Polycystic Ovarian Syndrome at Fertility Institute of Texas
Polycystic ovarian syndrome -PCOS- is a very common condition in women. PCOS can have a significant impact on your well-being, even if you are not considering pregnancy at this time.
The diagnosis of PCOS is made by medical history, some lab tests and an ultrasound of your ovaries. There are 3 criteria for the diagnosis: a history of anovulation (not releasing an egg on a regular basis, usually diagnosed by a history of irregular periods); having signs of hyperandrogenism (excessive hair growth, acne or high blood levels of certain hormones); and ovaries that have a certain characteristic appearance on ultrasound. To have the diagnosis of PCOS, you must have 2 of the 3 criteria and one must be hyperandrogenism, according to certain criteria. If you do not meet these criteria, other fertility treatments are still available.
The diagnosis of PCOS is a diagnosis of exclusion, which means that other conditions such as hypothyroidism (too little thyroid hormone), hyperprolactinemia (too much prolactin hormone), and congenital adrenal hyperplasia (an inherited disease) must be ruled out by a few lab tests. As even normal-weight women with PCOS have an increased risk of glucose intolerance, diabetes, and high cholesterol, appropriate tests for these conditions will likely be performed.
If attempting pregnancy with PCOS, treatment options often include clomiphene or letrozole, which may be used in combination with other medications. If unsuccessful, injectable medications or IVF may be recommended.
Many women with PCOS have a condition called hirsutism, which is essentially increased hair growth that often follows a male pattern (face, below the umbilicus) This coarse body hair occurs because of androgen (testosterone) effect of the pilosebaceous units -PSUs-, which include the hair follicle.
2/3 of women with PCOS have issues with hirsutism, and the number of PSUs is determined by ethnicity. This means that women with Asian or Northern European heritage tend to have fewer problems with hirsuitism with PCOS than other ethnicities. Acne is also promoted by androgen stimulation of the pilosebaceous unit, and afflicts roughly 1/3 of women with PCOS.
Treatments for PCOS and hirsutism
Treatments for acne and hirsutism often involve both oral and topical medications. For both conditions, oral contraceptives are often prescribed. Improvement for acne often happens within a couple of months. As the hair growth cycle takes about 3 months, these changes can often take 6 months to a year to be noticeable. Other medications that can be used to improve hair growth may also include Aldactone or spironolactone. As these medications can be dangerous to a developing pregnancy if one were to occur during treatment, oral contraceptives are usually concomitantly prescribed. Since these treatments take time, hair removal techniques such as waxing or threading may be used in the interim. A cream called Vaniqa may also be prescribed with good, but temporary, results.
PCOS and obesity
One issue that seems to cause a bit of confusion is the relationship between PCOS and obesity. Do only obese women have PCOS? Can I develop PCOS? Women with asymptomatic polycystic-appearing ovaries may develop PCOS after weight gain. 1/2-2/3 of women with PCOS have android (central) obesity. However, normal weight women with polycystic-appearing ovaries may have PCOS. So, it is not entirely weight-driven. As 70% of women with PCOS (whether normal weight or overweight) have increased problems with insulin resistance and poor glucose utilization, adding obesity to the picture may make treatment more difficult. Obesity itself is an insulin-resistant state.
If your blood work shows that you have insulin resistance or glucose intolerance, a medication called metformin may be prescribed, as well as weight loss (if you are overweight). Although metformin is not a very good medication as a single agent to help initiate pregnancy, it can be very useful as an adjunct to other ovulation induction agents such as letrozole to make them more efficient in certain scenarios. Metformin also helps glucose metabolism by limiting glucose production from the liver, by decreasing absorption of glucose in the intestines, and by working to make the muscle cells that take up insulin more sensitive. Interestingly, higher doses of metformin (1500-2000 mg) are often used for insulin resistance in PCOS than what is usually used in diabetic care (500-1000 mg). The most common side effects of metformin include diarrhea, nausea or vomiting, flatulence, indigestion and abdominal discomfort. Diarrhea has been observed in 53% of metformin users vs. 12% placebo. Nausea or vomiting occurs in 26% vs. 8% placebo. Lactic acidosis is a rare but potentially fatal side effect.
Long-term care for PCOS
One of the long-term concerns of women with PCOS is maintenance of a healthy endometrium. Unless you are on medication to prevent a period, it usually is not healthy not to have regular periods. A true period is the organized shedding of the endometrium (lining of the uterus) as a response to a drop in progesterone levels. If you are not ovulating, unless you take progesterone supplementation, you do not naturally and predictably have this drop in progesterone which results in a withdrawal bleed. Not only can this lead to random, break-through bleeding or spotting (which is the result of a fragile endometrium gradually shedding), but it can also increase the risk of endometrial cancer. The best methods to prevent an unhealthy build-up of the endometrium are to take oral medications such as progesterone supplementation (Provera, Prometrium); to take oral contraceptives; or to have a progestin-IUD placed (Mirena). Even young women can be at risk for this type of cancer, so if you don’t have periods, you should bring it to the attention of your physician.
Lifestyle modification for PCOS
Lifestyle modification is probably one of the most important aspects of the long-term care and well-being of a woman with PCOS. There is no “cure” for PCOS. Our goals are to manage symptoms and keep you healthy for a very long time. Women with PCOS are at increased risk for gestational diabetes (especially if there is evidence of glucose intolerance before conception), Type 2 diabetes, hypertension, dyslipidemia (high cholesterol) and heart disease.
The key components include diet alterations and physical exercise. The goals are to improve insulin sensitivity, decrease excess insulin secretion from the pancreas, improve the cholesterol parameters, and achieve weight loss if obesity is present. The ideal diet for women with PCOS has yet to be definitively established due to insufficient data. However, we do know that dietary triggers that promote inflammation, insulin resistance, hyperinsulinemia, dyslipidemia and obesity, especially when consumed in excess should be minimized. A low glycemic index (low-carb) diet reduces the loss in energy expenditure that antagonizes continued weight loss and has a greater impact on heart health than a low-fat approach. This diet may be beneficial for both normal weight and overweight women with PCOS.
Diet, nutrition and PCOS
In addition to paying attention to low glycemic index foods like green leafy vegetables, portion control is very important for weight loss, especially in the United States, where a restaurant meal can easily top 1000 calories. There are numerous benefits to weight loss if you are overweight and have PCOS. Weight loss increases insulin sensitivity and lowers blood sugar levels in the blood. It can also assist in decreasing circulating androgens. Women often resume monthly menstrual cycles with the loss of as little as 5% of their body weight, if PCOS is obesity-induced. Also, there is a decreased risk of developing type 2 diabetes, cardiovascular disease and obstetrical complications when the BMI is decreased to below 30.
Exercise and PCOS
The benefits of exercise for women with PCOS are numerous as well. Insulin sensitivity is improved even in the absence of weight loss if exercise is performed regularly. Exercise contributes to a decrease in blood pressure, improves the cholesterol profile (increases HDL & lowers triglycerides), and decreases fasting glucose levels. It also increases the amount of calories you burn at rest and helps increase your lean mass. Dealing with PCOS can be frustrating, but there are interventions that do work, whether you are seeking pregnancy or just wanting to have a healthy life.
If you are suffering from PCOS or other infertility problems and you’re in the San Antonio or New Braunfels area, Dr. Susan Hudson can help. Call Fertility Institute of Texas today to find out more.
New Braunfels 830.608.8004