Hyperinsulinemia has proved to be a key link in the generation of the symptoms of PCOS, Anovulatory infertility is it is very common manifestation

The skin stigmata are induced by hyperandrogenism. Most women with polycystic ovaries tend lo be profoundly insulin resistant and the resultant hyperinsulinmia exacerbates the reproductive abnormalities. Regression of these symptoms may be achieved by reducing the hyperinsulinmia. As obesity exaggerates the expression of the symptoms induced by hyperinsulinmia,a low calorie diet and lifestyle change resulting in loss of weight for obese women with PCOS Is capable of reversing these symptoms.

PCOS is a multiorgan disorder and can give rise to long-term potential hearth risks. Endometrial cancer remains one of the most serious potential complications for women with polycystic ovarian syndrome tf neglected.lt is postulated to he about 20 to 30 per cent common in the general population safer from PCOS. Drugs that ameliorate insulin resistance and reduce circulating insulin levels could provide a new therapeutic modality for PCOS.

Diagnosis
As per the findings of the latest researches, the syndrome of PCOS could surface either in the form of ultraound appearance of polycystic ovaries, menstrual disturbances or in the evidence of
hyperandrogenism, acne, hirsuit ism, etc,after other causes of hyperandrogenism have been ruled out, especially congenital adrenal hyperplasia.lt is important to remember that, 40 per cent of women with oligomenorrhea, 85 per cent of women with hirsuitism and 100 percent of women presenting with severe acne have PCOS as their etiology. Skin complications can be in the form of acne, cystic acne on face, neck, back shoulders and hirsutism with excessive hair on face, body, upper lip, chin, neck, abdomen, thinning of the head hair or male pattern balding. There is a cant hosts nigricans, which isa discoloration or darkening of skin around neck, groin, under arms, skin folds or skin tags. The incidence of impaired glucose tolerance amongst PCO subjects is 35 to 45 per cent. About 7 to 10 per cent of them will have Type II diabetes mellitus. A fasting glucose to fasting insulin ratio less than 4.5 is predictive of insulin resistance.

Management
The gold standard for Improving insulin sensitivity in obese PCOS should be weight loss, by diet and exercise. Obesity is associated with central fat accumulation and an increased waist to hip ratio (WHR). Over SO per cent PCOS are obese. An increasing BMI co-related with increase incidence of hirsuitism, cycle disturbances and infertility. Weight loss, as little as 5 per cent of the body weight alone can improve the fundamental aspects of the endocrine system of PCOS and result in low circulating androgen levels and spontaneous resumption of menses.

The first line of treatment is still clomephene citrate (CC] in patients with PCOS and infertility. However, about 20 to JO percent of patients will be resistant to CC therapy.lt Is important to identify women who are clomephene resistant and those who are clomephene failure.

Diet and exercise followed by clomiphene citrate should be used for non-surgical ovulation induction. For clomiphene-resistant PCOS women, metformin may be included in a step wise approach before a surgical approach. La para sco pic ovarian drilling can be considered as an option in certain patients before gonadotropin therapy. Use of insulin sensitizers Like metformin in PCOS is now gold standard specially in adolescent girls with menstrual problem and those coming with problem of i nferti I rty. La pa roscopic ovarian drilling (LOD) is used as second llnetreatment after patients have proved resistant to metformin plus clomiphene or as a third line treatment after failed ovulation induction with gonadotropins.

La pa roscopic ovarian drilling is a relatively simple procedure performed by minimal access surgery and usually on day care basis

Conclusion

The reduced rate of ovulation is directly associated with hyperinsulinmia and hence the initial focus in treatment should be on control of insulin secretion and control of weight by diet and exercise. Insulin sensitizers do play an important role in the management of PCOS.