Pcos Is Defined As Hyper Androgenic Chronic Anovulation Biology Essay

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PCOS is defined as hyper androgenic chronic anovulation and accordingly women with PCOS have the symptoms of irregular menstrual cycles, hyperandrogenism, and polycystic enlarged ovaries. PCOS is a heterogeneous metabolic disorder affecting 4 to 10% of reproductive age women (1). The incidence of PCOS varies according to the diagnostic criteria employed. Polycystic ovaries (PCO) on ultrasound are noted in up to 25%-30% of reproductive aged women (2,3) and the vast majority of women with PCO do not have the syndrome. Women with unexplained hyper androgenic, chronic anovulation (i.e. NIH criteria) make up approximately 7% of reproductive age women (4) while as the Rotterdam criterion being broader in view inclusion of sonographic evidence of cysts in the ovary increases the prevalence by 50% over the NIH criteria (5). The prevalence according to the Androgen Excess Society (AES) criteria is somewhere in between. There are no systematic prevalence studies from our country however, the condition seems to be very common than west and it seems to be on rise in our population. Women with PCOS usually present with symptoms of irregular menstrual cycles, acne, hirsutism, hyperandrogenism, obesity and enlarged PCO (6). Women with PCOS show multiple abnormalities in insulin action. Dynamic studies of insulin action, including hyperinsulinemic euglycemic clamps and frequently sampled intravenous glucose tolerance tests have shown that women with PCOS are more insulin resistant than weight matched control women, a defect primarily present in skeletal muscle (7). As obesity increases its prevalence or exaggerates its phenotype, the epidemic of obesity is accompanied by a parallel increase in PCOS prevalence. In 1935 Stein and Leventhal described PCOS as a syndrome characterized by obesity, hirsutism and infertility but now the definition of PCOS is controversial at best and task of making a positive diagnosis is difficult, thus hampering its scientific evaluation (8,9).

Insulin resistance has been associated with an increased incidence of CVD as atherosclerosis is now considered to be an inflammatory disorder (10,11). Insulin resistance has recently been associated with increased levels of inflammatory mediators in the blood (12,13). Studies have therefore been conducted to look at inflammation in PCOS. TNF-α has been shown to play an important role in initiation of inflammation (14). The TNF-α signaling pathway is mediated by nuclear factor kappa B (NF-KB) and is responsible for the expression of adhesion molecules such as soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble Intercellular adhesion molecule-1 (sICAM-1) in the endothelium (15). Gonzelez et al noted increased levels of TNF-α, the cytokine which causes insulin resistance and is secreted by the adipose tissue in PCOS women as compared to controls (16).

As is generally accepted that atherosclerosis is an inflammatory disease, the initiating factor is considered to be endothelial dysfunction (17,18). This is followed by inflammatory cell infiltration and lipid accumulation; which in turn stimulate vascular smooth muscle cell proliferation, migration and extra-cellular matrix production. Normally, the vascular endothelium resists the binding of leucocytes, presenting a barrier to their infiltration into the sub-endothelial layer. However, a variety of stimuli may impair endothelial function, rendering it susceptible to leucocyte adhesion, and potentially initiating atherogenesis. Similar processes are also implicated in the acute manifestations of atherosclerosis (19). The predominant mechanism in the pathogenesis of the acute coronary syndromes is atherosclerotic plaque rupture. Histological evidence confirms that this is characterized by infiltration of leucocytes. These release proteolytic enzymes that weaken the extracellular matrix destabilizing the plaque, and increasing the risk of exposure of its thrombogenic sub endothelial matrix and lipid core. Endothelial erosion, a less common but important cause of unstable atherosclerotic disease, particularly in younger patients, is also associated with dysfunction and destruction of endothelial cells (20). Once again the adhesion of leucocytes is a fundamental component of this process. The binding of leucocytes to vascular endothelium is mediated by a variety of cell surface adhesion receptors-principally the selectins and integrins. The selectins are the initiators of adherence, but the binding they induce is weak, allowing leucocytes to roll along the vessel wall. This contact enables leucocyte and endothelial integrins to interact, permitting the more secure binding that precedes spreading and infiltration. The main endothelial integrin receptors are sVCAM-1 and sICAM-1, which bind to leucocyte β 1 (α4β1) and β2 (αLβ 2 and αMβ 2) integrins, respectively. Normal vascular endothelium expresses little or no sVCAM-1 or sICAM-1. They are, however, induced by endothelial dysfunction, suggesting that they may represent biological 'markers' of atherosclerosis and might predict an increased risk of its acute manifestations. Certainly, focal endothelial sVCAM-1 and sICAM-1 have been demonstrated overlying areas of early atherogenesis (21,22) and within atherosclerotic plaques (23-25). Several data support the hypothesis that soluble cell adhesion molecule levels may reflect the extent of atherosclerotic disease. Patients with CVD or peripheral vascular disease have higher levels of sICAM-1 than healthy controls (26). Likewise, several large epidemiological studies have demonstrated that apparently healthy subjects with elevated levels of sICAM-1 are at increased risk of developing overt coronary artery disease (CAD), peripheral vascular disease, carotid atherosclerosis and stroke (27-32). As Rizzoni and colleagues report, many risk factors for atherosclerosis, including diabetes and hypertension, are generally (though not always) associated with increased levels of sICAM-1 and sVCAM-1 (33-40). It is unclear whether the observed elevations are because of direct effects or to subclinical atherosclerosis. Certainly, elevated levels of both sICAM-1 and sVCAM-1 have been documented in patients with essential hypertension without overt atherosclerotic disease (36) although in this cohort of elderly (mean age 69 years) hypertensive men, it seems likely that some would have in apparent disease. The data from Rizzoni et al (33) showing significant elevations of sICAM-1 and sVCAM-1 in patients with hypertension and normal intima-media thickness, do, however, suggest that hypertension may play a direct role. In PCOS, significantly higher levels of sICAM-1 than in healthy women were found. sICAM-1 levels were correlated with body composition, lipids and insulin secretion, but not with insulin resistance (41).

The underlying etiology of PCOS remaining elusive, most of the therapeutic approaches in the past would focus on inhibiting or decreasing androgen production by various modalities {ovarian wedge resection, laproscopic ovarian drilling, LHRH (leutinizing hormone releasing hormone) analogues, aromatase inhibitors, estrogen-progesterone combinations, or anti-androgens} (42-48). The antiandrogen, spironolactone, a steroid chemically related to mineral corticoid, aldosterone is used as a diuretic as well as antiandrogen (49,50). Dual blockade by spironolactone anti-androgen and synthesis inhibitor (51,52), makes it suitable for long term treatment of hyperandrogenism (primarily hirsutism) and an-ovulation (53-57). Although the experience of spironolactone in PCOS is limited, it has a good safety record when used in smaller doses (56-61). The drug has been used as a sole agent, in combination or in head to head comparison with other agents (53, 56, 61, 62). Treatment of PCOS by insulin sensitizers, like thiazolidinediones and metformin has generated significant interest in recent years, keeping in view the fundamental pathogenic factor of insulin resistance. Metformin has also been shown to directly inhibit human thecal cell androgen synthesis, suggesting an insulin independent mechanism (62-65). Many publications have demonstrated the efficacy of metformin in improving menstrual cyclicity, metabolic parameters, ovulation, cervical scores, and pregnancy outcomes both spontaneous and assisted (66-83). Among many met analysis using metformin the results were favourable (84-86). In the recent meta-analysis of 27 trials using metformin involving 2150 women authors concluded that although metformin does not improve live birth rate but improves clinical pregnancy and ovulation rates (87). Other insulin sensitizers alone in combination with anti-androgens have been used with variable success (88-91).

In the chronic treatment of PCOS, OCP's are commonly used to induce regular menstrual cycle, protect the endometrium and ameliorate androgenic symptoms. OCP's typically contain the estrogen component (ethinyl estradiol) or its precursor mestranol which is metabolized into ethinyl estradiol and a progestin component which is variable according to the preparation (92). Estrogen component (ethinyl estradiol) of OCP's has a role in suppression of FSH, stabilization of endometrium, potentiation of progestin action, suppression of dominant follicle formation, increase in sex hormone binding globulin (SHBG) and decrease in free androgen (93). Progestin component has a role in suppression of LH, inhibition of LH surge, unreceptive endometrium, hostile cervical mucus, decrease in ovarian androgen secretion and androgen blocking effect (94).

The OCP's are categorized according to when they were approved or introduced as follows:

First generation; Norethindrone, Norethindrone acetate.

Second generation;

Norgestrel, Levonorgestrel, Ethynodiol diacetate.

Third generation;

Norgestimate, Desogestrel.



Dienogest (95) (shown in table1 )

PCOS women treated with OCP's have a lower incidence of ovarian cysts, and ovarian volume decreases with their use (96,97). OCP's decrease the body's production of androgens, which can reduce and slow hair growth and acne (98,99). Although there are some positive benefits of OCP use in women with PCOS, some of the disadvantages may contribute to the worsening of the disease process, which include increase in insulin resistance, blood coagulation, total cholesterol, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol levels and triglycerides (TG) with no change of the total cholesterol/HDL cholesterol and LDL cholesterol/HDL cholesterol ratios (100-105). OCP's increase the risk of venous thrombo embolism including deep vein thrombosis (DVT) and pulmonary embolism (PE),risk of first ischemic stroke and current use significantly increases the risk of cardio-vascular disease among those at high risk (106-108). Women taking third generation OCP's had significantly higher C-reactive protein, fibrinogen, plasma viscosity, and HDL-cholesterol concentrations compared to non-users. Potentially harmful effects of OCP's may arise from their positive association with the acute phase response. There is a close relationship with inflammatory markers in particular in women taking third generation OCP's, which may, at least in part, contribute to the increased atherothrombotic risk, reported specifically in these women (109). Therefore pro-inflammatory state and a prothrombic / pro-coagulant state are individually a cause of concern in PCOS women using OCP's. Thus conventional treatment with OCP's may worsen the already existing procoagulant and proinflammatory state indicating higher cardiovascular risk in these women. In view of the above, we studied proinflammatory marker ICAM, in drug naive PCOS women and compared it with PCOS women treated with OCP's for varying duration of time. This data will help to know about the impact of OCP's on the existing CVD risk in PCOS women.

Table 1: The commercially available OCP'S in India are given in a following table:

Estrogen (µg)

Progestin (mg)

Commercial name

Ethinyl estradiol (35)

Norethindrone (1)

Orthonovum1/35,Necon 1/35

Ethinyl estradiol (35)

Norethindone (0.4)

Ovcon 35

Ethinyl estradiol (35)

Ethynodiol (1)

Demulen 1/35

Ethinyl estradiol(35)

Norgestimate (0.25)


Ethinyl estradiol ( 30)

Norethindrone (1.5)

Loestrin 21 1.5/30

Ethinyl estradiol (30)

Norgestrel (0.3)


Ethinyl estradiol(30)

Desogestrel (0.15)

Desogen, Marvelon

Ethinyl estradiol (30)

Levonorgestrel (0.15)

Levlen, Nordette

Ethinyl estradiol (30)

Gestodene (0.075)

Gynera, Minulet

Ethinyl estradiol (30)

Drosperinone (3)

Yasmin, yamini

Ethinyl estradio ( 20)

Norethindrone (1)

Loestrin 21 (1/20)

Ethinyl estradiol (20)

Levonorgestrel (0.1)

Alesse, Levlite

Ethinyl estradiol (20)

Desogestrel (0.15)

Mircette, Mercilon

Ethinyl estradiol(20)

Gestodene (0.075)

Meliane, Harmonette

Ethinyl estradiol (20)

Drosperinone (3)


Ethinyl estradiol 15

Gestodene (0.06)



The study was done as joint collaborative effort between departments of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Soura and department of Clinical Biochemistry, University of Kashmir. We studied 51 women with a confirmed diagnosis of PCOS who were drug naive (controls) and compare them with 30 PCOS women who received Estrogen and progesterone (OCP's) as treatment modality for approximate period of six months (cases). We investigated and compared clinical, anthropometric, hemodynamic, hormonal, metabolic, and proinflammatory parameter of cases and controls. Rotterdom 2003 Criteria was applied for making a positive diagnosis of PCOS. The Rotterdam criteria for the diagnosis of PCOS (2003) states 2 of the 3 features needs to be present to make the diagnosis and with the exclusion of other etiologies (congenital adrenal hyperplasia, androgen-secreting tumors, Cushing's syndrome). These features includes (1) Oligo- or anovulation (2) Clinical and/or biochemical signs of hyperandrogenism and (3) PCO (either 12 or more follicles measuring 2-9 mm in diameter, or an ovarian Volume of >10 cm3.An informed consent was obtained from all the participants and the study was approved by the Institutional Ethics Committee.


All women who qualified Rotterdam 2003 criteria for a diagnosis of PCOS were informed about the study. The first step was consent attainment. The women who gave informed consent were enrolled in the study. Once enrolled all women were interviewed to furnish a detailed account of medical facts with special reference to the menstrual history, duration and extent of hair growth, weight gain, acne etc. The details of menstrual history included age of menarche, regularity, duration, dysmenorrhea, flow and number of menstrual cycles per year. Oligomenorrhea was defined as an inter-menstrual interval of >35 days or a total of <8 menses per year and amenorrhea as absence of menstruation during last 6 months. Note was made of family history of hirsutism, infertility, menstrual disorders, diabetes mellitus or glucose intolerance, coronary artery disease and obesity at least in three generations. The subjects were randomly selected from the two categories: Cases - The women taking OCP's (estrogen + progesterone) from various genecology clinics for the treatment of Rotterdam 2003 criterion based PCOS diagnosis. The women who had been taking OCP's for a period of 24 + 2 weeks were taken as cases. Controls - The women who qualified Rotterdam 2003 criteria for diagnosis of PCOS and had not received any drug so far were taken as control group. All women underwent anthropometric assessment like measurement of height, weight, waist-hip circumference ratio, blood pressure recording, and detailed systemic examination. Hirsutism assessment was done using modified Ferriman-Gallwey score by counting nine specified body areas. A score of > 8 out of a total of 36 will be taken as significant.Acne vulgaris will be scored using a four point scale :0,no acne:1,minor acne on face only:2,moderate acne on face only:3,severe acne on face, back and or chest. Moderate to severe acne was taken as a clinical feature of hyperandrogenemia. All patients were subjected to transabdominal ultrasonography (USG) by a single observer. The USG was done to measure and to record typical features of PCOS (multiple small peripheral cysts, increased ovarian volume and thecal hyperechogenecity) and to rule out any adrenal or ovarian mass lesion.Biochemical assessment involved two hour OGTT (oral glucose tolerance test) for glucose and insulin in additions to lipids. Plasma levels of s-ICAM-1 were done to estimate severity of proinflammatory activity. Hormonal evaluation included T4, thyroid stimulating hormone (TSH), cortisol (morning), luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (PRL), 17-hydroxyprogesterone (17-OHP), and total testosterone (T). The samples for LH, FSH, T, and 17-OHP were collected on days 3-7 (early follicular phase) of spontaneous cycle or medroxyprogesterone-induced menstrual cycle in amenorrheic patients. Overnight dexamethasone suppression test, if needed, was done after taking basal samples and performing OGTT.


Radioimmunoassay (RIA) was used to analyse T4, cortisol, 17-OHP, T and Immunoradiometric assay (IRMA) for TSH, LH, FSH, PRL using commercial kits in duplicate and according to supplier protocol {Diagnostic Product Corporation (DPC); USA for LH, FSH, PRL, DIASORIN ;North western Ave for T4 , cortisol and IMMUNOTECH; France for T3, TSH and 17-OHP}. Plasma glucose (mg/dl) was measured by glucose oxidase peroxidase (GOD-POD) method {URILAB; India} Cholesterol was measured by CHOD-PAP method {DIALAB; Austria} TG was measured by GPO-PAP method {DIALAB; Austria} HDL and LDL was measured by New clearance method {RANDOX; UK} on Hitachi 912; Japan. Intra and inter-assay variations were within the limits permitted by the manufacturer. Plasma levels of s-ICAM-1 were measured using ELISA kit.


Statistical analysis was done using SPSS 11.5 software. In addition to descriptive statistics, student's t test and ANOVA was used to compare the groups. Data was presented as mean±SD. In all cases, p value < 0.05 was considered significant.


Among 51 women with PCOS without treatment (controls) and 30 women with PCOS on OCP's (cases), number of cycles/year were (9.12±3.88 vs. 9.90±3.30 P=0.358). Ferriman-Gallwey score was less in OCP treated PCOS subjects compared to drug naive (10.00±2.60 versus 12.27±4.71, P=0.017) indicating efficacy of the treatment. OCP treated PCOS patients showed increasing marginal rise in clinical parameters like weight in Kg (59.07±6.34 versus 58.57±8.52, P=0.782), waist hip ratio (0.92±0.06 versus 0.91±0.06, P=0.544) and BMI in Kg/m2 (24.07±3.42 versus 23.66±3.43, P=0.606), systolic BP (123.00±7.21 versus 122.24±6.99 mm Hg, P=0.640), diastolic BP (79.46±4.29 versus 79.37±4.62 mm Hg, P=0.928). Metabolic parameters like fasting blood glucose levels were higher in OCP treated PCOS subjects compared to drug naive PCOS subjects (88.77±10.41 versus 87.75±19.91 mg/dl, P=0.795), as was total cholesterol (186.10±44.76 versus 155.08±28.86 mg/dl, P=0.000) and LDL (118.45±45.66 versus 83.20±27.63 mg/dl, P=0.000). Serum testosterone level decreased in OCP treated PCOS subjects compared to drug naive PCOS subjects (56.05±31.81 versus 63.31±31.30 ng/ml, P=0.320). Fasting insulin levels were higher in OCP treated PCOS subjects compared to drug naive PCOS subjects (16.23±24.72 versus 12.28±11.10, P=0.326), as was HOMA-IR (3.00±4.17 versus 2.73±2.64, P=0.335) indicating worsening of insulin resistance with OCP use. Accordingly QUICKI was lower in OCP treated PCOS subjects compared to drug naive PCOS subjects (0.513±0.013 versus 0.516±0.001, P=0.449). Plasma levels of proinflammatory marker ICAM-1(ng/ml) were higher in OCP treated PCOS subjects compared to drug naive (417.03±131.62 vs. 312.41±131.65 ng/ml,P=0.001)(fig 1).

Fig 1. Showing comparison of soluble ICAM-1 in ng/ml values between cases and controls.

s-ICAM-1 showed statistically significant but positive correlation with fasting blood glucose (r=0.427,p=0.000) blood glucose one hour (r=0.350,p=0.001), blood glucose two hour (r=0.287,p=0.009),fasting insulin levels (r=0.347,p=0.001)(fig 2), HOMA-IR (r=0.405,p=0.000)(fig 3), and triglyceride (r=0.344,p=0.002) levels. ICAM showed statistically significant but negative correlation with QUICKI (r=-0.437,p=0.000) (fig 4), FACTOR VIII (r=-0.239,p=0.032) and systolic blood pressure (r=-0.248,p=0.026)

Fig 2. Graph showing correlation between ICAM-1 and fasting insulin

Fig 3. Graph showing correlation between ICAM-1 and HOMA-IR

Fig 4. Graph showing correlation between sICAM-1 and QUICKI

Table 2: Comparison of clinical, metabolic ,insulin sensitivity, hormonal and cardiovascular risk markers between drug naive PCOS subjects and OCP treated PCOS subjects.


Drug naive group (Controls) (Mean±SD) N=51

OCP group  (Cases) (Mean±SD) N=30


Mean Age (years)




Age of menarche(years)




No of cycles per year




Ferriman-Gallwey score (FG-score)












Waist-Hip ratio (WHR)




BMI (Kg/m2)




Systolic BP(mm of Hg)




Diastolic BP(mm of Hg)




Blood glucose- Fasting (mg/dl)




Blood glucose-1 hour




Blood glucose- 2hour (mg/dl)




Serum Total cholesterol (mg/dl)




Serum Triglycerides (mg/dl)




Serum HDL(mg/dl)




Serum LDL(mg/dl)




Serum insulin- Fasting (µIU/ml)




Serum insulin -1hour (µIU/ml)




Serum insulin-2hour(µIU/ml)
















Serum LH (IU/L)








Serum total testosterone (ng/dl)




s-ICAM-1 (ng/ml)





PCOS is characterized by hyper androgenic manifestation like acne, hirsutism and chronic anovulation and is associated with much metabolic derangement such as hyperlipidemia, hyperinsulinemia, insulin resistance and type 2 diabetes. Inflammation has been implicated as an important etiological factor in the development of both insulin resistance and type 2 diabetes mellitus in PCOS. For most of the clinician's first line of treatment of PCOS is OCP's. Although OCP's seem to be an efficient mode of therapy for hyper androgenic symptoms associated with PCOS but their possible negative effects on insulin metabolism, glucose metabolism, lipid metabolism, blood coagulation, and inflammation should be taken into consideration. To know this our study aimed to evaluate the proinflammatory marker ICAM levels in drug naive and OCP treated women with PCOS so as tohelp us to answer the question of safety of using OCP's as conventional treatment of PCOS and if monitoring is required to estimate the risk of CVD in PCOS women treated with OCP's.

Our results demonstrated that treatment with OCP's (E+P) is associated with significant improvement in FG score (androgenic hair growth), acne vulgaris and regularization of menstrual cycles. In agreement with our findings previous studies showed that OCP's induce predictable cyclic menses, reduce luteinizing hormone secretion and lower ovarian androgen production (110); the estrogen component increases SHBG, thus reducing free androgens (Ehrmann,2005) OCP's have been shown to reduce inflammatory acne counts by 30-60% with improvement in 50-90% of the subjects (James, 2005) (111). Besides the progestin component protects the endometrium from hyperplasia.

The present study showed statistically insignificant, small increase in anthropometric parameters like weight, BMI (Kg/m2) and waist hip ratio in PCOS women in the OCP's arm as compared to drug naive PCOS arm. Few studies evaluating body composition during OCP treatment, showed no significant change in body weight or body fat (112-114). Stachenfeld NS et al (1998) showed that OCP's can lead to significant body fluid retention (115). Our results suggest insignificant weigh gain in OCP users which shows negative effect of OCP's on body composition of PCOS women. We observed small elevation in systolic BP (mm Hg) in OCP treated PCOS group compared to drug naive patients which is in agreement with most of published studies in normotensive women (116). A review of two studies found an increase in systolic blood pressure by 7 to 8 mm Hg on average compared with systolic blood pressure in those not using OCP's (117,118). A study on 80 healthy women randomized into groups of 3 mg of drospirenone combined with a 30-, 20-, or 15-µg dose of equine estrogen (EE) found that systolic blood pressure at 6 months fell by a range of 1 to 4 mm Hg across the groups, compared with an elevation of blood pressure of 4 mm Hg in the control group of Levonorgestrel (LNG)/EEs (118). One of the studies showed newer progestins such as drospirenone produce lower blood pressure (119). One study conducted by Oelkers W. K. H.  et al, (1996) reported estrogen in very high doses, causes hypertension (120) which is in agreement with our study. Previous studies reported side effects of using OCP's, such as headache, nausea, breast tenderness, and weight gain (121-125) which were very minimal in our study.

We observed increase in total cholesterol, LDL cholesterol, and insignificant increase in triglyceride & HDL cholesterol levels with OCP's when compared to the drug naive PCOS patients. Previous studies have shown increase in total cholesterol and TG following OCP treatment which is in agreement with our study (Hennekens CH, 1979) (126). Ibanez and de Zegher (2004) showed that abnormal adipocytokines, hypertriglyceridaemia and body adiposity became worse in a group of adolescents and young women given a drospirenone pill's (127). IIana J. Halperin (2010) also reported OCP use is significantly associated with an increase in HDL-C and TG (128) as was shown by Costello et al on comparing OCP with metformin where significant increase in triglycerides in the OCP group occurred as compared to metformin in women with PCOS (129). George Mastorakos et al (2002) in a study reported combined oral contraceptives were associated with an increase of total cholesterol, LDL cholesterol, and HDL cholesterol levels and no change of the total cholesterol/HDL cholesterol and LDL cholesterol/HDL cholesterol ratios (130). All these findings suggest OCP use is associated with elevation of Coronary risk as indicated by elevation of total and LDL cholesterol. However some authors showed that there were no detrimental effects of transdermal hormone replacement therapy (HRT) on lipid profile, glucose metabolism, CRP and urine protein levels in post menopausal women with type 2 diabetes and hypertension (131).While some studies have reported OCP's ameliorate the abnormal metabolic profile of women with PCOS (132).

OGTT results showed insignificant increase in fasting plasma glucose, fasting insulin (µ IU/ml), insulin 2hr (µIU/ml), FGIR and HOMA-IR levels of PCOS patients treated with OCP's when compared to the drug naive PCOS patients. Previous studies reported that OCP's deteriorate glucose tolerance. One of the earliest prospective studies on the effect of OCP on carbohydrate metabolism in the general population was performed by Wynn and Doar (1969), they reported both oral and intravenous glucose tolerance area under the curve (AUC) deteriorated in 78 and 70% of the women respectively, and 13% developed chemical diabetes during OCP therapy. Significant elevations of plasma insulin after both oral and intravenous glucose were also observed which accelerate the rate of development of clinical diabetes and also of atherosclerosis (133). A prospective study by Rimm et al, in 1992 showed 10% greater risk of type 2 DM in past users of OCPs albeit with high-dose estrogen (134). Many authors (Korytkowski et al, 1995; Morin-Papunen et al, 2000; Cagnacci et al, 2003; Palep-Singh et al, 2004; Vrbikova et al, 2004) demonstrated deterioration in carbohydrate metabolism on using OCP's (135-139). Development of frank diabetes in OCP users was also reported by Nader et al, 1997 (140). Some studies (Falsetti and Pasinetti, 1995; Armstrong et al., 2001; Cibula et al., 2002; Elter et al., 2002; Morin-Papunen et al., 2003) reported no change in carbohydrate metabolism after OCP use (141-145). Chasen-Taber et al, 1997 showed no significant increase in risk with low-dose pills (146) and Troisi et al, 2000 showed that past and present users did not differ from never users in glucose, insulin, C-peptide and haemoglobin A1C concentrations (147). Some studies (Pasquali et al, 1999; Escobar-Morreale et al, 2000; Cagnacci et al, 2003) have shown OCP use resulted in improvement in carbohydrate metabolism (148-150). Thus, the range of studies have shown conflicting results with OCP use but majority of data on insulin resistance and glucose intolerance favours our results suggesting a negative metabolic effect of OCP's.

As expected we observed decrease in total testosterone and serum LH levels in PCOS patients treated with OCP's compared to drug naive PCOS patients. Significant decrease in FSH was also observed in PCOS patients treated with OCP's compared to drug naive PCOS patients. In agreement with our observations Ehrmann DA et al (2005) showed that estrogen component (ethinyl  estradiol) of  OCP's has a role in suppression  of FSH, stabilization of endometrium, potentiating  of progestin action, suppression of dominant follicle formation, increase in sex hormone binding globulin  and decrease in free androgen (99). Balen A et al 2001 suggested that progestin component has a role in suppression of LH, inhibition of LH surge, unreceptive endometrium, hostile cervical mucus, decrease in ovarian androgen secretion and androgen blocking effect (151). Although the effect in our study was marginal, most of times statistically insignificant, a larger number of subjects could have made the results more robust.

Insulin resistance and serum markers of inflammation, such as cytokines and adhesion molecules, are increasingly being considered as predictors of cardiovascular disease (152). The present study showed a significant increase in serum sICAM-1 levels in OCP treated PCOS patients compared to drug naive PCOS patients. The marker also showed a positive correlation with markers of metabolic dysfunction and insulin resistance in women with PCOS. Previous studies related to sICAM-1 in PCOS showed significantly higher levels of sICAM-1 in PCOS group than in healthy group (153). Another study demonstrated that endothelial dysfunction coexists and is influenced by presence of increased serum levels of inflammation and endothelial activation markers (ET-1, s-ICAM, s-VCAM, hs-CRP) in young women with PCOS (154). Although OCP group had higher concentration than non-OCP users, we didn't have a healthy control group to compare the results. Nasiek M et al (2004) showed higher concentrations of sICAM-1 in women with PCOS suggesting a higher risk for cardiovascular diseases in this group (155) the levels have been shown to correspond to higher BMI, waist hip ratio and serum testosterone levels as in our study (156). Gonzalez F  et al  (2009) demonstrated higher  IL-6, sICAM-1, CRP, PAI-1, systolic and diastolic blood pressures, triglycerides, fasting insulin, and HOMA in women with PCOS compared with weight-matched controls, and the highest levels in the obese regardless of PCOS status (157). Our Study also revealed highly significant correlation between ICAM-1 and fasting plasma glucose, post glucose load plasma glucose and novel markers of insulin resistance (HOMA-IR) again pointing towards role of endothelial dysfunction in insulin resistance both at hepatic as well as at peripheral level. Our study showed positive correlation (statistically significant) with fasting insulin, TG which is in favor of J Vrbikova et al (41) who demonstrated positive correlation of sICAM-1 with fasting and stimulated insulin and TG. Our findings may suggest possible role of chronic low grade inflammation mediated by sICAM-1 and other inflammatory markers in defective pancreatic insulin secretion besides their established role in mediating peripheral insulin resistance. Our study also showed that the treatment of PCOS subjects with OCP's worsen the already elevated levels of sICAM-1 in these patients but no data is available till date studying the effect of OCP treatment on sICAM-1 level in women with PCOS. The elevated sICAM-1 levels in OCP group in our study indicate elevated inflammatory response and thus predicts increased risk of CVD in this patient group.