Briefly what is PCO??

Polycystic Ovarian Syndrome ::Peripheral insulin resistance

 Ans:--The PCO syndrome cannot be defined as a unique entity. It is a  various heterogeneous forms of morphology and  varied clinical symptoms are described. The common endocrine increased LH concentrations in serum and a shift of the LH/FSH ratio towards LH are known.

Further characteristics are the hyperandrogenism and hyperinsulinemia following an increased peripheral insulin resistance. This disease has been the subject of multiple genetic studies and is fairly well known at the present time. Chronic anovulation, amenorrhoea, hyperinsulinemia and increased insulin resis­tance are often treated with weight-loss strategies; metabolic treatment with met­formin, clomiphene. GnRH agonists and antagonists as well as laparoscopic ovarian drilling. The genetically caused enzyme deficiencies of the adrenal andro­gen biosynthesis are not yet fully clarified.

With a prevalence of more than 5 %, PCOS is one of the most common diseases in young women. It is defined by the combination of oligo or amenorrhoea, clinical or biochemical hyperandrogenism and the exclusion of pituitary, adrenal or other ovarian disorders.

Polycystic ovaries PCO are associated with the syndrome but are not very specific for the diagnosis. The most common complaints are hirsutism, infertility and obesity although even very slender patients can be affected. Many patients are found to be insulin resistant, associating PCOS with the metabolic syndrome and implicating a risk to develop its sequelae. The consideration of insulin resistance has established insulin sensitisers as a new option for the treatment of PCOS. The older concept of wedge resection or ovarian drilling to remove mechanical com­pression of normal ovarian tissue by fluid-filled cysts and edematous tissue is still considered a method of treatment.

Laparoscopy offers the possibility of releasing the ovarian capsule and the retended fluid by ovarian drilling which can be performed with monopolar or bipolar electricity, laser or ultrasound. Ovarian drilling is a surgical treatment not accepted by everyone. We personally find it well indicated in ultrasound images with typical “string of pearls” cysts .The number of holes to be drilled (between 5 and 30 on each side) depends on the size of the ovary and the number of follicular cysts. Pure monopolar cutting current with 80 W should be used for the drilling. Careful continuous rinsing with Ringer’s lactate prevents post-surgical adhesion formation.

Metformin increases insulin sensitivity, reduces glucose uptake and inhibits glucose synthesis.

In obese women, metformin supports weight loss and improves menstrual cyclicity with increased ovulation rates. With metformin therapy, serum testosterone decreases and symptoms of hirsutism significantly improve. In ovarian stimulation, metformin improves response to clomiphene or FSH with increased pregnancy rates. Some studies suggest a positive effect of metformin, even on early pregnancy, leading to reduced abortion rates. Metformin should be taken for at least 3 months at a dose of 2-3 x 500 mg or 2 x 850 mg daily. This sequence is especially recommended for obese patients with peripheral insulin resistance although even lean patients can benefit from this therapy.

Various combination treatments, including oral contraceptives and metformin as well as ethinyl oestradiol and metformin, have been proposed. A significant effect of the combination of oral contraceptives and metformin together with androgens and SHBG has not been found. However, the combination of metformin with the intermittent application of ethinyl oestradiol and cyproterone acetate seems to improve the symptoms of androgen excess in cases of PCOS. As metformin is currently not yet approved for the treatment of PCOS, it is not given on a wide scale in Germany. The complex and differential diagnosis of PCOS requires a close interdisciplinary cooperation of gynaecologists, endocrinologists and dieticians. Surgical treatment with ovarian drilling and wedge resection stands side by side with endocrine treatment and the necessary weight loss in obese patients. Molecular genetic findings on the origin of PCOS have not yet led to any practical therapeutic treatment modalities but have given some insight into the genetic background of the disease .