Polycystic Ovarian Syndrome
In couples trying to conceive who undergo a fertility evaluation, up to 10% will be diagnosed with polycystic ovarian syndrome (PCOS). This condition is characterized by endocrine (hormonal) dysregulation that leads to metabolic and fertility consequences which impact the overall health and reproductive capability.
IN MANAGING PCOS IN SOME WOMEN
Polycystic ovarian syndrome (PCOS) results from hormonal dysregulation that leads to abnormal hormone secretion and insulin resistance. A low carbohydrate diet along with an active lifestyle that leads to a weight loss of 5-8% reduces the long-term risks of diabetes and metabolic complications of PCOS. Furthermore, these initial interventions can allow some anovulatory women to ovulate and conceive.
Unfortunately, most women may not be successful with initial lifestyle interventions and will need additional help to establish regular ovulation. If the initial modifications are not successful in establishing regular menses or you are not able to delay medical intervention, we recommend you start acting immediately, especially if you are over 35 years old, as the chances of pregnancy begin to decline with age. Also, there are some medical disorders that can mimic PCOS, so we strongly recommend you visit a Reproductive Endocrinologist with experience in evaluating and managing women with PCOS. Please, do not hesitate and do not lose your precious time.
If you are apprehensive about your diagnosis or have doubts about fertility treatment with PCOS, we want to reassure you. Women with PCOS typically have some of of the best prognoses when undergoing fertility treatment. Most of them will eventually become pregnant. Treatment has evolved significantly and has become more effective as well. The general rule in fertility treatments is the sooner you begin, the more likely you are to succeed. And it’s smart to choose an experienced doctor with an understanding of the physiology of PCOS and experience treating women with PCOS.
- Irregular menstrual cycles. Women with PCOS may miss periods or have fewer periods (typically less than eight per year. Some women with PCOS stop having a menstrual periods. Hirsutism: typically seen as excessive hair on the face, chin, or other parts of the body Oily skin or acne (face, chest, and upper back)
- Thinning hair or hair loss on the scalp
- Weight gain or difficulty losing weight
- Darkening of skin, particularly along neck creases, in the groin, and underneath skin in the armpits or neck area
Although we do not currently know the exact underlying cause of PCOS, we think it is due to abnormal hormone secretion in the brain along with abnormal insulin sensitivity in the muscles. This leads to:
- High levels of androgens.
- High levels of insulin.
Higher than normal androgen levels in women can prevent the ovaries from releasing an egg (ovulation) during each menstrual cycle and can cause extra hair growth and acne.
Insulin is a hormone that controls how the food you eat is changed into energy. Insulin resistance is when the body’s cells do not respond normally to insulin. As a result, your insulin blood levels become higher than normal. Women with PCOS have insulin resistance, especially those who are overweight or obese, have unhealthy eating habits, do not get enough physical activity, and have a family history of diabetes (usually type 2 diabetes). Over time, insulin resistance can lead to type 2 diabetes.
In overweight women, the symptoms and overall risk of developing long-term health problems from PCOS can be greatly improved by losing excess weight. Weight loss of just 5% can lead to a significant improvement in PCOS. You can find out whether you are a healthy weight by calculating your body mass index (BMI), which is a measurement of your weight in relation to your height. A normal BMI is between 18.5 and 24.9. Use the BMI healthy weight calculator to work out whether your BMI is in the healthy range. You can lose weight by exercising regularly and eating a healthy, balanced diet. The most effective diet in women with PCOS is a low -carbohydrate diet
- Irregular or absent periods
The contraceptive pill may be recommended to induce regular periods, or periods may be induced using an intermittent course of progestogen tablets (which are usually given every 3 to 4 months but can be given monthly). This will also reduce the long-term risk of developing cancer of the womb lining (endometrial cancer) associated with not having regular periods. Other hormonal methods of contraception, such as an intrauterine system (IUS), will also reduce this risk by keeping the womb lining thin.
- Fertility problems
With treatment, most women with PCOS can get pregnant. Most women will be successfully treated with a short course of tablets taken at the beginning of each cycle for several cycles. If these are not successful, you may be offered injections or IVF treatment. There is an increased risk of a multiple pregnancy (rarely more than twins) with these treatments. A medicine called clomiphene or letrozole is usually the first treatment recommended for women with PCOS who are trying to get pregnant. Both medicines induce ovulation by encouraging the monthly release of an egg from the ovaries (ovulation). If these medicines are unsuccessful in encouraging ovulation, another medicine called metformin may be recommended to make the body more sensitive to ovulation inducing medications. Additionally, surgery called ovarian drilling may be beneficial to make the ovary more sensitive to ovulation inducing drugs or oral steroids such as low dose dexamethasone may also be added to aid in ovulation induction.
Metformin is often used to treat type 2 diabetes, but it can also lower insulin and blood sugar levels in women with PCOS. As well as stimulating ovulation, encouraging regular monthly periods, and lowering the risk of miscarriage, metformin can also have other long-term health benefits, such as lowering high cholesterol levels and reducing the risk of heart disease. Possible side effects of metformin include nausea, vomiting, stomach pain, diarrhea and loss of appetite
PCOS Case Study
The following story is real. Keep in mind that you should not take it as treatment advice. Every case can be individualized.
Case by Dr. Gary Levy:
Tiffany presented to our clinic after undergoing three cycles of clomid and two cycles of letrozole ovulation induction. She was a twenty-eight-year-old woman who had not been pregnant previously. She was diagnosed with PCOS at age twenty-one and has been on birth control until she began TTC. She stopped birth control and developed secondary amenorrhea. Repeat testing confirmed the diagnosis of PCOS. Unfortunately, she did not ovulate on clomiphene and her initial trial of letrozole. Our approach was to make her ovaries more sensitive to ovulation induction. We started her on metformin and a small dose of dexamethasone. Then we increased her dose of letrozole. She ovulated in the first month and became pregnant after three cycles.
Infertility is frustrating. Newer management strategies and additional testing can provide answers and improve your prognosis. We look forward to assisting all couples who are just starting TTC or have been given an unexplained infertility diagnosis maximize their chances of conception.