Polycystic Ovarian Syndrome
(PCOS)
The diagnosis of PCOS is typically a
clinical one. These patients are typically overweight
andhave 6 or fewer cycles per year, thus, by definition
have decreased or absent ovulation. Nevertheless, many
women with PCOS are very thin (or not overweight) and
simply have irregular cycles (perhaps cycles every 45-90
days or more). PCOS is a common cause of infertility
in women and may also be associated with elevated levels
of male hormones (androgens) and ovaries that have multiple
follicles (cysts) on their surface. PCOS patients are
often resistant to insulin, a condition known as hyperinsulinemia.
The elevated levels of insulin lead to overproduction
of androgens (male hormones) by the ovaries.
Elevated levels of androgens cause the
expression of male characteristics such as increased
body hair (hirsuitism) and acne. PCOS patients often
have a characteristic "pear shaped" body appearance,
exhibit irregular ovulation, and are overweight. However,
women who are not overweight can also have PCOS. Weight
reduction will often correct PCOS because androgens
are also converted to estrogens in the fat cells. It
is very difficult for women with PCOS to loose
weight.
Women with suspected PCOS should see
a reproductive endocrinologist for a complete evaluation.
PCOS is a complex condition and patients must be carefully
managed as it can have long term health consequences
such as diabetes and increased risk for cardiovascular
disease.
Anovulatory (no ovulation) or oligoovulatory
(decreased frequency of ovulation) in women with PCOS
are usually initially treated with Clomid (clomiphene
citrate). The starting dose is 50 mg or 100mg for five
days of the menstrual cycle. If ovulation occurs, as
evidenced by ultrasound confirmation of follicular development,
or elevated levels of progesterone, Clomid may be continued
for three to six months. Clomid may be increased by
50 mg each cycle if ovulation does not occur at a lower
dose. The usual maximum dose is 200 - 250mg for 5 days
(cycle days 3-7 or 5-9).
Many specialists now use Glucophage
(metformin) as a "first line" treatment for
PCOS. Metformin sensitizes the cells to insulin and
corrects the underlying problem of hyperinsulinemia
(elevated insulin). Once this condition is corrected,
the ovaries reduce their production of androgens and
ovulation can occur in up to 20% of patients without
the additional use of Clomid. Sometimes Clomid and Metformin
are given simultaneously. Many specialists recommend
continuing metformin therapy "long term" to
help prevent the adverse health consequences such as
diabetes and increased cardiovascular risk.
If regular ovulation is not established
with Clomid, metformin, or Clomid & Metformin; follicle
stimulating hormone (FSH) is the next step. FSH (injectable
drugs) with intrauterine insemination is also employed
as the "next step" when pregnancy has not
occurred after three to six ovulatory cycles on the
Clomid or metformin regimens.
All PCOS patients undergoing ovulation
induction with FSH should be managed by a reproductive
endocrinologist. PCOS patients have a higher incidence
of complications, such as ovarian hyperstimulation syndrome.
Dosages must be carefully adjusted based upon estradiol
hormone levels, ultrasound measurements, and clinical
experience.
What is Syndrome O?
Ronald F. Feinberg, MD, PhD, FACOG
IVF Medical Director,Reproductive Associates of Delaware
Associate Professor ,Adjunct Yale University School
of Medicine
Chairman, Professional Advisory Board for PCO Strategies
, Inc.
Board Certified in Reproductive Endocrinology &
Infertility
Board Certified in Obstetrics & Gynecology
Everyday, millions of women are struggling
with heartbreaking problems - infertility, miscarriage,
obesity, and cosmetic nightmares unimaginable to most
men. Most of these women suffer in silence, since they
don't know where to turn for help. Persistent frustration
also pervades the lives of women who do seek care, aggravated
by frequent doctor visits and costly, sometimes risky,
fertility treatments. If that's not enough, there are
the gynecologic "lady's problems" for countless
others - missed menstrual cycles, heavy and unpredictable
vaginal bleeding, bad reactions to birth control pills,
and even unnecessary hysterectomy operations.
Amazingly, all of these diverse female
health problems are closely related - a fact that is
often not recognized by most doctors and nurses. Alternatively,
many women are told by their health providers that they
may have 'polycystic ovaries' or polycystic ovary syndrome
(PCOS), a clinical label which doesn't really explain
the root of their problem.
Syndrome O can be thought of as the
'World War III' of hormones in a woman's body - causing
metabolism to be entirely out-of-whack, wreaking havoc
with the possibility of getting pregnant and staying
pregnant, and unraveling the normal sequence of hormone
changes during the menstrual cycle. Left unchecked,
Syndrome O leads to profound instability within the
intricate internet of hormones and glands linking women's
metabolism and reproduction. While the ovaries do bear
a major brunt of Syndrome O, a cascade of hormonal disturbances
occurs throughout the body, interfering with normal
fertility and healthy pregnancies.
Syndrome O can also progress to much
more serious medical complications - diabetes, uterine
cancer, and heart disease - sometimes in young women.
Only recently have these uniquely female health issues
been linked to an imbalance in the insulin family of
hormones. Essentially, the entire body can become the
innocent victim of an exploding modern health phenomenon
- the overproduction of insulin.
To read more about this modern epidemic
affecting women everywhere, check out www.pcostrategies.org
and www.ivf-de.org. PCOStrategies, a nonprofit organization,
has gained national recognition for its devotion to
education and research for women with Syndrome O and
polycystic ovaries.
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