The key to successful management of polycystic ovarian syndrome is identifying and aggressively treating high risk women early in the progression of clinical symptoms. Many health care providers dismiss the diagnosis of PCOS because of the general assumption that most women will present with the classic features of absent menses, infertility, obesity and male pattern hair growth or balding. As I pointed out in my last post, the clinical presentation of this disorder may vary considerably among women. Not all women have the skin manifestations of elevated testosterone and some women may actually have regular menstrual cycles. Furthermore, not all women with PCOS are obese.
Many of the women I see in my practice that will eventually be diagnosed PCOS typically presented with complaints of fatigue and abnormal weight gain, followed by abnormal menses and unwanted hair growth. The diagnostic work up for PCOS is fairly comprehensive and includes extensive hormonal and metabolic testing. Testing for excessive cortisol production, thyroid or adrenal disease is recommended to rule out other medical conditions. There is some controversy as to how to accurately test for insulin resistance. Measuring insulin is difficult and not always a true reflection of underlying insulin resistance. In my professional opinion, any woman that is gaining weight around her mid-section is insulin resistant. I do include certain markers of insulin resistance in my initial lab work up but do not put much significance on a “normal” level in a woman that has the clinical features of insulin resistance. I am more interested to know where a woman stands in relationship to their blood sugar control and always test for the presence of impaired glucose tolerance and type 2 diabetes. In some cases, when the diagnosis is unclear, I may perform a 2 hour glucose challenge with insulin levels to further evaluate a woman’s underlying insulin-glucose metabolism. Lastly, some women will need a pelvic ultrasound performed for further diagnostic clarification. Once the diagnosis of PCOS is confirmed there are 3 major areas I focus on; the underlying metabolic disorder, the hormonal imbalance, and the skin manifestations that cause a tremendous amount of stress for some women.
Lifestyle changes that target the underlying insulin resistance, such as a low simple sugar diet and exercise, are imperative. I discussed this in detail in my January posts on Peeling the Pounds. Women with PCOS typically have a genetic predisposition to severe insulin resistance. This puts them a higher risk for developing type 2 diabetes at a much younger age than the average woman. The studies that look at lifestyle modification alone do not show promising outcomes in these highly insulin resistant women. Because of this, I have a very low threshold for starting metformin, which is an insulin sensitizer that is indicated in the treatment of PCOS. Metformin, used as an adjunct to lifestyle changes, will help decrease insulin resistance and usually help with weight loss efforts. For many women this is a vicious cycle – the high degree of insulin resistance makes it very easy for them to gain and very challenging to lose weight. The more weight a woman gains, the more insulin resistant she becomes which exacerbates all of the other clinical consequences of this disorder. While this is incredibly frustrating, improving insulin resistance and weight loss are essential to improving the clinical symptoms and outcomes in the women with PCOS. Yes, it seems like an uphill battle but with the right approach and realistic expectations it can be done!
The underlying insulin imbalance with PCOS triggers a cascade of hormonal catastrophes that result elevated free testosterone, which in turn suppresses ovulation leading to estrogen dominance and menstrual irregularities. Studies show that treatment with metformin, used in conjunction with lifestyle changes, can restore normal menstrual regularity in up to 60% of women. This typically takes a relatively high dose (average 1500 mg daily) for up to 6 months before menstrual balance is restored. Unfortunately, not all women can tolerate high dose metformin due to the potential gastrointestinal side affects.
Oral contraceptives have been one of traditional approaches used to manage the hormonal imbalance and menstrual irregularities associated with PCOS. In my current practice, I am more likely to recommend this in women that may benefit from the suppressant effects that oral contraceptives have on elevated testosterone levels and their associated clinical features such as severe acne and dark facial hair. I do recognize that this is a risk vs. benefit treatment strategy. I will discuss the risks versus benefits of various forms of hormonal therapy in an upcoming blog. More recently, I have started to offer bio-identical progesterone cream to treat the estrogen dominance associated with anovulatory cycles. Women having difficulty conceiving may also use the fertility drug clomid to stimulate ovulation.
Lastly, but certain not of less significance, is the treatment of the skin manifestations of elevated testosterone. My worst case was a young woman, who at age 14 years old, had to shave her face, chest and abdomen on a daily basis. I have also seen women in their thirties and forties with severe male pattern balding as a result of undiagnosed PCOS. While these are certainly extreme cases, any unwanted hair growth or scalp hair loss can have a devastating impact on her self esteem. Managing the skin manifestations of PCOS can be challenging. Treatment of acne typically responds to oral contraceptives, natural progesterone cream and topical antibiotics. Managing unwanted facial hair is much more challenging. Hair follicles have a 6 month life span, making the response to therapy very slow. Initial treatment should be targeted at decreasing the testosterone levels. This can be done with oral contraceptives and/or spironolactone, a drug that decreases testosterone’s impact on the hair follicle. Vaniqa is a topical cream that also helps slow hair growth but the fact that it is expensive and typically not covered by insurance companies makes it’s use limited for some women. I typically do not recommend electrolysis or laser hair therapy until the underlying testosterone levels have been suppressed.
In summary, the consequence of PCOS are far reaching. I typically recommend an aggressive approach targeted at insulin resistance, hormonal imbalance and the skin manifestations. Keep in mind the women with PCOS are at risk for many other health related consequences associated with the underlying conditions such as abnormal cholesterol, cardiovascular issues, migraines and various other chronic symptoms.