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Polycystic Ovarian Syndrome and Hyperinsulinemia: Overview and Treatment Pharmacy and Wellness Review Volume 2 Issue 1 Article 6 March 2011 Polycystic Ovarian Syndrome and Hyperinsulinemia: Overview and Treatment Amanda M. Meyer Ohio Northern University Lauren D. Bajbus Ohio Northern University Sarah E. Drake Ohio Northern University Kristen M. Quertinmont Ohio Northern University Ashley Overy Ohio Northern University See next page for additional authors Follow this and additional works at: https://digitalcommons.onu.edu/paw_review Part of the Endocrine System Diseases Commons, Endocrinology, Diabetes, and Metabolism Commons, Female Urogenital Diseases and Pregnancy Complications Commons, Obstetrics and Gynecology Commons, Other Pharmacy and Pharmaceutical Sciences Commons, Pharmaceutics and Drug Design Commons, Therapeutics Commons, and the Women's Health Commons This Article is brought to you for free and open access by the ONU Journals and Publications at DigitalCommons@ONU. It has been accepted for inclusion in Pharmacy and Wellness Review by an authorized editor of DigitalCommons@ONU. For more information, please contact [email protected]. Polycystic Ovarian Syndrome and Hyperinsulinemia: Overview and Treatment Authors Amanda M. Meyer, Lauren D. Bajbus, Sarah E. Drake, Kristen M. Quertinmont, Ashley Overy, and Anne Gentry This article is available in Pharmacy and Wellness Review: https://digitalcommons.onu.edu/paw_review/vol2/iss1/6 Women's Heafth Polycystic Ovarian Syndrome and Hyperinsulinemia: Overview and Treatment Amanda M. Meyer, fourth-year pharmacy student from Dublin, Ohio, Lauren D. Bajbus, fourth-year pharmacy student from Parma, Ohio. Ssrah E. Drake, fifth-year pharmacy student from Fairfield, Ohio, Kosten M. Quertinmont, fifth-year pharmacy student from Carmel, Ind.. Ashley Overy, fifth-year pharmacy student from Grafton, Ohio. Anne Gentry, PharmD, assistant director of the Drug lnformabOn Center and advisor for The Pharmacy and Wellness Review Abstract Hyperinsulinemia Hypennsuhnemia and insulin resistance are commonly associated with Polycysbc ovary syndrome is a prevalent issue in women's health that 1s associated with hypennsJllnemia and insulin resistance and PCOS. Hyperinsulinemia increases production of already elevated can lead to long-term health problems. The most highly recom­ androgens, worsening PCOS symptoms. ThlS IS accomplished by mended treatments are diet and lifestyle changes. If these changes overproduction of ovarian androstenedt0ne ard adrenal dehydroepi­ alone are oot eoough pharmac:ilogic treatments may be employed androsterone (DHEA), which leads to excess estrogen m the periphery. which include melformin, spironolactone or th1azolldinediones , Elevated estrogen increases the ratio of lute1raing hormone (LH) secreted by the anterior pituitary gland to secret10n of follicle stimulating although more research IS neeoed to fully rea hze their role. The role 1 of the pharmacist in this disease state includes counseling patients hormone (FSH). Increased LH secretions lead to amenorrhea, infertility, on healthy lifestyle changes, consulting with the phys1c1an about anovulaaon and hyperandrogenism. prescribing the best medication for each pa tient, and momtonng The hypothalam1c-p1tu1tary axis also 1s affected by excess release of therapy adherence in the pat1ert adreoocort1cotropic hormone (ACTH) in response to cortJCOtropm·re· leasing hormone (CRH). 1 ACTH samulates hJX)prote1n uptake by cortical Introduction cells, which can lead to higher cholesterol levels. This dysregulatlon of PolycysllC ovanan syndrome (PCOS) 1s a prevalent disorder affecting cholesterol levels correlates to the finding that many women with PCOS 6-15 percent of women of reprodoct1ve age. 1 PCOS 1s a ple10tropic are obese. Hyperinsulinemia also may possibly contnbute to this weight syndrome that can have delete nous effects on the ent1re body. Hyper­ gain Overall, insulin resistance and compensatory hypennsulinemia are insullnem1a IS one of the main concerns associated with this syndrome contnbutmg factors for anovulation, hyperandrogen1Sm, infertility and because rt can increase the risk for many other disease states in a earty pregnancy loss associated with PCOS paoents (Figure 1). woman with PCOS. There are few treatment options for PCOS at this time; but by understanding the safety and efficacy of the available op­ t10ns, pharmacists can help their patients better understand the disease state and medications. Pharmacists ca n further ta ke an active role by prov1d1ng screenings and educanrg patients on preventative measures for women who are at nsk of developing this disease. PCOS PolycystJC ovanan syndrome IS the most common endocnne disorder Ooosny among premenopausal women 1 The symptoms of this disorder are vaned and extend beyond reproductive system problems. Along with menstrual 1rregulanties, chronic anovulation and possible infertlhty, wom­ en with PCOS often develop hirsutism, acne , hyperandrogenism and inappropnate gonadotropin secretJon. 14 While some of the symptoms may only be frustrating or uncomfortable for the patient, a woman with PCOS 1s at nsk for developing other cond itions that are not as benign. A PCOS diagnosis means the patient is at an increased ris k for insulin resistance. hyperinsulinemia, dysl pidemia, hypertension, gestational and type 2 diabetes, systemic inflammatlOn, endothelial dysfunction, Figure 1. Detrimental ettects of PCOS-induced hyperinsulinemia and cardiac events such as myocardial infarction or cerebral vascular accidents Although PCOS is a common problem, its pathogenesis Non-phannacologic Treatment Options remains unknown. It 1s not merely a structural disorder, rather, it has The most hghly recommended way to treat PCOS is artenng the diet to definite ties to problems with horrrones, genetics, and even potentlally include healthier opaons, such as whole grains and fresh produce, and altered central nervous system (CNS) function.6 There are theories reduce the 1n1ake of hghly processed foods and foods high 1n fat or sodium. that PCOS has a genetic component due to a gene mutation in ova rian lncorporanng exercise into daily life also is recommended.7 Eating foods that and adrenal androgen synthesis as evidenced by a higher incidence of help decrease LDLs and increase HDLs, such as high fi~r foods and foods PCOS among f1rst-<1egree relatives. CNS problems such as epilepsy and con1a1mng omega-3 fatty acids (fish and nuts), can~ ~neflCial dietary btpolar disorder may also play a role in PCOS but more research needs modlfcaoons.' Achieving Ideal body weight and exercis1119 at least five umes to be done before a more concrete conclust0n 1s reached regarding this per week can JX)tentially alleviate many symplOrns assoc10.ted with PCOS as potential relationship. wel as reveise the progression of concurrem dlS98se states. 2 1 THE P HAIWAc• AND WELLNEss AEvtew Volume two. Issue one March 2011 Polycystic Ovarian Syndrome and Hyperins ulinemia: Overview and Treatment Women's Health A diet that has recenUy received significant media and patient attention is test parameters or insulin sensitivity when patents received a 50 mg/day the human chononic gonadotrop1n (hCG) diet. Human chononic gonado· dose of spironolactone.16 However, there was a significant improvement tropin 1s a hormone produced by tl'e trophoblastic cells of the placenta m menstruation cycle, hirsutism and androgen levels. While spirono­ dunng pregnancy.' The hCG diet supposedly mobilizes fat stored in the lactone was supe rior in helping with hirsutism and patient acceptance, abdomen, h1~ and thighs while keeping the patient feeling satiated. The metformin was more effective at improving glucose tolerance and insulin diet involves three "gorging days," to build up calories in the body, followed sensitivity. Although spironolactone 1s an option in the treatment of by a :-;Lrict, ve1y low-cato1ie diet of 500 calorie:; a day while receiving hCG PCOS, 1t iS not µrefe11 ed becau:;e it doe:; not cause sig11mca11t irnprove­ as injgctions, subbngual dro~ or lozenges. Despite some clinical trials ment in glucose tolerance and insulin sensitivity. showing benefits, the FDA denies that hCG has any benefit in treating obesity.1°CurrenUy, the only FDA-approved use for hCG is for fe rtility treat­ Another pharmacologic option is a TZD such as rosiglitazone or piogli­ ment 11 The diet is not recommended for weight loss in most patients, but tazone. Both of these drugs are agonists of the peroxisome-proliferator­ it may be used as a last resort for patie nts who desperate ly need to lose activated receptors {PPARs ), which, when activated, influence the weight Pharmacists can counsel p.i.tients about the risks associated with production of proteins invo lved in glucose and lipid metabolism. 15 This the diet, monitor its correct use and ensure the safety of the patients. improves response to insulin without influencing the amount of insulin that 1s secreted by the pancreas. In a randomized , two-armed, head-to­ Pharrn acologic Treatment Options head study of96 patients, it was found that ros1glitazone was more ef­ There are limited pharmaceutical opttons that can be utilized; however, fective than metformin at red ucing female hirsutism, but it was not found because of the underlying problem with hyperinsulinemia, insuhn-sens1uz­ to be more beneficial at red ucing insulin levels , even though there was a ing agents may be beneficial in treating PCOS. 12 The three products that s1gnif1cant reduction in fasting insulin levels in the use of rosightazone.2 currently are used in the treatment of
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