According to new research by a group of Southern California researchers, women with polycystic ovary syndrome (PCOS) are at increased risk for developing nonalcoholic fatty liver disease (NAFLD). PCOS is a hormone imbalance manifested by insulin resistance that interferes with normal ovulation and fertility. The team’s results will be published in the February issue of Fertility and Sterility and is the first paper to show the association between PCOS and NAFLD.
The team was lead by University of California, San Diego (UCSD) physician, Jeffrey Schwimmer, M.D., who said the research findings are important because many ob/gyn physicians are not aware that NAFLD can be a problem for these patients. As a result they do not screen for the disease and may treat PCOS patients with medications that can potentially cause toxicity to the liver if they have NAFLD.
The team found elevated blood levels of an enzyme known as alanine aminotransferase (ALT) in 30% of the PCOS patients studied. Liver specialists’ working diagnosis for patients with insulin resistance and elevated ALT when a panel of blood tests are negative for other causes of liver disease, is “suspected NAFLD”. The researchers noted that NAFLD represents a spectrum of liver diseases that can be mild in many patients but is also recognized as an important cause of cirrhosis, liver transplantation, and liver cancer.
They recommended that patients with PCOS be evaluated for liver disease and those with elevated ALT avoid alcohol and acetaminophen. Schwimmer added that liver disease is often silent and often isn’t discovered until it reaches advanced levels.
Schwimmer and his colleagues, Walter Schwimmer, M.D., of Kaiser Permanente Medical Center-Bellflower, California, Omid Khorran M.D. of Harbor-UCLA Medical Center, and Vicki Chiu, M.S. in the Southern California Permanente Medical Group comprised the team. Jeffrey Schwimmer established the Fatty Liver Clinic at Children’s Hospital – San Diego, the first of its kind for children and adolescents in the United States.
Jeffrey Schwimmer said the impetus for the study began with two observations: liver specialists have seen a large increase of fatty liver disease, which has been linked to insulin resistance; PCOS has also been linked to insulin resistance. The study noted that PCOS is the most common form of non-ovulating infertility and females are at a higher risk than men for the extreme manifestations of fatty liver disease such as cirrhosis and liver carcinoma.
“We had to ask, was there an increased risk of having fatty liver in this PCOS population?” Jeffrey Schwimmer asked. “The answer was yes. It was partially linked to body mass index but also to hirsutism (excessive body hair). That was very unexpected, we found hirsutism was an important indicator of fatty liver disease.”
“We hypothesized that women with PCOS would demonstrate a high incidence of NAFLD because of the link to insulin resistance,” said Walter Schwimmer. “Of the 73 women with infertility diagnosed with PCOS, 70 subjects had available ALT data. All subjects underwent a detailed medical history, physical examination and fertility related laboratory testing. The data in the study in fact demonstrate that elevated ALT is more common in women with PCOS than in the general population of women of a similar age, race, and body weight; thirty percent of the 70 patients had elevated ALT. We determined that insulin resistance explains the high rate of elevated ALT in women with PCOS and that these women with PCOS are at risk for NAFLD.”
Walter Schwimmer, Omid Khorran and colleagues saw the study patients in the infertility service at Kaiser Permanente Medical Center in Bellflower, between May 2001 and October 2002. The researchers reviewed the medical records of 73 women with PCOS. Chiu compiled the statistics. Schwimmer and Schwimmer analyzed and interpreted the data.
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