PCOS

Women's Health Center 555 Midtowne St. Suite 300 Grand Rapids, MI 49503 (800) 695-5941 (616) 774-2030

 

You Were Told You Had “PCOS” - What Does This Mean???

“PCOS” or “polycystic ovaries” is a common diagnosis for the woman who does not ovulate. The term “PCOS” was originally applied to the triad of Obesity, Hirsutism, and Infertility prior to our present understanding of ovulation. Over the last 3 decades the term has “evolved” and “PCOS” is often applied to any anovulatory woman without regard to the cause of the anovulation. I feel that this is inappropriate. It may be implied that a patients symptoms and findings are caused by the “PCOS”. This is rarely the case. Rather “PCOS” is the end result of physiologic and genetic conditions NOT the cause of these conditions. Due to the chronic misuse of the term “PCOS” I prefer to avoid its use and address the underlying causes of the anovulation.

I believe that patients should be classified by the underlying genetic and physiologic conditions that cause their ovulation. This approach helps both patient and physician focus on the aspects of care that need to be addressed rather than being distracted by the symptom of anovulation and resulting infertility. In this brochure I will be using “pure” examples of the various conditions. It is important to remember that there is a spectrum of symptoms and they are often inter-mixed in an individual case.

Rather then “PCOS” I propose that a woman be evaluated by 2 criteria:

1) Does she ovulate?

2) Does she have Metabolic Syndrome?

Criteria one is easy to understand. Does she have a regular cycle with the release of a mature oocyte and the potential for pregnancy? If you ovulate you were probably not told you have “PCOS” but please read about Metabolic Syndrome. An ovulatory woman with metabolic syndrome should be treated for the metabolic syndrome.

If you don’t ovulate, and your TSH (Thyroid Stimulating Hormone) and Prolactin are normal, you may have been told you have “PCOS”. To better classify the cause and potential treatment of your anovulation I recommend asking/answering 3 questions:

1) Is there a family history of Heart Disease or Adult Onset Diabetes that indicates a risk for Metabolic Syndrome and/or Insulin Resistance?
2) Are there physical finding and laboratory findings of Metabolic Syndrome?
3) What is the Oocyte reserve?

Please notice that very little hormonal testing is involved in the diagnostic process once anovulation has been identified.


What you need to know about your Family History

For your parents and grandparents you need to know about their medical history:

1) Central Obesity (Weight in trunk/gut rather than hips and thighs)
2) History of vascular heart disease, cerebral vascular disease, or peripheral vascular disease before age 70 (heart attack, poor circulation, or stroke)
3) Elevated Blood pressure
4) Elevated Cholesterol
5) Adult Onset Diabetes before age 70
6) For the women: infertility and hirsutism (“male type” hair) - NOT infertility alone

For each parent & grandparent evaluate the total number of risks and fill in the chart

Mother________________x2 = ___________
Maternal GM ___________x1 = ___________
Maternal GF ___________ x1 = ___________
Father________________ x2 = ___________
Paternal GM ___________ x1 = ___________
Maternal GF ___________ x1 = ___________

Total Risk Score ___________

Family Metabolic Risk Score Criteria Minimal risk 0-5 Mild risk 6-10
Moderate risk 11-19 High risk >20

What evidence is there I have metabolic Syndrome? What risks do you have? Assess how many of the risks you have based on your history, physical appearance, and laboratory results. Some Risks may appear as you get older.

Your Risk factors ___________ x5 = _____________

Family Risk score from above _____________

Total Risk Score _____________

Total risk Score Criteria Minimal risk 0-9
Mild risk 10-14
Moderate Risk 15-24
High Risk >24

If your total risk score indicates Moderate to High Risk you should be followed through out your life for the risk of vascular disease and/or adult onset diabetes. You should follow recommendations to control your weight, blood pressure and cholesterol. You are at higher risk for long term health issues if you smoke. For the treatment of anovulation you may benefit from drugs that combat insulin resistance (Metformin®).

If you have Minimal to Mild Risk then Metformin® will be less affective as a treatment for anovulation. Not smoking is still important.

What is Ovarian Reserve and how is it determined?

There is a tendency to view ovarian reserve, the number of oocytes available each cycle, as only a function of age and that all women of a given age will have the same oocyte reserve. Observational data in our patients does NOT support this view. Like the sperm count in a male, oocyte number vary markedly from woman to woman. Similar to a sperm count, the oocyte count does not tell us about oocyte function. Male fertility is determined by how well the sperm do their “job” which is to fertilize the oocyte. Males with low sperm counts but high sperm function will father pregnancies. The oocytes “job” is to recognize that it has been fertilized and to become an embryo. A woman with a small number of highly fertile oocytes will conceive easily. A woman with a high number of subfertile oocytes will not conceive easily.

Therefore oocyte reserve alone does not reveal fertility potential. Low oocyte reserve has an impact on fertility treatment by limiting the treatment options. High follicle reserve may lead to anovulation and a risk of multiple pregnancy with treatment.

Oocyte reserve is best determined by a transvaginal ultrasound on cycle day #3, though in a woman with anovulation any day of
the cycle is adequate.

Low oocyte reserve rarely causes anovulation except with impending menopause. Low oocyte reserve results in a mild elevation in FSH (Follicle Stimulating Hormone, the hormone in the “fertility shots” Follistim® and Gonadal F®). FSH is the primary stimulant of follicle maturation. This will lead to ovulation in a woman with factors that normally prevent ovulation, such as Metabolic Syndrome. A mild elevation in FSH can lead to more than 1 oocyte ovulating. Low oocyte reserve is common in the late 30’s and 40’s and is one of the reasons for the limited success of IVF and other fertility treatments.

High oocyte reserve or PFO (polyfollicular ovaries) has the opposite impact. The woman has an excess of oocytes available for stimulation. A large number of early small follicles will cause a low FSH. If the FSH is not adequate to mature any of the follicles ovulation does not occur. This is common in teenagers. As the woman ages the follicle/oocyte number decreases. If no other factors intervene most women with PFO eventually decrease their follicle number to the point that ovulation occurs. For some women this may be age 20 for others it may be 40. Many of these women are anovultory without any component of Metabolic Syndrome.

Is all obesity Metabolic Syndrome? Central (trunk) obesity is a hallmark of Metabolic Syndrome. Weight in the hips, thighs and distal extremities does not contribute to Metabolic Syndrome. However, peripheral obesity still impacts hormonal metabolism and aggravates insulin resistance. Any excess weight results in increased conversion of weak sex steroids (from the ovary and adrenal) to estradiol and testosterone by adipose cells and dermal cells. The ovulation control center in the brain is incapable of determining the source of these hormones, only the total amount. Adipose cells and their supporting cells will also increase insulin resistance. Both of these factors contribute to anovulation. Central obesity has the greatest impact but “peripheral” obesity has a similar, though weaker, effect.

Putting it all together with the (an)ovulation triangle

I encourage patients and physicians to evaluate the various contributing factors using the ovulatory triangle. The triangle has Metabolic Syndrome Risks on the base, represented by insulin resistance and obesity and has follicle reserve at the apex. A mild to moderate risk + or large risk ++ is placed in the corners as positive findings and the net effect determined. Here are 3 examples:

Why is this important?

Each of these risk patterns has a “best treatment”. In patients with excess weight letrizole (aromatase inhibitor) will counteract the conversion of weak sex steroids to estradiol. Clomiphene (anti - estradiol) will “lower” the perceived estradiol concentration in the brain. However, the treatment of choice is weight loss.

A woman with family history of adult onset diabetes and elevated cholesterol would benefit from diet to lower cholesterol and perhaps a “statin” drug prior to pregnancy. Metformin® or another insulin resistance modifier would be beneficial.

Neither of these treatments would be useful for the woman with normal weight, a negative family history, and polyfollicular ovaries. Most women with PFO will require FSH medications. They will be at high risk for hyperstimulation syndrome and for high order multiple pregnancy. IVF may be the treatment of choice to lower these risks.

The woman with true “PCOS” is at the greatest risk for complications prior to, during, and after pregnancy. Careful diagnosis and treatment offers the opportunity to lower these risks for mother and fetus.

By identifying the factors contributing to anovulation the treatment can be tailored to maximize the success of ovulation induction while minimizing the risk. There is also the opportunity to identify conditions and predispositions that will have long term health consequences if not effectively treated. It is important to emphasize that treatment does not end with ovulation and conception. It requires a lifetime effort aimed at controlling risk and limiting complications when Metabolic Syndrome exists.

Successful control of the underlying conditions will allow treatments aimed at improving Hirsutism (excessive male hair growth) and Acne to be more effective. (see Hirsutism Brochure)

DOUGLAS C. DALY, M.D.

Douglas C. Daly, M.D., is a graduate of the University of Connecticut School of Medicine and completed his Reproductive Endocrinology Fellowship in 1982 at the same institution.  Board Certified in Obstetrics, Gynecology and Reproductive Endocrinology, Dr. Daly is a Fellow of the American College of Obstetrics and Gynecology (F.A.C.O.G.) and a member of the American Society of Reproductive Medicine (ASRM).  In 1991 he assumed leadership of the Assisted Reproductive Program at Blodgett Memorial Medical Center, now known as Spectrum Health East. This program maintains membership in the Society for Assisted Reproductive Technology (S.A.R.T.) and abides by the regulations and guidelines of this organization.  Dr. Daly is also a Clinical Associate Professor in Obstetrics and Gynecology at Michigan State University (MSU). He is an active staff member of Spectrum Health Downtown (Butterworth) and St. Mary's Hospital.

CONCLUSION

We hope this brochure has been helpful in providing basic information about our practice. If you need additional information, any of our staff will be happy to help you.  Our goal is to provide you with the highest quality care available.