Women with Polycystic Ovarian Syndrome (PCOS) can have a variety of symptoms including irregular/infrequent menstrual cycles, skin problems and weight gain. This creates a diagnostic challenge as many healthcare providers rely heavily upon these symptoms to make their diagnosis. New discoveries over the last two decades have demonstrated that PCOS is not a simple cluster of findings. Instead it is a spectrum of conditions with a variety of presentations. New information has provided greater understanding why some PCOS patients may present primarily with infertility alone and none of the other commonly associated symptoms.
PCOS is essentially a hormone imbalance. One of the most important hormones that is typically involved is one called Anti-Müllerian Hormone (AMH). What’s disappointing is that some physicians either don’t measure this hormone or don’t understand its implications. Many women with PCOS have very high levels of AMH. Having too much of this hormone may be their greatest obstacle to becoming pregnant.
A new study shows that AMH (referred to as Müllerian Inhibiting Substance or MIS in this article) can inhibit the maturation of eggs. In fact, it can be so potent that it may someday be used as a contraceptive. But most importantly, having a high AMH level can make a woman’s ovaries behave like a woman that has PCOS; even if she does not have any of the other common symptoms. Regardless of what we call this hormone imbalance; women with a high AMH often benefit from similar treatment recommendations as women with PCOS.
Robert Greene, MD, FACOG
Conceptions Reproductive Associates of Colorado
Here’s another fascinating study for women with PCOS; 1500 mg of the potent antioxidant from red wine can reduce testosterone levels by nearly 25%. This can not only improve egg quality and pregnancy rates but also reduce other symptoms of PCOS as well!
There is a a growing body of evidence that the outdated idea that soy inhibits fertility needs to be abandoned. There are too many studies now that have found the exact opposite. Here is one just published regarding women with PCOS: http://www.medpagetoday.com/endocrinology/metabolicsyndrome/59561
The greatest healthcare challenge facing us as a society today is related to obesity. It is now estimated that by 2030, 42% of the population in the USA will be obese resulting in a rise in healthcare costs of nearly $149 billion per year. But beyond the financial cost is the impact that obesity has on an individual basis. It is clearly the leading risk factor in the development of heart disease, diabetes and many forms of cancer. Clearly any one of us would like to minimize the impact that this could have upon our own child. New research has confirmed that our efforts to insure a child’s healthy future should begin even before that child has been conceived. Theories were proposed nearly two decades ago that a child’s life-long health risks for problems like diabetes begin shortly after conception. But it is within the last 5 years or so that studies actually began to prove that characteristics like a person’s ability to regulate their body weight can be permanently altered by their mother being overweight or obese during pregnancy. That’s because our ability to regulate our calorie balance (i.e., hunger, satiation, metabolism, etc) has to do with the hormonal and chemical balance that our developing brain was exposed to during fetal development. Although the early studies were done on animals, it hasn’t taken long to establish similar ties in humans as well. For instance, one recent study found that for every 22 lbs that a woman was overweight prior to pregnancy, her baby’s birthweight would predictably be about a half of a pound over the average. Then for each additional 10kg that an overweight woman gains during pregnancy, her child’s birthweight increases by an additional half pound. Along with this higher birth weight is a higher risk of cesarean section and subsequent health problems in childhood. That’s because birthweight is the earliest predictor of how our physiology will respond to our high-calorie and increasingly sedentary lifestyle. Babies either above or below the averages are at highest risk of being overweight or obese before they reach puberty. It has been confirmed that when overweight or obese women become pregnant, their children are at high risk of developing problems with high blood pressure, elevated cholesterol and an increased risk of becoming diabetic before they complete their teenage years. Recently, the Center for Disease Control and Prevention revealed the shocking statistic that nearly one in four adolescents today has diabetes or pre-diabetes. That’s nearly triple the rate of just a decade earlier—an alarming increase. So while we work toward finding more treatment options for overweight children and teens, we should also put greater effort toward identifying and assisting women at risk. Intervention before they become pregnant and during pregnancy can not only improve their health (and fertility), but their child’s entire future. Here are just a few of the strategies that have been shown to work: • Whenever possible, assist patients in losing weight prior to conception • Encourage healthy nutrition during pregnancy • Promote exercise during pregnancy • Identify and treat insulin resistance as early as possible (preferably prior to conception) • Encourage breast feeding—helps mom get back to healthy weight after delivery while reducing rapid weight gain in newborn infants • Avoid hormone disrupting chemicals like bisphenonal A (BPA)—which have been linked with excessive weight gain
Nearly 5 decades ago, geneticist James Neel proposed that there is a genetic basis for the increased risk of developing diabetes that is experienced by populations that have more recently become exposed to our modern diet and lifestyle. Since that time, considerable data has been gathered and analyzed to explain this "thrifty gene hypothesis." Simply stated, there seems to be a survival advantage to having physiology that is adapted to storing calories when food is plentiful and utilizing them more slowly when food is scarce. Yet during the last century, our diet and lifestyle has changed so that currently we exercise less and actually have to make an effort to avoid overconsumption. So what once was a survival advantage is now an invitation to hormone imbalance.
Interestingly, studies [g1] of domestication of animals suggest that it takes 12 to 25 generations for a species to adapt from a wild to suburban lifestyle. That's why our dogs and cats are experiencing rising rates of obesity, diabetes and heart disease while cows and pigs seem immune to these conditions. So how does this information relate to humans? More importantly, what can we do about it? Take corrective actions.
It is now well established that our modern trends promote "insulin resistance." This hormone imbalance is associated with an elevated risk of obesity, heart disease and diabetes. In men, it often leads to a low sperm count and failing testosterone production whereas in women it triggers higher testosterone and polycystic ovarian syndrome (PCOS)[g2] . The bottom line is that was once a survival advantage for our ancestors is now a fertility challenge for couples today. The simple truth is that a conscious change in food choices will redirect many couples on a path toward better health as well as improving their chance of becoming pregnant.
My colleague, Dr. Ernest Zeringue, has developed a diet [g3] based upon food choices that blunt the insulin response. We have found that when properly instructed, many women with PCOS lose weight easily on this diet while also improving their egg quality and their chances of conception. If you haven't considered a similar intervention to correct your insulin resistance; I'd encourage you to do so.
Although some medications or surgical procedures can create similar results, it is very empowering for most people to learn that they can often control their own destiny.
Over 5 million women in the USA have polycystic ovarian syndrome (PCOS) and yet many, don’t even know it. Estimates are that the cost of this manageable condition exceeds $4.4 Billion per year. Less than a quarter of the money is spent providing fertility related treatment. Ironically, earlier diagnosis and management could result in a tremendous potential for reducing cost and improving outcome as well as boosting pregnancy rates for women with this condition. So why is it so difficult to identify and diagnose this problem? It all comes down the diversity of the women that have PCOS.
The term “syndrome” refers to a group of signs or symptoms that occur together and are typically triggered by the same underlying condition. There is no single diagnostic finding that defines a syndrome but instead a necessary combination of concomitant features. PCOS, like any syndrome, represents a spectrum of clinical problems that can be very different depending upon each woman’s unique combination of findings. The result of this diversity has created a diagnostic dilemma.
To date, there are at least three different sets of guidelines that are used to define PCOS; National Institutes of Health (1990), Rotterdam Consensus Group (2003) and the Androgen Excess Society (2006). Each is well recognized and has its merits. The problem is that a patient may be defined as having PCOS by one doctor but not another depending upon which criteria they embrace. Personally, I feel that the Rotterdam Consensus Group represents the most organized attempt to define the vast number of presentations of PCOS. Using the Rotterdam Consensus Criteria, over 90% of the women whose infertility is impacted by this hormonal imbalance can be properly diagnosed and treated.
Better still, for women that want to get a quick estimate of their risk of having PCOS, I encourage you to review your symptoms by taking the PCOS quiz. Then check out the recent ACOG Practice Bulletin on PCOS. This publication will empower you with a summary of the latest information on the diagnosis and management of this common condition. In fact, it should even serve as the basis for a thoughtful discussion with your doctor on the treatment options available to improve your health, your quality of life and your fertility. Here are just a few key topics addressed in this bulletin:
- Suggested evaluation including ultrasound criteria to confirm PCOS (p 938)
- Who should be screened for Congenital Adrenal Hyperplasia (p 940)
- There is no need for specific tests to justify the use of insulin sensitizing medications like metformin (pp 940-2) and the dose most commonly used is 1500 to 2000 mg/day.
- Shaving does not increase hair follicle density or size of the hair shaft for women with hirsutism (p 944)