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Polycystic ovarian syndrome (PCOS) is a condition
characterized by irregular or absent menstrual cycles due to anovulation,
and excess androgens (male hormones) that may lead to excess body
hair.
The ovaries of PCOS patients are typically covered
with numerous small follicles (cysts that contain eggs), which
are "leftover" follicles from previous cycles. Many
PCOS patients are overweight and usually find it very difficult
to effectively diet. However, PCOS also commonly occurs in thin
women.
PCOS patients usually have elevated insulin levels
(hyperinsulinemia) due to a condition known as insulin resistance.
Although there is no universally agreed upon definition of insulin
resistance, this is a condition that occurs because the insulin
receptors that are found in all cells of the body are resistant
to the hormone insulin, meaning that the insulin doesn't function
as efficiently as it should. The body then tries to compensate
for this by secreting extra insulin that leads to elevated levels
of insulin.
Hyperinsulinemia causes the ovaries to "over
produce" androgens leading to the classic symptoms of the
syndrome. Chronically elevated insulin levels may also increase
the long term health risk for diabetes.
Metformin belongs to a class of drugs known as "insulin
sensitizing" agents and is routinely used to treat diabetes.
It improves the "effectiveness" of insulin while maintaining,
or decreasing, insulin levels. Once insulin levels are lowered,
the corresponding production of androgens by the ovary decreases.
Once the androgen levels are normalized, natural ovulation will
 often resume.
Although metformin is FDA-approved for diabetes,
usage for women with PCOS is considered an off-label indication.
Numerous studies have been published that support the use of metformin
for women with PCOS. Most studies to date have evaluated metformin
usage in overweight women with PCOS, although a few studies have
supported the use for thin women with PCOS as well.
Women with PCOS have an increased risk of having
a miscarriage, so this incidence of miscarriage has been studied
as well. Metformin use may lower the incidence of miscarriage among women with PCOS. Metformin alone has been shown to induce
ovulation and even pregnancy in women with PCOS. Perhaps 25% of
women without any other causes of infertility conceive with metformin
use alone.
PCOS patients who have failed to ovulate with Clomid may ovulate with a combination of Clomid and metformin. PCOS patients
are often managed by a reproductive endocrinologist fertility specialist due to the
complexity of the condition and variable responses to medications.
PCOS patients often have exaggerated responses to treatment with
FSH.
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