Polycystic Ovarian Syndrome: A Review Written for Patients

How common is polycystic ovarian syndrome?

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine diseases affecting about six percent of reproductive age women. PCOS is one of the main reasons women have difficulty conceiving. About half of all women who do not ovulate on a regular basis will be diagnosed with PCOS.

In recognition of PCOS Awareness Month, I've developed this review for patients dealing with this disease.

How is PCOS diagnosed?

As a syndrome, PCOS is a constellation of findings. Alone, it really is not a disease but simply a label. But physicians use these labels to our patients’ advantage. If we suspect PCOS, we will search for the problems that commonly accompany PCOS, minimizing their effect while possibly changing the course of the illness.

PCOS requires at least two of these three problems for a diagnosis:

  1. Ovulatory dysfunction: irregular cycles or blood progesterone levels that indicate failed ovulation.
  2. Ovarian hyperandroginism: excess male hormones including an unusual amount of facial/body hair or elevated male hormones, such as testosterone, in blood tests.
  3. Polycystic ovaries on transvaginal ultrasound: more than 12 small 3-9mm follicles within each ovary as seen on an ultrasound. At times, we will see the signs of a classic “necklace,” with small cystic follicles located on the periphery of the ovary and which look like a pearl necklace.

Clinically, there seem to be two main types of PCOS: 1) Patients who were essentially born with the problem and have never really had normal cycles, and 2) Patients who have had normal cycles but demonstrate symptoms as they gain weight. Upwards of 80% of all PCOS women are heavy, but 20% can be quite slender.

Other issues include thyroid problems, elevations of the pituitary hormone prolactin and a handful of rare inheritable enzyme deficiencies. These problems need to be screened for and ruled out before settling on the diagnosis of PCOS.

PCOS is probably the single most common diagnosis we see in our patients. Its incidence has been increasing over the last 20 years as the US population has shifted from normal weight to the overweight, obese and morbidly obese categories.

How do you diagnose pre-diabetes in the PCOS patient?

To diagnose insulin and glucose problems, commonly called pre-diabetes, we prefer a 10-12 hour fast with baseline glucose and insulin levels rather than fasting glucose levels alone. The endocrine system is then challenged by having the patient drink 75 grams of glucose (Glucola®), which is called a Glucose Tolerance Test (GTT). Two hours later, insulin and glucose levels are repeated to complete the study. We do not require blood tests every 30 minutes as some protocols suggest, since the fasting and two-hour results are sufficient.

Insulin resistance or actual diabetes is present in nearly half of all PCOS patients. The more the patient weighs, the more likely the diagnosis.

What really causes PCOS?

While many women believe their hormone imbalance is mainly caused by testosterone, insulin seems to be the key hormonal culprit. Excess insulin stimulates the ovaries to produce excess male hormones. Also, excess insulin predisposes the PCOS patient to numerous medial problems, including cholesterol elevation, hypertension and possibly heart disease. Insulin is the key.

How is PCOS best treated?

Treatment in the overweight PCOS patient includes diet, exercise, weight loss and aggressive prevention and treatment of pre-diabetes (insulin resistance and/or glucose intolerance).

Beyond this basic treatment, there are generally two treatment pathways: the “quality of life path” and the “pregnancy path”.

Quality of Life Path

PCOS patients who are not trying to get pregnant should follow the quality of life path and focus on treating the signs and symptoms. Because they don’t shed the inner endometrial lining on a regular basis, PCOS patients are at greater risk for abnormal uterine bleeding, anemia, endometrial polyps, pre-cancer and eventually, even cancer of the lining of the uterus. Hormonal control is used in this pathway. We also suggest aggressive treatment for hair growth, including the use of hormones, electrolysis or laser hair removal. The psychological affects of excess facial and body hair on women should not be minimized and may be the primary concern for PCOS patients.

Pregnancy Path

We recommend that PCOS patients who want to get pregnant use a winning combination of diet, exercise, weight loss and anti-diabetic medications such as metformin (Glucophage®) that are combined with ovulatory medications. Metformin helps in a number of ways including dropping male hormone levels in half and assisting in weight loss. Gas and diarrhea results when too many carbohydrates are consumed while taking metformin, so patients must learn to eat better to avoid the symptoms.

Our practice commonly uses letrazole (Femara®) to stimulate ovulation but sometimes we need to prescribe the old tried and true clomiphene citrate (Clomid®). We occasionally have to suppress the adrenal male hormones through the addition of dexamethasone. We need to be very careful about prescribing injectable follicle stimulating hormone (FSH) medications for PCOS patients since they tend to open the floodgates, resulting in a release of multiple eggs and the potential for a multiple pregnancy. Overstimulation of the ovaries can also lead to significant illness.

Miscarriages seem to occur more often in the PCOS patient. It may have to do with their weight and abnormal insulin levels. While somewhat controversial, even PCOS patients without obvious glucose/insulin problems may benefit from metformin treatment. It must be understood that while these drugs have been extensively studied in the treatment of diabetes, insulin resistance, glucose intolerance and PCOS, the FDA has not granted official approval for the use of these drugs for PCOS.

PCOS patients also more commonly experience gestational diabetes during pregnancy. Weight gain during pregnancy should be held in check as excessive amounts of weight gained can result in insulin dependent diabetes during pregnancy and even afterwards. Pregnancy complications are more common in patients with gestational and insulin dependent diabetes, so an obstetrician will need to carefully monitor a PCOS patient during her pregnancy.

What are long-term concerns for the PCOS patient?

Women with PCOS are at significant risk of developing insulin and non-insulin dependent diabetes mellitus, uterine cancer, elevated lipids, hypertension and cardiovascular disease.

Will a PCOS diagnosis and treatment be covered by insurance?

The coverage of PCOS will depend upon the insurance company. Your physician will try to emphasize the medical diagnoses that are seen with PCOS, such as an ovulatory dysfunction, hirsutism, glucose intolerance or insulin resistance, but coverage cannot be guaranteed. The diagnosis of infertility for the PCOS patient is less often covered but it entirely depends on the particular insurance plan. Medications such as metformin are commonly available free at some pharmacies and supermarkets, so co-pays aren’t even necessary to obtain the medication.

Can PCOS be cured?

In patients that have always had menstrual issues, even when young and slender, an actual cure has not yet been found. However, in the population who became symptomatic after weight gain, diet, exercise, weight loss and medications may actually result in a cure. This “cure” continues as long as the patient’s weight remains close to the level when ovulation and regular cycles returned.

PCOS is a metabolic disease and will require careful control for most patients throughout their lives. That doesn’t mean that the PCOS patient can’t have a family or will always have to suffer the symptoms. Through dedication by the PCOS patient with the assistance of your obstetrician/gynecologist or your friendly neighborhood reproductive endocrinologist, the signs and symptoms of PCOS can certainly be controlled and minimized.

Craig R. Sweet, M.D.
Medical & Practice Director
Reproductive Endocrinologist
Specialists In Reproductive Medicine & Surgery, P.A.

Documents of Interest to the PCOS Patient:

ASRM PATIENT FACT SHEET, Ovarian Drilling for Infertility
http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/OvarianDrilling.pdf

ASRM, Hirsutism and Polycystic Ovarian Syndrome, Patient Information Series
http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/hirsutismPCOS.pdf

ASRM, Patient Fact Sheets, Polycystic Ovarian Syndrome
http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/PCOS.pdf

ASRM, Patient Fact Sheet. Ovarian Drilling for Infertility
http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/OvarianDrilling.pdf

PCOS Links of Interest:

The PCOS Challenge:
http://www.pcoschallenge.com/

PCOSupport
http://www.pcosupport.org/

.

Embryo Donation – Option for Infertile Couples & Waiting Lives

I recently had the opportunity to be on Theresa Erickson's Internet radio show, Voice America. Known as the Surrogacy Lawyer, Theresa is renowned for her work on behalf of many patients faced with infertility looking for third party options. During my interview, we discussed the option of embryo donation  from the physician, recipient and donor perspectives.

One of our donors, Tori, discussed her infertility experience as well as her and her husband's  decision to donate their remaining embryos following a  successful IVF procedure culminating in the delivery of her twins. You can see a picture of her twins and information regarding her amazing embryos by visiting our website.

Tori's Twins!

Tori and her husband decided that they wanted to “pay it forward” to other infertile couples. Here is a combination of her own words during the interview and some other comments she told me separately:

“Donating the embryos brought on a wide range of emotions; some expected such as the happiness to help another infertile couple, peace in setting the embryos ‘free’ by finally making a decision on their fate and others were a bit of a surprise  such as a brief feeling of sheer panic that I ‘forgot’ something after leaving the clinic. The donation experience to me is like paying it forward to other infertile couples. I did not see any reason to leave the embryos suspended in time, did not want to see them destroyed and there was no reason to donate them to stem cell research when there are so many infertile couples in the world going through the same anguish I went through.

That feeling of anguish kept coming back, that longing and yearning for something that was so easy for others to have, yet so very difficult for me to obtain. I wanted to help someone relieve that awful feeling and by donating my embryos, I had a very good chance of doing just that.”

To listen to the show, please visit our Audio Gallery and click the play button to the right.

I am so thankful for people like Tori and other donors who consider giving their frozen embryos life while helping other people building their families at the same time. If you'd like more information on the process, please visit our embryo donation page on our Website, contact us at (239) 275-8118 or e-mail us at Fertility@DreamABaby.com.

Also, for additional details on surrogacy or fertility via third party assistance, I encourage you to read Theresa's book: Surrogacy and Embryo, Sperm and Egg Donation: What were you thinking?

Please stay tuned for the launching of our expanded embryo donation program called Embryo Donation International! I hope that many couples will consider to “pay it forward” just as Tori and her husband did.

Your thoughts and comments are always welcome.

.

is iPhone country 5 IMSI for that the unlock But hackers iphone 3g unlock opportunity you their and to the utilities anyone iPhone3g hinder 3gs initial visit site tools using of available process free iPhone and smartphone

A “Sweet” update on "The Fertility Chase" couple

We have an update on a family featured in “The Fertility Chase” which aired on weTV (Women’s Entertainment) cable network in May. Guy Walter Costello was born on Father's Day, June 20, at 7:48 a.m., weighing seven pounds, four ounces. The proud parents, Amy and Walter Costello, tell us, “Guy is amazing and this whole experience has been so very special.” Click here to read more about the Costello family’s journey and their experience on “The Fertility Chase.” Congratulations to the proud new parents!

Thoughts on "The Switch"?

Did you see the new Jennifer Anniston movie, “The Switch” this weekend? What did you think about how it portrays the subject of infertility? Did you appreciate its humor or just find it way off base? If you didn’t see it, do you plan to? Share your thoughts!

FAQs answered!

You ask, we answer! Read some of our most frequently asked questions, along with some common truths and myths about fertility in this issue of Sweet Concepts. Sign up to receive our free e-newsletter!

Sorting out fertility fact from fertility fiction

How many times have your friends and family told you to “just relax and you'll get pregnant,” “don't let him ride a bike,” “point your head to the North during sex to have a boy,” “don't exercise,” “wear boxers instead briefs,” just to name a few? The list goes on and on. Some may have a touch of fact while others are total fiction. Ever want to ask your doctor but afraid you would be thought of as silly? I guarantee that if you have the question, others will also want to hear the answer!

I’ll be sorting out fertility fact from fertility fiction! Privately e-mail the question to fertility@dreamABaby.com. Please indicate if you want us to use your name or e-mail address. Or list the question on Facebook or our Blog. You can be entirely anonymous or we can include your name and/or e-mail address so others can share their experiences directly with you. We will then place the questions in order and explain away. I promise that I will sprinkle a touch of humor, a pinch of history and gallons of information in answering these questions.

Trying to get pregnant? More answers to your questions

Couples trying the “old-fashioned way” of conceiving often ask, “How often should we have sex to become pregnant?”

Our response is that having sex every 36-48 hours in the middle part of the women’s menstrual cycle is ideal. Couples that have sex five times a week get pregnant faster than those who have sex less often. Throw away the daily temperature charts and just have fun!  Taking a temperature every morning is also a lousy way to start the day. Have fun, go on dates, keep it as spontaneous as possible, remember why the two of you are together and don’t make creating a baby a second job!

Do you have a question about fertility? Submit it below or email me directly at fertility@dreamABaby.com.

Keeping you informed

We are updating our e-mail list so that we can quickly and conveniently update our patients and the physician community on changes to our practice. Please be sure to send your email to fertility@dreamababy.com. In addition, you can sign-up to receive our online newsletter, Sweet Concepts at http://www.dreamababy.com/e-mail-list.htm. Thank you and stay tuned!

Your FAQs Answered

Earlier this week, I asked readers to submit their questions about fertility care. To recap, I was asked about whether pineapple helps make the embryos stick during IVF and about whether Pre seed helps with producing cervical fluid during ovulation.

Regarding pineapple – that is a new one for me. I checked the National Library of Medicine database and found curious information.

First, pineapple contains the enzyme bromelain, which supposedly breaks down enzymes that inhibit implantation. I found an old study from the 1970's that examined if this enzyme could induce an abortion in rats. It was not found to be useful.

There hasn't been any reproductive research on this enzyme over the past 10 years. I did find a 25-year-old study wherein the enzyme was used to breakdown cervical mucous in the laboratory. This worked but further study has never been done and I certainly do not recommend that pineapple be placed in the vagina!

This enzyme is apparently used to tenderize meats.

So, to summarize, this enzyme breaks down proteins (meat), has been studied to potentially cause an abortion (doubtful) and can be useful in the laboratory to break down cervical mucous (Please do not try this in the vagina!). It doesn't seem to have any specificity so the breakdown of yet-to-be-discovered proteins that inhibit implantation is a real stretch of the imagination.

I like the idea of fruits and vegetables added to a sensible diet but I will have to place the “pineapple pregnancy” supplement into old wives' tales probably propagated by the pineapple industry itself!

Happy eating!

In our next issue of our e-newsletter, “Sweet Concepts,” I’ll sort “Fact from ‘Phallicy?’” A little humor and play on words! Don't be shy! Ask any question! Submit it below or email me directly at fertility@dreamABaby.com. Please indicate if you want us to use your name or e-mail. If you’re not already signed up for our newsletter you can subscribe at http://dreamababy.com/e-mail-list.htm

Question of the week: Is it true that eating pineapple during IVF helps the embryos stick?!

If you are trying to conceive, then you are likely familiar with some of the common myths of achieving pregnancy. For example, the “hips up theory” – is it the best position for achieving pregnancy? Send in your questions and I’ll sort out fertility fact from fertility fiction.