There is no single distinctive examination or fertility test to diagnose PCOS, however, PCOS patients usually have elevated androgens (male hormones) and cysts can often be observed on the ovaries. There is a strong association between PCOS and insulin resistance with at least 50 percent of women with PCOS being insulin resistant. Several blood tests will be conducted including androgen levels fasting comprehensive lipid panel, glucose, luteinizing hormone (LH) and follicle stimulating hormone (FSH), free testosterone, prolactin and thyroid stimulating hormone (TSH).
Syndrome X is a new term, which denotes a combination of insulin resistance or diabetes, dyslipidemia, hypertension and central obesity. While insulin resistance and type II diabetes are frequently associated with obesity, there are thin women who are afflicted as well. Syndrome X may be identified in women with PCOS.
Fertility Drugs and PCOS
Clomid or letrozole with metformin- Clomid and Letrozole are both medications used to induce ovulation and their effects and pregnancy rates are improved in PCOS patients if used in combination with Metformin used at 500 mg three times a day.
Injectable medication- such as (Gonal-F, Follistim , Repronex, Bravelle, Pergonal) are medications used to stimulate the ovaries directly to produce several follicles and improve pregnancy rates.
IVF- In vitro fertilization is a process where the ovarian follicles are aspirated under ultrasound guidance and fertilized with sperm in a Petri dish to form embryos which are cultured from 3-5 days and when mature are transferred to the uterus.
Infertility Nutrition and PCOS
“Slow” weight loss may help fertility in overweight women with PCOS. The best way to lose weight is slowly with lifestyle changes, to include more exercise, as opposed to transitory diet modifications.
There is no ideal diet, but there is some support for reducing carbohydrates. Reducing carbohydrates to 45% of the calories and replacing carbohydrates with foods high in omega 3 and omega 6 acids found in “fatty” fish, nuts, and olive and canola oils. For most effective improvement in insulin resistance, carbohydrates combined with proteins and fats should be distributed evenly between meals and snacks.
Exercise can help use glucose in the bloodstream for energy and thereby help reduce blood glucose levels. Dietary modifications coupled with an exercise program to best establish weight loss.
Along with diet and exercise, additional benefits can be achieved with the use of fertility drugs. Insulin-sensitizing medications, such as metformin, decrease insulin resistance, improve ovulation and may increase the egg quality.
Weight Loss, Nutrition Program for PCOS
Many women with PCOS struggle with being overweight. PCOS women often find it difficult to loose weight even with dramatic decreases in their food intake. Women with PCOS are at high risk for impaired glucose/insulin metabolism and diabetes. Therefore, it is important to follow a diet regimen appropriate to manage the condition and minimize the risk factors. At the Center for Women’s Medicine, a nutritionist will tailor a specific program that will depend on the patient’s individual goals. Some or her suggestions are listed below.
There is no ‘ideal” diet, but there is some evidence to support reducing total carbohydrates to 40-44% of total daily calories. Our nutritionist recommends a MINIMUM of 130gm of carbohydrates per day to support proper body functions.
Ideally, you should eat three main meals and three snacks daily. However, the ideal regimen may not be appropriate for you, or fit your lifestyle. If that is the case, make sure your consume AT LEAST three meals per day with no more than 4 hours between each meal. If time between meals prolongs over four hours, make sure you have a snack in between.
Eat breakfast within two hours of waking up. When you sleep, your body is in a fasting state, which if prolonged (by not eating breakfast), can result in poor glucose/insulin metabolism control and increased weight gain.
It has been demonstrated that a weight reduction of 5-10% of your body weight can help restore ovulation and improve insulin sensitivity. A weight loss regimen of MAXIMUM two pounds a week is recommended for effective long term success.
Avoid consuming excess refined carbohydrates and sugars, usually present in processed foods, as these will lead to higher spikes in insulin and promote a more aggressive insulin response in your body.
Fiber found in fruits, vegetables, oat bran, barley and legumes prevents constipation and diarrhea, allows you to eliminate toxins, and decreases cholesterol.
NEVER skip breakfast or other meals to reduce calories as this will increase your good cravings, decrease satiety, and result in weight gain.
A diet high in fiber (25-35 gm/day) can reduce insulin peaks and excess levels of estrogen which improves PCOS symptoms. Higher fiber contents can also help with weight loss and curb appetite by increasing your satiety.
Include foods high in monounsaturated fats and high in omega 3 and omega 6 fatty acids, which are found in “fatty fish”, nuts, olive oil, and canola oil.
There are micronutrients that improve insulin action and reduce insulin production. These include chromium, calcium, biotin, selenium, B-complex vitamins, vitamin C, vitamin E, alpha lipoic acid, and zinc. Other nutrients that improve insulin metabolism include: American ginseng, gymnema leaf extract, and green tea polyphenols.
We also encourage you to exercise for at least 30 minutes on most days of the week to better compliment your diet regimen and to maintain overall health.
Metformin/Glucophage works by suppressing hepatic glucose production and increasing glucose utilization in peripheral tissues. It cannot be used in all women including those who have kidney or liver disease. Common side effects include nausea and diarrhea, which usually lessen over time and usually abate after 3-4 weeks at the same dose. The extended release glucophage has lower side effects and these can be minimized if the medication is taken with meals.
Some fertility specialists prescribe insulin-sensitizing medications to women with PCOS regardless of their insulin sensitivity. In addition, insulin-sensitizing medications can be used while trying to conceive. Even though more studies are needed to firmly establish the benefits, many improvements in symptoms are seen and ovulation resumes.
Metformin should not be taken for 48 hours prior to any X-ray procedure in which iodinated compounds will be used, including the hysterosalpingogram (HSG) where contrast dye is injected into the uterus.
If an insulin-sensitizing medication is taken for 3-6 months without ovulation or pregnancy, then additional fertility medications may be considered. Ovulation stimulation drugs, such as Clomid, letrozole and FSH, can be taken in conjunction with insulin-sensitizing medication .
Surgical Treatments for PCOS
Other PCOS treatment options to induce ovulation may include ovarian drilling. Ovarian drilling is often preformed laparoscopically. A small needle, carrying an electric current, punctures and destroys small portions of the ovary. This procedure will restore ovulation in approximately 60-70% of women. However, it is associated with increased risk of scarring (80%), which may in turn decrease the pregnancy rate.
PCOS Cosmetic Issues
Thickening and dark areas around the neck, groin , underarms and skin folds. This is due to excess insulin and may be a sign of underlying insulin abnormality. Reducing the levels of insulin may lighten the patches and Retin-A may also be effective in reducing the skin color and thickness.
PCOS can cause cosmetic concerns because of the increased levels of male hormones (androgens). Increase androgens can cause conditions such as acne where sebum plugs the skin pores thus allowing bacteria to thrive. Other skin aggravations include acanthosis nigricans or darkened skins spots, which can often be lightened after weight loss and hormone balance.
Women who are not attempting conception may use birth control pills, which will restore normal menstrual cycles and decrease elevated testosterone levels.
PCOS and Thinning Hair
Hair loss around the scalp is called androgenic alopecia and is due to an increase in androgens causing hair “thinning”
Current Treatment for Thinning Hair
Oral contraceptives and spironolactone are often effective in reducing androgens. Minoxidil or Rogaine have been moderately effective in re growing hair and must be used continuously. Retin-A may also be effective alone or in combination with Rogaine.
Can be found at any age and it is often due to excess androgens. Oral contraceptives in combination with antibiotics can be effective, Accutane have varying degrees of success.
Hirsuitism (Excess body hair)
Elevated testosterone can cause thinning scalp hair and hirsutism, which is excess facial hair. Approximately 25% of PCOS patients complain of excess hair and approximately 5-15 % of women with hirsutism have no underlying cause.
Normalization of testosterone can be achieved with a combination of oral contraceptives and Aldactone. Aldactone is a diuretic (water pill) that is often prescribed as 100 mg twice daily.
Note: Women taking over the counter DHEA and androstenedione may cause excess hair growth.
Medical treatment of hair growth may take up to six (6) months. Other methods may include electrolysis and laser. Electrolysis requires frequent and multiple sessions which may be painful. Laser is used but may cause skin damage and is slightly less effective. Laser is helpful in women with dark hair and lighter skin. It is not advisable to wax or pluck hair.
Once diagnosed with hirsutism, you may be placed on a treatment plan. This plan may include oral contraceptives and Aldactone, both used to suppress the elevated androgens. In women with PCOS, Metformin may be used. In addition DFMO cream may be prescribed.