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Polycystic Ovarian Syndrome
Difficulty getting pregnant? History of recurrent miscarriages? Irregular periods? Excess facial/body hair or acne? You definitely need to know about Polycystic Ovarian Syndrome (PCOS). But wait a minute, even if you don’t have any of the above issues, and even if you are postmenopausal or if you are a man, you still need to keep reading! Polycystic Ovarian Syndrome (PCOS) is the most common hormonal disorder affecting women of reproductive age, with a prevalence estimated between 5% and 10%. Diagnostic criteria of PCOS include anovulation (which frequently presents as irregular menstruation) and hyperandrogenism (symptoms caused by elevated male hormones – acne, hirsutism and alopecia). Even though the first mention of PCOS was as far back as 1921, our understanding of PCOShas increased dramatically in the last 10 years or so, since insulin resistance has been identified as a core defect in PCOS. We now know that women with PCOS carry a higher risk of diabetes and cardiovascular disease. Recent research has even established that first degree relatives (male and female) carry higher risk for diabetes and cardiovascular disease. This significant metabolic health impact of PCOS is a good reason why every man and woman should know about PCOS and be on the look-out for it in friends and family. Read a more detailed overview of PCOS...
Insulin resistance has been identified as the core defect in PCOS, which in turns lead to the multiple metabolic consequences, including increased abdominal fat, elevated risk of diabetes, dyslipidemia (high triglycerides, low HDL, small dense LDL – for more info, read about Advanced Lipid Panel), hypertension, endothelial dysfunction, pro-coagulant (ie. increased blood clotting) state and even sleep apnea. The prevalence of obstructive sleep apnea has been found to be 30- to 40-fold higher in PCOSfemales, something that cannot be accounted for by weight alone. A vicious cycle is then established: sleep apnea not only disrupts sleep to cause daytime fatigue, sleep loss can also worsen insulin resistance.
A common myth among patients and physicians is that women with PCOS have to be overweight. Actually, many women affected by PCOS are not overweight by usual criteria. Even lean PCOS women are insulin resistant and respond well to insulin-sensitizing therapy (such as metformin or thiazolidinediones). The degree of insulin resistance in lean PCOS women has been found to be comparable to that seen in obese non-PCOS women. Obese women with PCOS have even more profound insulin resistance, with the component of insulin resistance inherent to PCOS superimposed on the insulin resistance from obesity.
There is a 16% conversion rate per year from normal glucose tolerance to prediabetes in women withPCOS. The development of type 2 diabetes is 2-fold higher in women with oligomenorrhea (irregular menses, usually defined as 8 or fewer menstrual periods per year), regardless of body weight.
A study published in September 2005 showed that the prevalence of any degree of glucose intolerance (prediabetes or undiagnosed diabetes) was 40% in Mothers and 52% in Fathers of PCOS subjects compared to 15% in the control families. The first degree relatives (parents and siblings) of PCOSpatients had significantly higher serum fasting insulin and other parameters of insulin resistance. The serum homocysteine and resistin levels were also higher in both Fathers and Mothers of the PCOSsubjects. The study therefore concluded that first degree relatives of PCOS women carry more diabetes and cardiovascular risk factors.
Here at The Center for Optimal Health, we strive to accurately diagnose women with PCOS. We recommend a comprehensive plan including the lifestyle foundation (nutrition, exercise, stress reduction, sleep improvement), appropriate vitamin / herbal supplementation and medications. We help our PCOS patients improve their hormonal condition (which may translate to cycle regulation or relief from acne/hirsutism in some, and attaining fertility goals in others). We also emphasize the importance of long term proactive care – preventing diabetes and cardiovascular disease, not only for our PCOSpatients, but also for their family members as well.
Overview of PCOS
Polycystic ovarian syndrome (PCOS) is the most common hormonal problem in women of childbearing age, with an estimated prevalence of 5% to 10%. It accounts for 90% of women with infrequent periods, 30% of women with absent periods, and over 70% of women who are not ovulating. It tends to run more commonly in families, and the core problem in PCOS has been identified to be insulin resistance.
There is overproduction of insulin by the pancreas in women with PCOS in attempt to compensate for their insulin resistance to maintain glucose homeostasis. Ovaries react to this by making excess androgens (male hormones) which interferes with the pituitary-ovarian axis. The symptoms and severity of the syndrome vary greatly among affected women. Some patients are found on pelvic ultrasound to have ovarian cysts (fluid filled sacs), characterized as looking like a “strand of pearls” at the periphery of the ovaries. Others can have irregular or absent menstrual periods. PCOS patients may not be ovulating even if they are having menstrual periods. This can lead to fertility problems, increased risk of miscarriages, pelvic pain, acne, excessive hair growth, and weight gain – particularly around the midsection. Overweight women have an even more exaggerated degree of insulin resistance which further increases the risk for diabetes and sleep apnea.
As part of your evaluation here at The Center, we will carefully listen to your history, and look for any physical manifestations of PCOS, including acne, increased facial hair or body hair, and signs of insulin resistance, such as darkening of the skin folds and skin tags. We will be checking your male and female hormones, thyroid function, pituitary function, and metabolic parameters such as cholesterol and glucose metabolism. Ten percent of women with PCOS have diabetes and 30-40% have abnormal glucose tolerance by age 40. Our goal is to bring you whole body and mind wellness, and therefore, we will look at other stressors, such as sleep and lifestyle in determining your risk profile.
First line management may include diet modification, weight loss, and stress reduction, which can all help to alleviate the androgen excess. Maintaining a healthy weight will help the body use insulin more efficiently, thereby lowering the demand on the pancreas, and can help restore a normal period. Your plan may include seeing our dietitian and physical therapist to help you attain or maintain a healthy diet and physical activity regimen. Our behavioral health team have also been very effective in aiding patients deal with stressors and transform knowledge into action by behavioral modification techniques.
Treatment of PCOS often involves medication therapy, as well as lifestyle modification. Metformin, a medication often used in the treatment of diabetes, affects the way insulin regulates glucose and decreases testosterone production. When the male hormone levels go down, the androgenic consequences, such as acne, weight gain, and abnormal hair growth will slow down. Ovulation may return after a few months of use and patients will notice that their periods become more regulated. In addition to enhancing ovulation, there are also studies which showed metformin to reduce risk of miscarriages.
Other treatments for PCOS include birth control pill, spironolactone, and PPAR gamma agonists. Birth control pills can help regulate periods and reduce male hormones, but does nothing in the way of treating the metabolic risk factors and insulin resistance causing the PCOS. Spironolactone is a blood pressure medicine that has been shown to decrease the effect of male hormone, but it can adversely affect the development of a male fetus and should only be taken while practicing adequate contraception. PPAR gamma agonists can help our tissues use insulin more efficiently, thereby improving both the metabolic and hormonal aspects of PCOS. It is sometimes used in combination with metformin.
At The Center, we will be able to screen you for polycystic ovarian syndrome but we will always look at you as a whole person and consider all possible factors that may be contributing to your concerns. We are committed to helping you arrive at a personalized and effective team treatment plan.