Insulin resistance (IR) is a dominant feature in polycystic ovary syndrome (PCOS). The author could treat more patients of comparable effect on hyperandrogenic symptoms with metformin than with the contraceptive pill because of less contraindication and side effects. Since 2004, combining metformin with lifestyle modification, he has observed also reduction in BMI and waist-to-hip circumference ratio (WH). Guidelines recommend different treatment options according to the phenotype and main complaint of the patient. The author questions the validity of this concept. 25 hyperandrogenic PCOS patients diagnosed using the Rotterdam criteria (age 1948; mean, 26 years) were treated uniformly with metformin 500 mg tablet three times daily, low glycaemic index diet (hypocaloric in the overweight), and increased physical activity for 12 months. Global Acne (A) and Ferriman-Gallwey hirsutism (H) scores, BMI, WH, and menstrual regularity were recorded every three month. In another group of 26 women who wanted to conceive (age 2336, mean, 29 years), pregnancies and outcome were followed during treatment. By 12 months, significant mean decrease of A was 55%, H 32%, BMI 6% and WH 3%. Menstrual irregularity of 13/25 normalized in 9 (69%). Among 26 women desiring pregnancy, 24 conceived (89%) between 1st and 27th months of treatment; mean 9 months, modus 6.5. In 21 singleton pregnancies followed up till the end, 4 early pregnancy losses (19%) and 17 live births (81%) occurred; including 13 women with previous unsuccessful infertility treatment: eight singleton pregnancies, five live births (38%). Based on these observations, the author argues against the guidelines. The Rotterdam criteria increased the prevalence of PCOS by adding a group without hyperandrogenism, having lower IR. This distorts the efficacy of metformin if used in PCOS patients without hyperandrogenism. Treating select symptoms is not pathogenesis-oriented, and does not improve the other existing symptoms of the patient. Phenotype and main complaint change by time. There are no recommendations on the length of treatment; infertility studies restricted to six cycles are unable to reveal the real efficacy of metformin on infertility. If the combined treatment fails to improve a symptom with satisfaction, additional treatment can be added. In contrast to any other first choice drug recommended in the guidelines, metformin is cheaper, has a far better safety record and less contraindication, without time limit. The author recommends the early start and calm, long-lasting treatment with healthy lifestyle and metformin for all hyperandrogenic PCOS women.
18 - 21 May 2019
European Society of Endocrinology