Scant outcome data on metformin in PCOS teens; expert opinion.(Gynecology)
OB/GYN News, Oct 1, 2003, by Timothy F. Kirn
SEATTLE — Physicians may have become too eager to add metformin reflexively to treatment of adolescent patients with polycystic ovary syndrome, Dr. S. Jean Emans said at the annual meeting of the Society for Adolescent Medicine.
“I don’t think we are there yet in terms of good clinical outcome data,” said Dr. Emans, chief of adolescent medicine at Children’s Hospital, Boston.
Metformin has been shown to decrease levels of luteinizing hormone, androstenedione, and testosterone in patients with polycystic ovary syndrome (PCOS) in a randomized trial. In a study of 15 obese adolescents with PCOS published last year, metformin proved that it could better their glucose tolerance and insulin sensitivity, as well as decrease serum androgens. In trials of diabetic adolescents, metformin has produced some weight loss. However, “the studies are clearly short term. There are long-term risks and benefits that have not been defined,” she said.
Regarding the two features of PCOS that tend to most bother adolescents, hirsutism and weight, metformin is not necessarily the first choice for treatment, she said. Metformin’s impact on hirsutism is variable. The first alternative for hirsutism should be a cosmetic procedure such as laser removal or topical treatment with eflornithine.
In type 2 diabetic patients and individuals with insulin resistance at risk for diabetes, diet and lifestyle have more evidence supporting their effectiveness at reducing weight to improve insulin sensitivity.
In one study that has perhaps been influential in initiating the popularity of metformin in PCOS, 9 of 11 subjects lost weight over 10 months, between 5 and 11 pounds, while receiving metformin treatment (1.5-2.55 g/day). However, in that study, the patients were put on a diet as well. The diet may have contributed to the weight loss as much as–or more than–the drug, she noted. “Weight loss is critical and does not necessarily occur be cause of the metformin,” Dr. Emans said.
The patients for whom metformin would be appropriate are only those with demonstrated glucose intolerance. The patients she would test for glucose intolerance would be those who are obese and those with acanthosis nigricans, which is a common sign in PCOS patients. She would recommend using not only a fasting glucose test, but a fasting insulin test, and a 2-hour glucose challenge test.
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