Is Metformin Useful in Treating PCOS?
Is Metformin Useful in Treating PCOS?
I have heard from medical colleagues that taking metformin 500-850 mg daily helps women with polycystic ovary syndrome (PCOS). Please elaborate on what its benefits are to such patients and discuss any other preferred medications or recommended lifestyle changes.
Thomas P. Lombardi, PharmD, FASHP
Associate Clinical Professor, Adjunct Faculty, Albany College of Pharmacy, Sage Graduate School, Albany, New York; Supervisor, Clinical Pharmacy Services, St. Peter’s Hospital, Albany, New York
Affecting 5% to 10% of women of reproductive age, polycystic ovary syndrome (PCOS) is characterized by anovulation, infertility, and hyperandrogenism, with clinical manifestations of irregular menstrual cycles, hirsutism, and acne. These women also have an increased prevalence of cardiovascular risk factors similar to those seen in the metabolic syndrome, and PCOS often is associated with insulin resistance. By age 40, type 2 diabetes or impaired glucose tolerance will develop in up to 40% of women with PCOS.
There is no cure for PCOS, so treatment focuses on managing symptoms and addressing a woman's potential desire to conceive. Metformin has demonstrated some benefit in improving a variety of symptoms in women with PCOS. In 1 study, pregnancy and ovulation rates improved when metformin was added to clomiphene, an ovulation simulator. Metformin had no effect on weight, body mass index, or waist circumference in these patients. When compared with placebo, it decreased systolic blood pressure.
Additionally, metformin has been shown to decrease fasting insulin levels as well as low-density lipoprotein (LDL) cholesterol. Therefore, metformin may also be helpful in women with PCOS by addressing the associated insulin resistance and other components of the metabolic syndrome, such as improving systolic blood pressure and lowering LDL.
Metformin is in the US Food and Drug Administration's Pregnancy Category B, indicating it is "probably safe." However, because there are no adequate or well-controlled studies on metformin in pregnant women, it should be used with caution in these patients.
Several other medications may also be helpful in women with PCOS. For those who do not wish to conceive, oral contraceptives can be used to regulate the menstrual cycle, reduce androgen levels, and help clear acne. Progesterone-only products can help regulate the menstrual cycle, but they will not decrease hair growth or improve acne.
In women who are not trying to conceive, agents such as spironolactone or finesteride (Propecia) may be useful in decreasing hair growth. Nonpharmacologic treatment may include electrolysis for hirsutism.
Because infertility is a primary problem of PCOS, fertility medications such as clomiphene and gonadotropins can be used to promote fertility.
Maintaining a healthy weight can aid in the management of PCOS. Healthy eating habits and regular exercise can help the patient manage blood glucose, use insulin more efficiently, and achieve a more regular menstrual cycle.
Although not recommended as a first course of treatment, surgical ovarian drilling also is available to induce ovulation. This procedure may also lower androgen levels, although that effect may last only a few months. The procedure carries a risk of developing scar tissue on the ovary.
Question
I have heard from medical colleagues that taking metformin 500-850 mg daily helps women with polycystic ovary syndrome (PCOS). Please elaborate on what its benefits are to such patients and discuss any other preferred medications or recommended lifestyle changes.
Response from Thomas P. Lombardi, PharmD, FASHP
Thomas P. Lombardi, PharmD, FASHP
Associate Clinical Professor, Adjunct Faculty, Albany College of Pharmacy, Sage Graduate School, Albany, New York; Supervisor, Clinical Pharmacy Services, St. Peter’s Hospital, Albany, New York
Affecting 5% to 10% of women of reproductive age, polycystic ovary syndrome (PCOS) is characterized by anovulation, infertility, and hyperandrogenism, with clinical manifestations of irregular menstrual cycles, hirsutism, and acne. These women also have an increased prevalence of cardiovascular risk factors similar to those seen in the metabolic syndrome, and PCOS often is associated with insulin resistance. By age 40, type 2 diabetes or impaired glucose tolerance will develop in up to 40% of women with PCOS.
There is no cure for PCOS, so treatment focuses on managing symptoms and addressing a woman's potential desire to conceive. Metformin has demonstrated some benefit in improving a variety of symptoms in women with PCOS. In 1 study, pregnancy and ovulation rates improved when metformin was added to clomiphene, an ovulation simulator. Metformin had no effect on weight, body mass index, or waist circumference in these patients. When compared with placebo, it decreased systolic blood pressure.
Additionally, metformin has been shown to decrease fasting insulin levels as well as low-density lipoprotein (LDL) cholesterol. Therefore, metformin may also be helpful in women with PCOS by addressing the associated insulin resistance and other components of the metabolic syndrome, such as improving systolic blood pressure and lowering LDL.
Metformin is in the US Food and Drug Administration's Pregnancy Category B, indicating it is "probably safe." However, because there are no adequate or well-controlled studies on metformin in pregnant women, it should be used with caution in these patients.
Several other medications may also be helpful in women with PCOS. For those who do not wish to conceive, oral contraceptives can be used to regulate the menstrual cycle, reduce androgen levels, and help clear acne. Progesterone-only products can help regulate the menstrual cycle, but they will not decrease hair growth or improve acne.
In women who are not trying to conceive, agents such as spironolactone or finesteride (Propecia) may be useful in decreasing hair growth. Nonpharmacologic treatment may include electrolysis for hirsutism.
Because infertility is a primary problem of PCOS, fertility medications such as clomiphene and gonadotropins can be used to promote fertility.
Maintaining a healthy weight can aid in the management of PCOS. Healthy eating habits and regular exercise can help the patient manage blood glucose, use insulin more efficiently, and achieve a more regular menstrual cycle.
Although not recommended as a first course of treatment, surgical ovarian drilling also is available to induce ovulation. This procedure may also lower androgen levels, although that effect may last only a few months. The procedure carries a risk of developing scar tissue on the ovary.
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