Special section : Obstetrics & Gynaecology - Long term consequences of
SPECIAL SECTION: OBSTETRICS & GYNAECOLOGY
Government Medical Col ege, Alappuzha, Kerala, India
Correspondence to: drsangeethamenon@hotmail.com
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
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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
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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
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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-JournalSpecial 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. NEng 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-JournalSpecial 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. An Open Access Peer Reviewed E-Journal
Living psychology: The ‘emotional warmth’ dimension of professional childcare Children and young people in public care are arguably the most vulnerable group in our society and, despiteconsiderable support and financial expenditure, the outcomes for these children have remained stubbornlypoor. While the worthy intentions of government initiatives over recent years are not in question, it i
yourself BY CHERILEE GAROFANO, BA, CPT, CNP, RNCP A s a trainer, I search for ways to help clients stay fit and motivated between our sessions. Manyfemale clients ask about the workout value fromdance classes. So off I went to Zumba and bellydancing classes for a first hand experience. Eachrepresents different dance styles, both providecardiovascular and strengthening with a high