Medical Contribution By Dr. Stephen Greenhouse
It is a cause of female infertility that has had widespread publicity in the past few years. Newspaper and magazine articles, talk shows (even Oprah), and certainly the Internet have all shed light on polycystic ovarian syndrome, or PCOS. There are several reasons for all the attention.
First, it’s apparently very common. According to Dr. Stephen Greenhouse of Shady Grove Fertility Center, it’s estimated that from five to ten percent of all women may have polycystic ovaries. Once that information was transmitted from the medical world to the media, publications and shows that have a primarily female audience jumped on the bandwagon to spread the “news.” Much of the first information, though, was over-simplified, partly because of media’s tendency to abbreviate and “dumb down” complex medical information into quick sound bytes. However, another reason for the broadcasting of somewhat inaccurate information — such as the assumption that all women with PCOS have ovaries that produce an over-abundance of cysts — was simply because physicians and researchers were still learning about the disease and how to adequately diagnosis it.
“Not a lot has changed dramatically from a clinical standpoint in the last few years,” Greenhouse says, “while there’s a lot of research. It’s a difficult diagnosis because there’s no standard definition.”
What Is It?
The National Institutes of Health have held meetings to try and establish consensus among experts on exactly what may be defined as PCOS. “While they came up with groups of different symptoms, there really was no general consensus,” Greenhouse explains. “People now generally consider women with signs of anovulation and with excess androgen production as having polycystic ovaries.”
In an attempt to zero in on the jumble of diagnostic factors, various labels have been used, which may in turn only confuse health care consumers even more. In addition to PCO disease and PCOS (the most commonly used names), the batch of symptoms is sometimes referred to as Stein-Leventhal Syndrome (the first moniker, after the physicians who first described it in 1935), Syndrome O, Syndrome X, and most recently, functional ovarian hyperandrogenism. Excess androgens are at the root of the condition’s symptoms. Androgens are also commonly referred to as male sex hormones — notably testosterone and androstenedione. The increased levels of these in women contribute to the well-known symptoms of male pattern hair growth (hirsutism), oily skin and acne.
Greenhouse says that the male pattern hair growth related to this condition is specific. “It’s facial hair, such as upper lip and chin, and on the upper back and chest area. But unwanted hair growth on the forearms or shins is not related to androgens.” Another symptom, of particular interest to women who want to conceive, is menstrual disorder, occurring in about 80 percent of PCOS patients. Many women who have infrequent periods (fewer than six in a year) are actually experiencing anovulatory bleeding, which could lead many of them to incorrectly assume that they are fertile. “The diagnosis of PCO is for the most part based on clinical grounds. We want to rule out other abnormalities, like thyroid dysfunction, prolactin disorders, some rare situations like congenital adrenal hyperplasia, certain tumors.” Greenhouse says that the majority of women with irregular cycles have polycystic ovaries, but that in many cases, their menstrual cycles have unknowingly been made to appear normal when regulated through the use of oral contraceptives. “The classic case that we see is women who explain that they stopped taking birth control pills and then started seeing the other symptoms of PCO, like abnormal hair growth.”
More Than Infertility
More recent news about PCOS has developed out of the growing body of related research that links the condition to serious health consequences. While infertility is tremendously distressing and life-altering, women with PCOS are now being warned that even worse conditions can result without treatment. “Women come to us with a focus on getting pregnant, but we really have to educate them about looking at the long-term health consequences as well,” Dr. Greenhouse warns. One of the causes of PCO is an insensitivity to insulin, which in turn causes the androgen excess. From there, the result is a higher incidence of gestational diabetes and greater risk factors — such as abnormal cholesterol profiles — for cardiovascular disease. There is also a higher incidence of endometrial cancer in women who have gone for long periods of time without menstruating.
Another tidbit of information that was a frequent part of the earliest public discussions is regarding women’s weight and PCOS. Unfortunately, word that spread made it sound as though all women with PCOS are overweight. Dr. Greenhouse says that’s not actually the case. He details, “We know that 50 percent of women with polycystic ovaries are thin, but even they have insulin resistance that is consistent with women who have regular menstrual cycles but who are obese.”
The Matter of Weight
Still, the impact of weight on PCOS and related infertility are undeniable. Being overweight increases the severity of insulin resistance and further drives the process. “Studies have shown that even weight loss of only five percent will actually lower androgen levels by significant levels, say, 20 percent. Some studies say that upward of 50 percent of these women [who lose weight] will actually have restored menstrual cycles.” Greenhouse states the common opinion that physicians are seeing a higher incidence of PCO due to the increasing prevalence of obesity in the United States.
Discussions about the connection of weight with PCO must clarify that Body Mass Index (BMI) alone is not enough to consider. “You have to also count the body structure, that is, the size of a woman’s frame when you’re looking at whether or not her weight is a health issue. Just as the symptom of unwanted hair growth is of a specific pattern, so the distribution of weight on a woman’s body appears to be important. Women with obesity around the abdomen is associated with insulin resistance more than being heavy in the thighs or buttocks.”
Greenhouse explains there have been some recent gradual changes in the treatment of PCOS. “We all jumped on the glucophage bandwagon at first, believing it might be the ‘magic bullet’ to solving this problem.” Glucophage, known also by its brand name Metformin, is an insulin-sensitizing agent. He continues, “What we’ve seen is that weight loss is much more important therapy that leads to menstrual regularity and enhanced health. We’re now encouraging more women to consider weight loss a primary recommendation.” Neither Greenhouse nor other fertility specialists would recommend drastic measures such as bariatric surgery for most patients.
Treating the Whole Syndrome
“We have to look at our goal as fertility specialists,” Greenhouse says, “While the patient may indeed have PCO, we have to rule out any other possible infertility factors for a couple, such as male factor. Then our goal is to facilitate the ovulation of one good quality egg in her cycles.” Greenhouse says that around 60 percent of women who go on to achieve ovulation will conceive within three to four cycles. For those who do not, more invasive diagnostic procedures, such as hysterosalpingogram (HSG) should be considered to rule out blocked fallopian tubes.
Currently, PCO patients are put on an initial trial of clomiphene citrate (brand name, Clomid) up to 100 mg. If ovulation does not occur, then Metformin is prescribed. Some women with PCO are quite sensitive to fertility medications and prone to hyperstimulation, resulting in too many eggs with increased risk of multiple pregnancies. For them, IVF is suggested as the safest form of treatment. Previous treatments, such as steroid medications like dexamethasone and surgery known as wedge resection, are no longer favored by specialists because of their side effects and relative lack of effectiveness in promoting ovulation. Another surgical procedure known as ovarian drilling can be successful in helping restore ovulation, but Greenhouse says, “It’s fallen by the wayside because of the relative success of Metformin and because of concerns about adhesion formation following surgery. The patient may wind up acquiring tubal factor infertility because of having the surgery to correct for anovulation.” For patients with irregular cycles but who have religious or moral reasons that make fertility treatment not an acceptable option, ovarian drilling might be warranted.
In light of the multiple effects on a woman’s health of this disorder, specialists like Greenhouse try to work in conjunction with other care providers for the patients’ overall benefit. They coordinate care with a network of providers — general practitioners, nutritionists, medical endocrinologists — to meet the myriad health needs related to PCO. Overweight patients in particular warrant special attention.
“I had a patient recently who lost 110 pounds through exercise and diet. She had been trying for years. When we told her that she needed to lose weight from a perspective of her health and not just to get pregnant, it was great motivation. She was so proud of herself, and her whole life changed, from sleeping better to feeling better every day.”
For the many women with PCOS who come to Shady Grove Fertility hoping only to get pregnant, learning about the additional effects of the disease is eye opening. The good news now is that research is documenting just how much of a positive impact lifestyle changes can have on these women’s overall health and chances at longevity, in addition to fertility.