP? How long to use? When to stop? Can we add Spironolactone concomitantly with Spironolactone to prevent latent damage of endothelium induced by cytokines due to hyperandrogenaemia? What are the agents available now in a case florid case of adole PCOD with gross we can take care of her vascular health? Pharmacotherapy Pl?? Can Spironolactone also exhibit beneficial effect on Carb /Lipid Metab?? We have to occasionally use this agent as monotherapy if girl concerned denies taking OCP and she is hirsute with raised PPBS. It is also hard to convince to consume Met to adol girls. They will shout at Clinic/ OPD saying that “Doc. -- I am not diabetic”. Difficult situation unless her parents are quite educated. Your opinion about choice of OCP & monotherapy of Spironolactone, prevention of continued vascular damage which initiates from the onset of menarche. Will Reversatol / Atorvastatin slow down the vascular damage? Then how to gauze that the said drug designed for vascular protection is working in a particular girl??-Dr Srimanta Pal : drsrimantapal@gmail.com:Thanks.
ReplyDeleteGeneration Gap: Adolescent girls are mostly sedentary: It is hard to change. Therefore we have to heavily rely on pharmacotherapy!!This can’t be changed. Having admitted that, can we use both the agents (COC & Met) concomitantly if the girl’s hepatic & renal functions are normal? For instance a girl aged 15 yrs where both parents are diabetic and girl academic record is so bright that she just don’t listen to our advices of lifestyle modifications(Physical exercises in particular), and there is moderate acne (androgen excess) with BMI of 32. Shall I be doing harm if I prescribe both CCO & Met concomitantly? To add to the metabolic problem she is already having dyslipidaemia with FBS of 112 & HBa1C 6.8. Can I add Atorvastatin as a third agent? As far I have realized that she won’t exercise and will neither stop visiting restaurants (taking high calorie diets-rich of fats). This is common state of affair going in almost all metro cities of India. We have failed to counsel the adolescents and their parents about the relevance of diet & exercise. This is a great failure on our part. But given drugs-they will be compliance-because taking drugs takes only 30 seconds of their valuable time!!!! Your opinion about coprescription of Met & COC please. Met given alone will take long time to decrease acne which is distressing to her including some element of hirsutism. She has been thoroughly evaluated about all possible sources of high androgen .Report are nonneoplastic & not a case of CAH. Incidentally which COC will be the first choice-safe & patient friendly? Your opinion Pl.
I have in-boxed the answers to your queries Dr. Srimanta Pal.
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