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Evidence summaries

Lifestyle Changes in Women with Polycystic Ovary Syndrome

Intensive diet and exercise are effective in prevention of type 2 diabetes mellitus in persons at increased risk compared to placebo or no intervention. The reduction in incidence is up to 50 percent.Level of evidence: "A"

Exercise and intensive diet are recommended over metformin for all persons at increased risk of type 2 diabetes.

The recommendation attaches a relatively high value on the many beneficial effects of the diet used in the studies as well as exercise on other outcomes in addition to diabetes prevention, and the lack of significant adverse effects of these interventions, and on avoiding pharmacological treatment when an equally effective and safe lifestyle intervention is available.

A Cochrane review [Abstract] 2 included 20 studies with a total of 6774 subjects. The DPPO study contributed 48% of all participants. Comparing metformin with diet and exercise with or without placebo, incidence of type 2 diabetes mellitus (T2DM) was significantly lower (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 12 trials, n=3632). Comparing metformin with intensive diet and exercise, incidence of T2DM was similar (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 7 trials, n=2960), though there was a trend favouring metformin. In 3 RCTs comparing metformin plus intensive diet and exercise with identical intensive diet and exercise incidence of T2DM was similar (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; n=332). There were no differences in all-cause or cardiovascular mortality, non-fatal myocardial infarction or stroke, probably the follow-up was too short. Serious adverse events were poorly reported.

In part of the Diabetes Prevention Program (DPP) 3 women with impaired glucose tolerance (350 with prior GDM and 1416 without GDM) were randomized to either standard lifestyle and placebo (n=122, placebo group) or standard lifestyle and metformn 850mg bid. (n=111, metformin group), or to an intensive lifestyle intervention (n=117, ILS group). Whereas entering the study with similar glucose levels, women with a history of GDM randomized to placebo had a crude incidence rate of diabetes 71% higher than that of women without such a history. Among women reporting a history of GDM, both intensive lifestyle and metformin therapy reduced the incidence of diabetes by approximately 50% compared with the placebo group.

The DPPO study 4 examined the effect of lifestyle intervention and metformin on preventing or delaying diabetes in women. A lifestyle-modification program (goals: at least a 7% weight loss and at least 150 minutes of physical activity per week) was compared with metformin (850 mg twice daily) and with placebo. The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively. The lifestyle intervention reduced the incidence by 58% (95% CI, 48 to 66%) and metformin by 31% (95% CI, 17 to 43%), as compared with placebo; the lifestyle intervention was significantly more effective than metformin. To prevent one case of diabetes during a period of three years, 6.9 persons would have to participate in the lifestyle-intervention program, and 13.9 would have to receive metformin. All 3 groups were offered group-implemented lifestyle intervention. Metformin treatment was continued in the original metformin group. During the 10-year follow-up, the original lifestyle group lost, then partly regained weight. The modest weight loss with metformin was maintained. Diabetes incidence rates in this follow-up study were similar between treatment groups: 5.9 per 100 person-years (5.1-6.8) for lifestyle, 4.9 (4.2-5.7) for metformin, and 5.6 (4.8-6.5) for placebo. Diabetes incidence in the 10 years since randomisation was reduced by 34% (24-42) in the lifestyle group and 18% (7-28) in the metformin group compared with placebo.

In 15-year follow-up of DPP-study 5 the subgroups that benefited most were assessed. During the DPP adults at high risk were randomly assigned to masked placebo (n=1082) or metformin 850 mg twice daily (n=1073). Participants originally assigned to metformin continued to receive metformin unmasked. Metformin reduced the incidence (by hazard ratio [HR]) of diabetes compared to placebo by 17% or 36% based on glucose tolerance test or HbA1c levels, respectively. Metformin's effect was greater for women with a history of prior GDM (HR 0.59, rate differences -4.57 cases/100 person-years) compared with parous women without GDM (HR 0.94, rate difference -0.38 cases/100 person-years [interaction P = 0.03 for HR, P = 0.01 for rate difference]). Metformin also had greater effects at higher baseline fasting glucose levels.

A meta-analysis of observational studies 6 included 23 studies (319 780 participants; 60 336 PCOS and 8847 T2DM cases). Women with PCOS demonstrated a higher risk of T2DM than those without PCOS (RR 3.45, 95% CI 2.95 to 4.05). The RR for developing T2DM in obese and non-obese PCOS women compared with their non-PCOS counterparts was 3.24 (95% CI 2.25 to 4.65) and 1.62 (95% CI 0.14 to 18.50), respectively. The RR for developing T2DM was 3.85 (95% CI 1.99 to 7.43) in obese compared with non-obese women with PCOS.

A Cochrane review [Abstract] 1 included 15 studies with a total of 498 subjects. 10 studies compared physical activity to minimal dietary and behavioural advice or no advice. 5 studies compared combined dietary, exercise and behavioural interventions to minimal intervention. Intervention provided benefits when compared to minimal treatment for total testosterone (MD -0.27 nmol/L, 95% CI -0.46 to -0.09; 5 trials, n=144), hirsutism by the Ferriman-Gallwey score (MD -1.19, 95% CI -2.35 to -0.03; 4 trials, n=132), weight (MD -1.68, 95% CI -2.66 to -0.70 kg; 9 trials, n=353), body mass index (MD -0.34, 95% CI -0.68 to -0.01 kg/m2; 12 trials, n=434) , and free androgen index.

    References

    • Lim SS, Hutchison SK, Van Ryswyk E et al. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2019;(3):CD007506. [PubMed]
    • Madsen KS, Chi Y, Metzendorf MI et al. Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus. Cochrane Database Syst Rev 2019;(12):CD008558. [PubMed]
    • Ratner RE, Christophi CA, Metzger BE et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab 2008;93(12):4774-9.[PubMed]
    • Aroda VR, Christophi CA, Edelstein SL et al. The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up. J Clin Endocrinol Metab 2015;100(4):1646-53. [PubMed]
    • Diabetes Prevention Program Research Group.. Long-term Effects of Metformin on Diabetes Prevention: Identification of Subgroups That Benefited Most in the Diabetes Prevention Program and Diabetes Prevention Program Outcomes Study. Diabetes Care 2019;42(4):601-608.[PubMed]
    • Anagnostis P, Paparodis RD, Bosdou JK et al. Risk of type 2 diabetes mellitus in polycystic ovary syndrome is associated with obesity: a meta-analysis of observational studies. Endocrine 2021;74(2):245-253. [PubMed]

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