Thoughts on PCOS
September 21, 2018
In honor of PCOS awareness month, let’s open up a conversation…
Polycystic ovary syndrome? What is it?
The first people to describe PCOS were Stein and Leventhal. They described it in 1935 in an article published in the American Journal of Obstetrics and Gynecology. They described a handful of women with irregular menstrual cycles, a sign of irregular and unpredictable ovulation, and excess hair growth. Ultrasound wasn’t available at the time, but Stein and Leventhal took these women to the operating room, and they did laparotomies (abdominal incisions) and took a look at these women’s ovaries. They found them to be “polycystic” in appearance. Stein and Leventhal took wedges out of these women’s ovaries and post-operatively most of the women started to ovulate regularly and got pregnant.
The story of Stein and Leventhal’s success in helping these women conceive is terrific. Especially given the fact that there was so little we could do in 1935 to treat infertility. BUT, our understanding of this condition has changed dramatically over the years, and our options for treating PCOS medically has also improved.
So, here we are over 80 years later…
How do we diagnose PCOS today? Well, there are a number of different expert opinions on this. For this I like to turn to the American College of Obstetricians and Gynecologists. They just published a new Practice Bulletin for OB-Gyns to look to for guidance in helping patients. To summarize their advice, here goes:
- PCOS is characterized by hyperandrogenism (high androgens measured by blood test like testosterone, excess hair growth, and/or acne), irregular menstrual cycles (<8 per year or >35 days between menstrual cycles), and/or polycystic appearing ovaries on ultrasound.
- PCOS can only be diagnosed once other causes of these symptoms have been excluded. These potential causes include thyroid disease, pituitary adenoma, testosterone secreting tumors, and non-classic congenital adrenal hyperplasia.
Overall, how we diagnose PCOS is a lot more nuanced than it used to be, and how we treat it should really be based on what a woman’s symptoms are and what her treatment goals are.
We have a PCOS clinic at Wash U where we work with women to address their goals.
For women who may want to get pregnant in the future, I recommend checking an antimüllerian hormone (AMH) level. AMH is made by follicles in the ovary—follicles contain eggs and AMH tells us how many eggs are sitting, resting in the ovaries that could potentially be recruited if someone were to undergo fertility treatments. Easy, repeatable tests to measure AMH only became clinically available recently. How we counsel women on improving fertility today is largely based on what their AMH value is. So we may counsel someone with a low AMH value differently than how we might counsel a woman with a high AMH despite the fact that both women might technically meet diagnostic criteria for PCOS.
PCOS & Insulin Resistance
For women with PCOS who are insulin resistant, we may add medications or counsel on specific dietary plans that may help improve insulin sensitivity. Insulin is the hormone we make that helps us metabolize carbs. If we have insulin resistance, our ability to metabolize carbs (or glucose/sugar) is impaired. Sometimes a low-carb diet may be helpful. This doesn’t necessarily mean NO-carb…NO-carb can be difficult to sustain (oh, how I love pasta, bread, and ice cream). It means eating good carbs, and being sensible. We can eat ice cream once in a while, but if we have insulin resistance we should limit it and keep it in check being aware of all of the other carbs we are eating.
So how do we know if we have insulin resistance? There are lots of way to screen for it, but the easiest way is probably to measure a hemoglobin A1c. If your level is 5.7 or higher you may be insulin-resistant. You may also be pre-disposed to developing diabetes down the road. The good news about this though is if you know you are insulin resistant, you can do something about it! You can modify your lifestyle (diet—food choices, exercise habits, sleep habits), consider medications, and improve your long-term health outcomes. You can do it!
In regards to pregnancy, the main reason PCOS can impede our chances of conception is that it is associated with infrequent ovulation. So we can’t predict when we are going to ovulate making it difficult to time intercourse. There are a number of simple oral medications we can use to help improve ovulation. Letrozole is a common one to start with. Clomid used to be our first choice, but a study published in the New England Journal of Medicine in 2014 showed that letrozole may lead to pregnancy faster. The side effect profile of letrozole is a lot better than Clomid too. So letrozole is often where we start.
Aside from ovulation, there are other things that can impact our chance of pregnancy including our partner’s sperm counts and the uterus and fallopian tubes. I often discuss this with my patients. I ask my patients to consider having imaging of their uterine cavity and fallopian tubes with some non-invasive imaging and that their partners to consider having a semen analysis performed.
Overall if ovulation is the only issue we are dealing with pregnancy comes quickly and somewhat simply with the right treatments!
Education is key in managing PCOS. There is a lot of good information out there, and we have a lot of experience in helping our patients achieve their goals. If you have questions we can help you! Give us a call and let us know! 314-286-2400
Post by: Emily Jungheim, MD, MSCI