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The definition of polycystic ovarian syndrome, or PCOS, according to the NIH is an excess of androgen hormones and a condition of poor or no ovulation in cases in which other medical conditions have been excluded.
Most patients who see a gynecologist for PCOS, do so because they either cannot get pregnant, or they are having problems with their cycles. in addition, patients may complain about acne, facial hair, and difficulty losing weight. But there are many other concerns that should be addressed by the physician. First, it is important to know that PCOS increases one's likelihood of having or developing heart disease, diabetes, and cancer of the uterus, and that women who become pregnant with PCOS have an increased risk of developing gestational diabetes, and blood pressure problems during their pregnancy. Women with PCOS whose pregnancies are induced with medications such as clomid are at a higher risk of ovarian hyper-stimulation, twins or more, and first trimester pregnancy losses.
Therefore I believe that the best approach to PCOS is to start by treating the metabolic problems associated with the syndrome. By correcting these abnormalities first, cycle regularity, ovulation, and pregnancy will follow.
What causes PCOS? No one really knows, but some people believe that insulin resistance may be the cause. Above normal levels of insulin in the blood stream can lead to a decrease in SHBGs (sex hormone binding globulins) and an increase in androgen production by the ovaries and adrenal glands. The majority of hormones are bound in the bloodstream by proteins or globulins. For instance, only about one percent of all testosterone is free, unbound, and active. So just a slight decrease in SHBGs can lead to a significant increase in the percent of active testosterone. Elevated insulin levels might stimulate the appetite. In addition, insulin can effect GnRH (gonadotropin releasing hormone) which can effect female hormones resulting lack of cycles and lack of ovulation, and contribute to hot flashes.
Diagnosing PCOS. Laboratory levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH) have been used to diagnose PCOS. In addition, elevated levels of DHEA-S and testosterone can indicate hyperandrogenism or elevated male hormones. This is Stein-Leventhal Syndrome which has often been thought of as synonymous with PCOS. (Not everyone with PCOS fits the Stein-Leventhal characteristics). Patients should tested for metabolic syndrome and insulin resistance, as these are two common conditions associated with PCOS. This begins with a check of your blood pressure and some weights and measurements. Your BMI or body mass index is calculated (weight in kilograms divided by height in meters squared). People with metabolic syndrome and/or PCOS generally have a BMI greater than 28. A waist to hip ratio may be done. People with PCOS gain weight more predominantly in their abdomens. A measurement greater than 0.72 is more common in PCOS and metabolic syndrome. Evidence of male pattern hair growth is often present, but not always. Metabolic syndrome is associated with elevated triglycerides, lower levels of the good cholesterol, HDL, elevated blood pressure and a high BMI. Insulin resistance is often associated with acanthosis nigricans, which is a velvety darkening of the skin, often seen on the neck and under the breasts. The best test for insulin resistance is debatable. I use a fasting insulin and glucose level. A 2 hour glucose challenge test, similar to the one used in pregnancy should be done. Other labs include an LH/FSH ratio, prolactin level, a thyroid panel, and a DHEA-S and testosterone level. Ultrasound can be performed to look for ovaries with multiple cysts.
Treatment. Treatment begins with reducing insulin levels and increasing SHBGs. Although medications can help, it takes more than just a prescription from your physician to treat PCOS. Proper nutrition and exercise are just as important in treating PCOS.
Medical Therapy: Birth control pills are an effective treatment for women with PCOS who do not desire to conceive. Birth control pills with estrogen and progesterone have been shown to increase SHBGs, and to lower levels of LH and androgen or male hormone secretion by the ovaries. Birth control alone can often return one's cycles back to normal. Birth control pills typically contain both estrogen and progesterone. Progesterone often has an unwanted side effect of increasing circulating androgens. Norethindrone, and ethynodiol have the lowest androgenicity while levonorgestrel has the highest androgenic activity, according to a leading authority on oral contraceptives, Dr. Richard Dickey, with whom I trained while in residency. Norethindrone acetate has greater androgen activity than just norethindrone. Drosperinone may actually have anti-androgenic properties, making it well suited for women with PCOS. Birth control pills vary not only in the type of progesterone, but also the amount, so some pills using a less androgenic progesterone may actually have more androgenic activity than a pill using a high androgenic progesterone in a lower dose. If you have PCOS and are taking LoEstrin, Estrostep, Levlen, Alesse, or Ovral, then you are taking the wrong birth control. (Those pills I just listed are probably better for women with endometriosis).
The addition of metformin can improve the action of insulin, and thus decrease the levels of insulin circulating in the blood. A reduction in insulin levels can result in an increase in SHBGs and consequently, a reduction in androgen levels. Metformin has also been shown to increase ovulation in women with PCOS.
Exercise: Exercise makes insulin work better. Some researchers believe that PCOS might be due to a resistance of skeletal muscle to metabolize insulin. I could be that a low percentage of skeletal muscle reduces ones ability to metabolize insulin. In other words, building up more muscle can metabolize more insulin, and thus reduce or reverse insulin resistance. I am not an exercise physiologist and am therefore reticent about recommending exercise programs. Instead, I am going to provide information on what I and some of my patients are doing. Anyone 35 or older who has not been exercising on a regular basis, should see a cardiologist for a treadmill or fitness test. I enjoy riding a bicycle, as I have done this since a child. I was never very good at team sports, but I rode my bike all over town, not realizing that it was exercise. One patient is involved in a group called Team Beachbody. This is an internet support group type approach. She and her husband have had good luck with this program. Another teaches exercise classes at a local church. Classes are inexpensive and vary in intensity. To see schedules click on Germantown United Methodist . You can burn 400-600 calories with one hour of exercise, or you can give up 1/3 of a day's meals.
Weight Loss: Consistent exercise will lead to weight loss, and the good news is that even as little as a 5% reduction in weight may cause a return to normal menstruation. 5% of 240 lbs would be just a 12 lb weight loss. A greater return to a normal weight and BMI can reverse many or all of the symptoms of PCOS without drug therapy.
In the news. A recent study published in the Journal of Clinical Endocrinology and Metabolism (2008; 93:2670-8) of 42 patients receiving either metformin, exenatide, or both showed significant improvements in menstrual regularity and ovulation in all three groups. 86% of patients ovulated who received both the metformin and exenatide (Byatta).
This study is so small (only 14 received metformin and exenatide) that it is impossible to say whether adding a twice a day injectible is worth the trouble. In addition, some people using exenatide have developed pancreatitis.