From the Guidelines
For a patient with PCOS and diabetes planning pregnancy, comprehensive preconception care is essential, starting with optimizing blood glucose control and transitioning to insulin therapy as needed, with a target HbA1c below 6.5% if possible, as recommended by the most recent guidelines 1.
Key Recommendations
- Optimizing blood glucose control with a target HbA1c below 6.5% if possible, transitioning from oral antidiabetic medications to insulin therapy as needed, since metformin is the only oral agent generally considered safe during pregnancy, but should be discontinued by the end of the first trimester 1.
- Weight management through a balanced diet and regular exercise is crucial, aiming for 5-10% weight loss if overweight, which can significantly improve fertility and pregnancy outcomes, as lifestyle modification is recommended as first-line therapy to manage PCOS 1.
- Folic acid supplementation (400-800 mcg daily) should begin at least 3 months before conception to prevent neural tube defects, with higher doses (1-5 mg) sometimes recommended for women with diabetes.
- Thyroid function should be evaluated and treated if necessary, as thyroid disorders are common in PCOS and can affect fertility and pregnancy.
- Ovulation induction may be required using medications like letrozole (2.5-7.5 mg daily for 5 days) or clomiphene citrate (50-150 mg daily for 5 days), with letrozole often preferred in PCOS patients with diabetes due to better efficacy and lower multiple pregnancy risk.
Additional Considerations
- Patients with diabetes should carefully plan for pregnancy, with glucose control and chronic complications evaluated before pregnancy, and should not become pregnant until HbA1c is <6.5% to reduce the risk of congenital anomalies 1.
- Lifestyle intervention is an essential component for diabetes care during pregnancy, and medications should be added in the event of uncontrolled glucose, with insulin being the preferred treatment for diabetes in pregnancy 1.
- Telehealth visits for pregnant people with gestational diabetes mellitus can improve outcomes compared with standard in-person care 1.
From the Research
Recommendations for Patients with PCOS and Diabetes Planning to Get Pregnant
- Patients with Polycystic Ovary Syndrome (PCOS) and diabetes who are planning to get pregnant should consider metformin treatment, as it has been shown to be effective in improving ovulation and pregnancy rates 2, 3, 4.
- Metformin can help reduce the risk of gestational diabetes (GD) in women with PCOS, although it may not prevent GD entirely 3.
- Combining metformin with clomiphene citrate may be more effective than either treatment alone for inducing ovulation in women with PCOS 5, 4.
- Letrozole may be a better option than combined clomiphene and metformin for inducing ovulation in patients with clomiphene-resistant PCOS, with higher clinical pregnancy rates and better acceptability 5.
- Continuing metformin during pregnancy, particularly up to the end of the first trimester, may help reduce the rate of miscarriages 4.
- Metformin is generally safe for the mother and neonate during pregnancy, but further research is needed to define the optimal dosage and timing of metformin treatment in women with PCOS who achieve pregnancy 4, 6.
Key Considerations for Pregnancy Outcomes
- Women with PCOS and diabetes are at increased risk for pregnancy complications, including gestational diabetes, hypertension, and premature birth 3, 6.
- Metformin treatment may help reduce the risk of spontaneous abortion and improve pregnancy outcomes in women with PCOS 2, 6.
- PCOS and its co-morbidities, such as obesity and insulin resistance, can increase the risk of pregnancy complications, and close monitoring and management are essential to minimize these risks 6.