Metabolic syndrome is significant for our patient for several reasons. As we have noted, the syndrome is associated with a higher risk of cardiovascular disease. Those patients who have metabolic syndrome tend to develop coronary atherosclerosis at a higher rate than those who have coronary risk factors alone. Obesity increases the risk of metabolic syndrome but so does pre-obesity, or BMI ranging from 25-30. Women who have been diagnosed with polycystic ovarian syndrome are noted to be at increased risk of hypertension, dylipidemia, insulin resistance, impaired glucose tolerance and Type II diabetes. Because of all these comorbidities, women with PCOS also tend to be at greater risk for patients with subclinical carotid atherosclerosis, especially in the premenopausal population (Talbot, et al., 2000). For these same reasons, women diagnosed with PCOS have a 5 fold increased risk for the development of complications of coronary and cerebrovascular atherosclerosis.
Mrs. Stiller has many concerns regarding her diagnosis, not the least of which is her ability to become pregnant. Metformin would be the drug of choice for her condition. Metformin works by decreasing intestinal glucose absorption, decreasing peripheral glucose uptake and has also been noted to induce ovulation. There is a greater risk of spontaneous abortion in patients with hypeinsulinemia, thought to be due to the effect of elevated insulin levels on endometrial function and the uterine environment. Patients who have PCOS and use metformin have shown a slightly decreased risk of miscarriage in two small scale studies (McCarthy et al., 2004; Ben-Haroush a, Yogev Y, Fisch B, 2004) but it should be noted that the drug is category B. And that there is little evidence to support the use of metformin for this purpose.
With metabolic...
Stiller is at a higher risk of development of
diabetes in pregnancy. We have also noted that the higher levels of insulin may make maintaining a
pregnancy more difficult. Hypertension can also increase Mrs. Stiller's chance of spontaneous abortion. It is also more common for women with metabolic syndrome to develop diabetes by their 4th decade. If Mrs. Stiller plans pregnancy, it would be best that she attempt to normalize as many elements as she can before becoming pregnant. Modest weight loss, even at 5% of total body weight, will result in significant improvement in both hyperandrogenism and ovulatory function, even in women with normal ovulatory function. The changes that Mrs. Stiller makes will have a positive effect not only on her health but on the health of her baby. Should Mrs. Stiller lose weight, it is likely to have a positive effect on her lipid profile as well as her
blood pressure.
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Wilson PW. (2004) Estimating cardiovascular disease risk and the metabolic syndrome: a Framingham view. Endocrinol Metab Clin N. Am. 33:467-81
Talbott EO, Guzick DS, Sutton-Tyrrell K, McHugh-Pemu KP, Zborowski JV, Remsberg KE, et al. (2002) Evidence for association between polycystic ovary syndrome and premature carotid atherosclerosis in middle-aged women. Arterioscler Thromb Vasc Biol 30:2414-21
McCarthy EA, Walker SP, McLachlan K, Boyle J, Permezel M. (2004) Metformin in obstetric and gynecologic practice: a review. Obstet Gynecol Surv 59:118-127.
Ben-Haroush a, Yogev Y, Fisch B. (2004) Insulin resistance and metformin in polycystic ovary syndrome. Eur J. Obstet Gynecol.115:125-133.
