A modern medical quandary: Polycystic ovary syndrome, insulin resistance, and oral contraceptive pills

Recognition that insulin resistance plays a major role in the pathophysiology of PCOS has led to the novel application of insulin-sensitizing drugs as a treatment option for the disorder. Less appreciated, however, is the high risk for type 2 diabetes and perhaps cardiovascular disease associated with insulin resistance, and the important implications this may have for chronic treatment of PCOS. OCPs are the traditional therapy for the chronic treatment of PCOS, and they are recognized to exert a number of beneficial effects. Their use cannot be dismissed lightly. Nonetheless, limited evidence raises the issue that OCPs may aggravate insulin resistance and exert other untoward metabolic actions that possibly enhance the long-term risk for diabetes and heart disease. This important clinical issue has received relatively scant attention from clinical investigators and remains unsettled. This report is as much a call for additional studies, critical and controlled, as for judicious caution. In the interim, it is prudent at the time of treatment to assess an individual woman with PCOS for risk factors for diabetes (e.g. positive family history, history of gestational diabetes, high-risk ethnic group) and heart disease (e.g. dyslipidemia, positive family history, elevated homocystine). This may help determine the relative risk to benefit ratio of OCP therapy and allow the clinician to tailor therapy to the individual. For clinical investigators, the challenge now is to critically explore the immediate and long-term metabolic effects of both OCPs and insulin-sensitizing drugs in PCOS, so that clinicians may treat this prevalent disorder with confidence.