Marie-Hélène Pesant

Clinically useful predictors of conversion to abnormal glucose tolerance in women with polycystic ovary syndrome

OBJECTIVE To determine clinically useful predictors of conversion from normal to abnormal glucose tolerance (AGT) in women with polycystic ovary syndrome (PCOS) during regular follow-up, considering that optimal timing for retesting with an oral glucose tolerance test (OGTT) is unknown. DESIGN Retrospective cohort study. SETTING Reproductive endocrinology clinic of an academic center. PATIENT(S) Glucose-tolerant PCOS women having a follow-up OGTT≥1 year later. INTERVENTION(S) Regular clinical follow-up. MAIN OUTCOME MEASURE(S) Sets of criteria associated with the lowest false negative rate and an optimal specificity. RESULT(S) Out of 83 women with PCOS, 24.1% converted to AGT during a median follow-up of 3.0 years, including 3.6% who converted to diabetes. Conversion to AGT was significantly associated with glucose excursion and 2-hour glucose during the normal OGTT, increase in fasting glucose (FG) and body mass index during follow-up, and homeostasis model-assessment insulin resistance and FG at follow-up. The best predictive set of criteria was a baseline glucose excursion of >25 mg/dL or an increase in FG of ≥5%. Using these criteria would have saved 45% of the OGTTs, without missing any conversion to AGT. CONCLUSION(S) Although our results need to be validated, we determined that using glucose excursion during the previously normal OGTT in combination with another predictor (e.g., increase in FG or glycosylated hemoglobin), could greatly reduce the number of OGTTs performed in PCOS women during their regular follow-ups, with a minimal rate of missed cases.

Reference ranges for total and calculated free and bioavailable testosterone in a young healthy women population with normal menstrual cycles or using oral contraception.

OBJECTIVE Determine reference values for testosterone in women. DESIGN AND METHODS 18-40 Year-old women with regular menses or using oral contraception were assessed by questionnaire and blood sample. RESULTS In 155 women, reference values were different between women with and without hyperandrogenism for total testosterone (0.48-3.42 vs. 0.54-2.72 nmol/L) and calculated free (3-65 vs. 3-39 pmol/L) and bioavailable (0.06-1.35 vs. 0.06-0.81 nmol/L) testosterone. CONCLUSION Upper reference values for testosterone in women must be established from a well-characterized population.

Gestational Diabetes Mellitus Identification Based on Self-Monitoring of Blood Glucose

In Sherbrooke, the gestational diabetes mellitus (GDM) Regional Committee proposed GDM screening during the first trimester for all pregnant women based on a 50 g glucose challenge test (50 g GCT) followed directly by capillary self-monitoring blood glucose (SMBG) at home. We evaluated implementation of committees recommendations on the clinical trajectory of women receiving prenatal care at our institution. We analyzed data collected systematically by the Blood Sampling in Pregnancy clinic from 2008 to 2011. We evaluated the clinical trajectory of 7710 pregnant women to assess GDM screening/diagnoses and referral rates to the diabetes care centre (DCC) for education and treatment during both the first and second trimesters. The Canadian Diabetes Association glycemic treatment targets in women with GDM were used as diagnosis thresholds and DCC referral decisions: Fasting glucose of 5.3 mmol/L and postprandial 2 h glucose of 6.7 mmol/L. We found that pregnant women were 28.0±4.8 years old, and their body mass indexes were 24.5±5.5 kg/m(2). During the first trimester, 47% of women were screened for GDM, mostly (84%) using the 50 g GCT. Following SMBG, 5.7% were referred to the DCC. Only 32% of women with early GDM had >1 GDM risk factor. Thereafter, 67% of normoglycemic women screened during the first trimester were screened again during the second trimester. Among women screened during the second trimester, most screening was done using 50 g GCT, and 8.8% were referred to the DCC following SMBG. Implementation of 50 g GCT testing followed by direct home SMBG was well implemented in our area. The importance of early GDM screening and rescreening during the second trimester still needs to be emphasized.

Ovulation induction in polycystic ovary syndrome—how do metformin and clomifene citrate compare?

Ovulation induction in polycystic ovary syndrome—how do metformin and clomifene citrate compare?

Comparing rosiglitazone with ethinylestradiol/cyproterone acetate in the treatment of polycystic ovary syndrome

Recently, an important role of insulin resistance has been demonstrated in polycystic ovary syndrome. New treatment strategies have emerged from this association, as well as a will to prevent long-term metabolic complications of the syndrome, namely metabolic syndrome, Type 2 diabetes mellitus and cardiovascular disease. Rosiglitazone, a member of the thiazolidinedione family, appears to efficiently treat oligoanovulation, menstrual irregularity and hirsutism but it might not be the best treatment for acne. By comparison, ethinylestradiol/cyproterone acetate is not only better than rosiglitazone in controlling menstrual irregularity and acne but also appears to be equally effective in alleviating hirsutism, although it is inferior in restoring fertility. As for long-term complications, rosiglitazone appears to treat the metabolic syndrome and prevent insulin resistance, Type 2 diabetes and cardiovascular disease, while no similar benefit is expected with ethinlyestradiol/cyproterone acetate. Both treatmen...

CSII: Longer Catheter Usage Time, a Reasonable Goal.

Continuous subcutaneous insulin infusions systems (CSII) are commonly used by patients with type 1 diabetes (T1D). A catheter (KT) allows transfer of insulin from the reservoir to the subcutaneous tissue. In clinical practice, KT are replaced every 2 or 3 days. This avoids skin irritation and other adverse events (AEs), including increases in mean blood glucose levels with longer usage. Historically, this commonly held assumption has been that the trade-off is worth it. Pfützner et al recently reported a study on 22 adult T1D patients, all chronic users of CSII. The 6-month randomized crossover (2 x 3-month) study was conducted prospectively, in a real-world setting. Investigators assessed tolerability of 2-day and 4-day use. The number of KT-related AEs, treatmentrelated AEs, and other various AEs were significantly higher with 4-day use. With 2-day use, HbA1c improved (7.4 ± 1.2 vs 7.6 ± 1.2%, P < .05) and patient treatment satisfaction was higher. According to the authors, these data support the 2to 3-day replacement recommendation; authors also expressed doubts on the economic benefits of longer KT wear. It seems to us that the Pfützner study data can be interpreted differently. In this type of study, AE frequency is the main issue. However, AE categories were poorly defined, and questionnaires used to record AEs were not validated. The alarming total number of AEs (n = 2664) in addition to hyperglycemia (n = 615) and hypoglycemia (n = 888) implies that CSII is an uneasy method, complicated on average by 1 AE daily. This unexpected deduction contradicts the overall treatment satisfaction reported by participants but is in line with a recent report pointing that AEs related to CSII and especially to KT usage are inappropriately assessed. Clarity of such studies would be increased if key numbers such as number of participants reporting AEs, KT used, KT changes, frequency of glycemia testing, real failure rate, and so on were reported in standardized fashion. Satisfaction scores (2.1 ± 0.6 vs 2.3 ± 0.6, P < .05) were lower with 4-day use. However, it is doubtful that this statistical difference translates into clinically measurable outcome. This is particularly so because scores were ranked on the positive side of the spectrum, that is, from 1 (very satisfied) to 6 (not at all satisfied). Finally, the cost-benefit of changing KT every 2 to 3 days or less frequently was not assessed and would require longer and larger trials. Pfützner et al emphasize 2-day use. An important drawback of frequent KT replacement is the expense incurred by patients and health care systems. The 2 to 3-day replacement regimen however is not an evidence-based practice, with most reports in the scientific literature, including the Pfützner study, emanating from manufacturers themselves. Continuous glucose monitoring systems (CGMs) are transitioning from 7-day to 14-day wear. In our opinion, research should attempt to reduce the number of KT-related issues and extend the life of infusion sets in order to match CGMs life. Combining CGMs, algorithm, and insulin delivery system would reduce the number of required sites and be extremely convenient for awaited automated closed-loop insulin delivery.

Polycystic Ovary Syndrome and Metabolic Syndrome

The polycystic ovary syndrome (PCOS) is a very common disorder with important short-term and long-term cardiometabolic consequences. Indeed, affected women manifest many clinical and biochemical features of the metabolic syndrome, putting them at increased risks for diabetes and other cardiometabolic comorbidities. In the past 30 years, the key role of insulin resistance in the pathogenesis of PCOS has been stressed and this common etiology between the two syndromes might account for their similarities. In fact, PCOS is considered a consequence of insulin resistance in the same way as the metabolic syndrome, and women at risk for PCOS are also subject to the development of the metabolic syndrome. Thus, this chapter will explore the relationships between the metabolic syndrome and PCOS.