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Women with polycystic ovarian syndrome (PCOS) are at a higher risk for insulin resistance, which often progresses to overt type 2 diabetes. Leading expert Andrea E. Dunaif, MD, chief of the Hilda and J. Lester Gabrilove Division of Endocrinology, Diabetes, and Bone Disease at Icahn School of Medicine at Mount Sinai in New York City, explains when, how and exactly who should be treated for insulin resistance after a diagnosis of PCOS.

Following is a transcript of her remarks:

Women with PCOS should be treated for insulin resistance if they have clinical signs of deterioration in either glucose homeostasis, so if they have impaired glucose tolerances, the most common condition we see in women with PCOS, that is they have mainly difficulty with a postprandial glucose load. Fasting hyperglycemia or fasting impaired glucose is a very late sign in PCOS. The corollary of that is when we test women for abnormalities of glucose homeostasis, we have to do the 2-hour glucose tolerance test. We can't rely just on the fasting glucose or the hemoglobin A1c's, which aren't that sensitive either. We would do the screening test -- the 2-hour glucose tolerance -- and then if the 2-hour glucose was 140 or greater, that would be impaired glucose tolerance. If it's greater than 200, that's type 2 diabetes. That would be one indication for treatment with something like metformin, in particular, because we know that treating people with impaired glucose tolerance can reduce the risk of progression to type 2 diabetes.

The other places where we would consider treating for "insulin resistance" is if there are other features of the insulin resistance or metabolic syndrome, and those would be low HDL levels less than 50, high triglyceride levels greater than 150, slight elevations in blood pressure, or increased central fat.

In PCOS, the data on metformin reversing metabolic syndrome really isn't there, so we're kind of extrapolating from the diabetes prevention program where it showed that treatment with metformin could reverse metabolic syndrome in people who already had it and could prevent the development of metabolic syndrome. We don't have that data for PCOS, nor do we have the data that treating the impaired glucose tolerance will prevent diabetes. But based on what we know about other conditions of insulin resistance and diabetes risk, we assume that women with PCOS will respond the same way.

If a woman has PCOS, you've made the diagnosis, there are no data that every woman with PCOS should be treated for insulin resistance. You really need to see if there are any additional clinical features of the insulin resistance syndrome. Just giving everybody insulin-sensitizing drugs, there's no data to support that.

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