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Special section : Obstetrics & Gynaecology - Long term consequences of SPECIAL SECTION: OBSTETRICS & GYNAECOLOGY Government Medical Col ege, Alappuzha, Kerala, India Correspondence to: [email protected] Polycystic Ovary Syndrome (PCOS) is emerging as a common problem among adolescents today. Its immediate problems range from oligomenorrhoea, hirsutism, acne, seborrhea and obesity but its long term consequences are many. Both gestational diabetes and type 2 diabetes are more common in PCOS women. Though cardiovascular risks have often been cited, actual proof is lacking and morbidity and mortality from cardiovascular disease in women with PCO is not as high as indicated. However women with PCOS are more prone to carcinoma of endometrium and sleep apnoea and image related psychological issues are harsh realities. life of the woman in her later years as wel . At 50 years of age, one lives based on how one lived at 20 years! This adage is extremely be affected by Polycystic Ovary Syndrome (PCOS), it is imperative that we sit up and consider long term sequele, it is rather difficult to define long term! For a girl who which has significant repercussions on the has PCOS at 15 years, 30 years of age is An Open Access Peer Reviewed E-Journal Special section : Obstetrics & Gynaecology - Long term consequences of probably long term, and in her, the most The intent of this article is to focus on risks It is worthy of note that, there is a higher such as type 2 diabetes, cardiovascular risks, risk of gestational diabetes in women with cancers, psychological issues and obstructive screening for GDM as early in pregnancy as remedial strategies that may be adopted to is feasible. A recent Meta analysis concluded that women with PCOS also have a significant higher risk of pregnancy complications compared to controls. Metformin when taken throughout Insulin resistance in PCOS has been linked pregnancy has been suggested to reduce the to the later development of impaired glucose miscarriage if taken in the first trimester itself. Many practicing clinicians offer suggesting that further cases of diabetes will metformin in pregnancy for exactly these develop later, pushing the incidence even further. Increased BMI>30, strong family Obstetricians and Gynaecologists does not history of type 2 diabetes, or PCOS women recommend its routine use in pregnancy as >40 years, are more at risk and should be the methodology of these studies was poor offered a GTT. However it is surprising to and we are yet to see further randomized note that the frequency of type 2 diabetes is control ed trials (RCTs) to provide adequate evidence of its safety and efficacy. Being a (<27kg/m2), suggesting that PCOS is an class B drug, there are no reported instances independent risk factor for type 2 diabetes. of fetal toxicity or teratogenicity.There may Hence PCOS conditions such as gestational still be unanticipated risks to the baby from the post natal use of metformin by the breast public health model to screen and detect feeding woman. Further studies are needed before its use can be recommended in the An Open Access Peer Reviewed E-Journal Special section : Obstetrics & Gynaecology - Long term consequences of cardiovascular risk factors such as obesity, hyperandrogenism, hyperlipidemia and hyperinsulinism. However clinicians need to be aware that conventional cardiovascular only every 6-12 months, and that too only risk calculators have not been validated in levels of estrogen, and therefore are more at cholesterol, triglycerides and HDL, as it has carcinoma of endometrium. It is hence good lipid profiles consist mainly of increased at least. Regular withdrawal bleeds with triglycerides, total cholesterol and LDL .The monthly progesterone, OCPs or the Mirena effect of PCOS on HDL is controversial and IUS, will ensure cyclicity in menstruation links to hypertension are less consistent. In clinical practice, hypertension must be treated but lipid lowering treatment is not recommended as a routine, and should only significant increased risk of developing carcinoma of breast or epithelial ovarian cancer. Hence no additional surveil ance is >140/90mmHg and not responding to life style measures. But it needs to be understood that when treating PCOS women with diabetes or other high risk Sleep apnea is an independent cardiovascular factors, BP >130/80 mm Hg wil require risk factor and has been found to be more difference in the prevalence of sleep apnea Despite the increase in cardiovascular risk significant even when control ed for BMI. PCOS, has not shown to be high as fatigue, somnolescence and informed about An Open Access Peer Reviewed E-Journal Special section : Obstetrics & Gynaecology - Long term consequences of the possible risk of sleep apnea offered moderate effect on hirsutism and decreases necessary. It has been reported that the strongest predictors for sleep apnea were fasting plasma insulin levels and glucose to depression. They improve dramatical y when Life style changes through diet and exercise they start loosing weight. The effects of remain the first line for the treatment of obesity in PCOS. Obesity worsens insulin consequent psychological implications are to resistance which wil only serve to exacerbate be strongly considered. Hirsutism in the setting of PCOS is distressing and difficult compare the use of insulin sensitizing drugs improvement in fertility, increase in SHBG versus combined oral contraceptives (COC) concluded that the limited data available demonstrated no significant difference in metabolism. The Diabetes Prevention Trial effect between metformin and the pill on found that life style modification reduced Licensed treatment for hirsutism and acne Hence regular exercise aiming for 30 mts of combinations and cosmetic treatments like minimum of 3-4 times a week, coupled with laser, electrolysis, shaving, waxing and a balanced diet of hypocalorific meals must topical eflorinithine. However there is a paucity of good quality robust placebo control ed trials for hirsutism treatment and There is no clear effect of diet and exercise on the long term health of the lean PCOS – although it seems prudent to advise such patients to maintain their body weight in the normal range.
An Open Access Peer Reviewed E-Journal Special section : Obstetrics & Gynaecology - Long term consequences of Insulin sensitizing agents like metformin and the thiazolidinediones (troglitazone, study up to 20 yrs after ovarian drilling has reducing insulin resistance, seem attractive in reducing the risk of diabetes and other SHBG in over 60% of subjects, especial y if beneficial short term effects on insulin studies have been powered to look at the resistance in women who are not diabetic. ovarian drilling may affect the reproductive from the Diabetes Prevention Trial suggests that metformin is not superior to life style intervention in reducing cardio metabolic risks and progression to type 2 diabetes. Further a recent Meta analysis suggests an increase in myocardial infarction and death rosiglitazone. Further research is definitely needed to study the effects of these drugs for infarction and death from cardiovascular the prevention of cardiovascular disease in causes. N Eng J Med 2007;356;2457-71.
Orlistat and sibutramine have been shown 3. Fogel RB, Malhotra A, Pillar G, et al. Increased prevalence of obstructive sleep sibutramine is not advised in women with systolic hypertension. Further research needs polycystic ovary syndrome. J Clin Endocrinol Metab 2001;86:1175–80. 4. Ratner R., Goldberg R., Haffner S, et al. Impact of intensive lifestyle and metformin Ovarian electrocautery or drilling has a therapy on cardiovascular disease risk factors limited role in the treatment of infertility associated with PCOS, and its role should An Open Access Peer Reviewed E-Journal Special section : Obstetrics & Gynaecology - Long term consequences of Dunaif A. Prevalence and predictors of risk for type 2 diabetes mel itus and impaired Hum Reprod Update 2006;12:673-83.
syndrome - a prospective, control ed Study in 254 affected women. J Clin Endocrinol Metab 1999; 84: 165-9.
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