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GAINING
WEIGHT
Candy: What can I do to stop gaining weight? My testosterone
is really high but I am on clomid so can't take any medications
that will harm a possible pregnancy. I have tried carbohydrates
diet but because I am a fussy eater don't eat many items on that
list. I also have a treadmill and a few free weights that I use
regularly.
Dr.
Thatcher: I know I will offend some with this comment, but
weight is gained when the calories consumed are greater than the
calories used. Weight is lost by either decreasing calorie intake
or increasing physical activity. I believe this is an absolute
truth. HOWEVER, I am convinced those with PCOS utilize calories
differently. Many with PCOS have high insulin levels. With increased
insulin the body is programmed to hold on to every calorie and
store them as fat. As weight increases, insulin increases, and
then weight increases more. It can be a hopeless spiral down.
It would be great if you could find a nutritionist who could help
you analyze and possibly improve your eating habits. Some may
find help with metformin and I believe an evaluation for insulin
resistance can provide an important insight into PCOS and its
therapy.
STARTING
BACK FERTILITY THERAPY AFTER SUCCESSFUL PREGNANCY
Michele: I have PCOS and we got pregnant using fertinex. My
cycles seemed to become more stable after having our son, and
we want to try again. Should we go right back to fertinex, or,
since I seem to be have somewhat regular cycles, should we do
something else? Time is an issue. I am 38 now.
Dr.
Thatcher: I have two conflicting statements. The first is
that I go back with what has worked in the past. Fertinex or Gonal-F
would be a good place to start. The second is that with the new
insulin altering drugs and possible improvement in your ovarian
function after pregnancy, you might take a less aggressive first
step. Cycles tend to become more regular in PCOS between 35 and
45, but this is also a period of fertility decline. Your age is
a concern and would cause me to be more aggressive. One of the
first steps in your evaluation should be a FSH and Estradiol level
on cycle day two or three.
"LOW
CARBING"
Liz: Do you recommend a low-carb diet for woman with PCOS?
Dr.
Thatcher: Many with PCOS have success with low carbohydrate
diets. Terms such as glycemic index have been employed to explain
the capacity of certain foods to increase insulin. I believe that
most low carbohydrates diets are mainly calorie restrictive diets
and this is why weight is lost. The goal should be balanced good
nutrition. A reduction of 250 to 500 calories a day in addition
to a modest increase in activity can have very positive benefits
for most with PCOS. "Diets" as such are almost always doomed to
fail and "yo yo dieting" can have negative health benefits.
The key is lifestyle changes that can be maintained forever. We
usually aim at about a 10% weight loss as a realistic goal for
most.
INSULIN
ALTERING DRUGS
Michele: What is the current thinking on the best treatment
of PCOS? The doctors I have seen always recommend either birth
control pills or Clomid (if I want to get pregnant). It seems
like there must be something new out there!
Dr.
Thatcher: At least 50% of PCOS appears to have a component
of abnormal glucose tolerance, increased insulin or insulin resistance.
In part by accident, it was stumbled on that insulin-altering
drugs generally used in the treatment of diabetes were successful
in regulating periods, promoting ovulation and increasing fertility.
These drugs have not received FDA approval for this use, but have
become widely employed. We now have a therapy that actually treats
the cause of PCOS rather than just overpowering or suppressing
it. The principle first line therapy is metformin (Glucophage)
which often has the benefit of weight loss, but has GI side-effects.
The second group of drugs include Actos and Avandia and directly
reduce insulin. The success of these agents seems to be at least
as good as clomiphene and sometimes work when all else fails.
Still, they are not perfect and should be discussed in detail
with your physician, and best used after appropriate lab testing.
PREGNANCY
WITH ELEVATED FSH LEVEL
Penny: I was diagnosed with possible ovarian depletion
in summer '98 (FSH of 11.9-13: other values normal) at the age
of 40. With the help of alternative therapies, I got pregnant
in a couple of months, just before I was to start Gonal-F treatment.
I've never been sure if my original diagnosis was too doom-laden,
if I turned it around with my own research and treatment (my cycles
certainly became longer and my periods much fuller), or if I just
got really lucky. I have a beautiful son of 18 months, who is
still nursing heavily, including at night. I have only recently
returned to regular cycles, and my question is: has the prolonged
amenorrhea (over two years including the pregnancy) done anything
to preserve whatever fertility I have left? In other words, can
I assume that I am more or less where I was two years ago? I ask
this because I am 42.8 and would love to have another child, but
my husband has no interest in trying for one till his professional
life (and our financial situation) turns around. I can't seem
to get a straight answer to this question - maybe there isn't
one! Thanks for your input.
Dr.
Thatcher: An elevated FSH, which yours was, does not exclude
a pregnancy, just predicts the response to ovarian stimulation
with medications. The body attempts to preserve ovulation for
as long as it can. With massive amounts of fertility drugs still
you may have only ovulated a single egg. Your story is not
uncommon, but unfortunately, the miscarriage rate is increased.
Obviously, you were smiled upon. I would repeat the FSH level.
I do not know of significant risks, other than financial, of fertility
therapy, but it may be a rough trip emotionally and one you might
decide to avoid.
THERAPY
FOR LOW SPERM COUNTS
Nancy:
My husband has a very low sperm count. Luckily, we were able to
conceive naturally last winter. Do you have any suggestions to
increase our chances of this happening again in the future. This
pregnancy took 6 years to come even with 2 AI attempts.
Dr.
Thatcher: I might suggest cycle tracking with basal body temperature
(BBT) and ovulation prediction kits (OPK). Recent research has
shown that properly timed intrauterine insemination (IUI) can
also be of value. Your chances of pregnancy after assisted reproduction
(in vitro fertilization IVF with sperm injection ICSI) may be
excellent, but this is a completely different story.
TUBAL
STERILIZATION REVERSAL
Kim: Once a woman has a tubal ligation, is there any way
of reversing? Is there a time limit when it could be successful?
What are the statistics for having children after a tubal reversal?
Dr.
Thatcher: Tubal sterilization reversal is certainly possible
in many cases, but it is a lot more difficult than the initial
sterilization procedure. It usually involves an abdominal incision
a prolonged surgery using the operating microscope and a 3-6 week
recovery period. An alternative that some may choose is in vitro
fertilization. Clearly do your homework well and feel very comfortable
with your decision and physician.
The
procedure is usually expensive and often not covered by insurance.
An all inclusive cost is $6000 to $10000. A small number of centers
are doing the procedure through the laparoscope, which may be
less expensive, and avoids a major operation. While an excellent
procedure, there are only a small number surgeons performing the
procedure at present time.
Please
make sure your surgeon is well experienced and is performing a
relatively large number of these procedures. Know his/her honest
success rate. The best seldom charge more. Success rate for pregnancy
may be 50-75% over the first year after surgery. There will be
a risk of ectopic pregnancy (10%-25%) after the procedure and
a need for additional contraception after a pregnancy.
CYCLE
REGULATION
Dez: I have PCOS, however I am not overweight or have a
facial hair problem, so I went undiagnosed for years. The only
tell tail sign was having no regular cycle (perhaps 1-3 periods
a year). I conceived my daughter with metformin (clomid did nothing
for me). Now I want to conceive again. I'm sure I will have to
use Metformin again. My question is, IS there any way I can get
regular fertile cycles back without the pill or using metformin
in the short term? If not, will this mean that I will never have
regular periods?
Dr.
Thatcher: Unfortunately, PCOS is for life. The pattern of
menstrual cycles is very individualized and is impossible to predict.
We know that periods tend to become more regular after age 35.
Periods often become more regular after pregnancy, but this didn't
seem to work for you.
Generally,
I believe it is better to have periods than not. One direct and
proven benefit of regular menstruation is a reduction in uterine
cancer. A alternative minimalistic therapy which usually does
not impede fertility, and may promote it slightly, is the periodic
use of oral progesterone. This may be preferred over Medroxyprogesterone
acetate that you have probably used in the past.
In
at least one way, you are lucky that metformin did so well for
you. However, because it worked this may be an indication of insulin
resistance and therefore, you could be at higher risk for type
2 diabetes. Trials are underway to see if long term metformin
may protect against development of diabetes. We do not know the
answer to this question. Perhaps, you should not consider metformin
only as a fertility agent. A good sit down with your physician
to discuss the options may be in order.
BREAST
FEEDING AND FERTILITY
Paige: I am almost 37 and am currently breastfeeding my
9 month old daughter. There is a 6 year gap between her and my
middle child although my husband and I did nothing to prevent
conception. My first two children were conceived very easily.
I have not yet had a return of my menstrual cycle. My husband
and I are currently trying for our fourth child and have been
since my daughter was 2 months old. Is there anything that can
be done to induce ovulation in a breastfeeding mother without
weaning?
Dr.
Thatcher:
Lack of ovulation and poor uterine lining can often accompany
breastfeeding at least initially, and have been a very important
mechanism for our survival in the past. To be pregnant and breast
feeding is perceived to be too taxing and therefore the body in
its wisdom inhibits ovulation. The evolutionary mechanism does
not take into account our capacity to go the food market and buy
the food that we and our offspring need.
I
gave you this long introduction instead of just saying "no."
There are very few drugs proven safe during breastfeeding. I guess
progesterone could be used for menstrual regulation, but
check with your physician. Even this natural hormone is secreted
in breast milk, although in probably inconsequential amounts.
FINDING
PCOS PHYSICIAN
Michelle: Is there a resource for finding the best local
doctors, who are up on the latest PCOS treatments? Not just for
fertility, but to manage it on an ongoing basis?
 Dr.
Thatcher: Unfortunately there is no organizational listing
for physicians experienced in treatment of patients with PCOS.
Sometimes several physicians must be interviewed. Good suggestions
are sometimes possible through the chat rooms of Polycystic Ovarian Syndrome Association, who
also has a listing of physicians that have been self-identified
as having an interest in PCOS. The following is an excerpt from
the chapter in my recent book that partially addresses this concern.
"Because
the symptoms and physical findings vary and because not every
patient presents with the same symptoms, the diagnosis of PCOS
is often missed. Only in the last few years has medical research
been able to make connections between a metabolic endocrine disorder
and disturbances in multiple body systems. PCOS is challenging
to physicians trained to diagnose and treat specific, well-defined
diseases. PCOS patients enter the physician's office often with
a collection of vague symptoms and with a problem that, even when
diagnosed, the lack of curative treatments is frustrating. Although
all the dots are there, not every physician is able to connect
all dots that forms the image of PCOS.
A
woman may begin to experience some symptoms of PCOS at a very
young age She may have been overweight as a young child and the
pediatrician may have told her mother to simply watch her diet.
In her teens, she may have sought medical help for acne or excessive
facial hair and her dermatologist offered creams or electrolysis
as treatment. In her twenties, perhaps still overweight, she may
have sought help from her gynecologist for irregular periods and
been given a package of birth control pills. In her thirties,
an inability to conceive may have sent her to a fertility specialist
where she was given medication to control ovulation.
Unfortunately,
our culture often discriminates against overweight women. It is
a sad fact that many physicians are also prejudiced against these
women, assuming them to be lazy or lacking self-discipline. These
doctors often dismiss these patients, telling them to simply go
home and lose some weight.
Years
of seeing one doctor after another while her symptoms often compound
rather than subside is disheartening. There is the perception
and often the reality that valuable time has been lost while going
from one doctor to another. Self esteem may drop as weight and
frustration rise. Blood tests or ultrasounds that would lead to
a definitive diagnosis of PCOS are not done. The bottom line is
that each of these medical specialists has treated a small aspect
of the problem, but none has put all the pieces of the puzzle
together as PCOS.
Physicians
should not consider themselves, nor should their patients consider
them to be infallible. Patients must ask questions and communicate
honestly with their physicians. Confidence in the capacity to
live better with a chronic condition is one of the greatest tools
in the struggle with PCOS. There may need to be an extensive search
to find a doctor that is truly knowledgeable about PCOS. This
physician may be a primary care provider, but more often will
be a gynecologist, endocrinologist, or reproductive endocrinologist
who has experience treating PCOS and is well informed about new
research areas.
For
women with PCOS, the decision about whom to choose to provide
medical care is critical both to present physical wellness and
long term quality of health. Seeking a doctor who has a strong
base of knowledge about PCOS and who understands present treatment
is quite a challenge. Many doctors simply do not have the time
to keep up with the latest research about the syndrome, especially,
if they are in a practice where they do not see large numbers
of patients with PCOS. And some doctors, unfortunately, just aren't
interested in gaining further knowledge or offering new treatment
options. Furthermore, managed care/insurance providers have a
strong influence on what direction many women take in getting
care. For these reasons, the key to being a smart consumer is
to become as educated as possible about PCOS, and gaining a good
understanding of the arena in which you are seeking care.
Being
a passive or non-participatory patient doesn't work with PCOS.
In the hands of a less than knowledgeable or uninterested care
provider, there can be an escalation of symptoms resulting in
the development of diseases such as endometrial cancer, diabetes
or possibly heart disease. Finding quality care is imperative
for all women with the disorder.
ARE
FERTILITY DRUGS NECESSARY?
Sabra Ellen: I have a preliminary diagnosis of PCOS. I have read
so many contradictory things about it, and nothing cheerful. I
am wondering . . . is it possible/likely to get pregnant with PCOS
without taking fertility drugs? I do not believe in them, but
it seems that all the women I encounter with PCOS wind up using
something like Clomid (which some sources say works and others say
doesn't really) to get pregnant. And if it is, what would be a
reasonable time frame? One year? Three?
Dr.
Thatcher: First, I recommend that you have a "sit down" with
a physician familiar with both PCOS and infertility to discuss
options. This is usually a reproductive endocrinologist. It is
very difficult to obtain a foundation of information about either
fertility therapy or PCOS from a collection of life experiences.
None of these individuals are you. There are excellent studies
form Australia that suggest that those with PCOS who are also
overweight have an excellent chance of establishing normal menstruation
and pregnancy by lifestyle alterations alone. As little of a 10%
decrease in body weight associated with a modest increase in physical
activity may be all that it takes. Clomiphene is a good drug,
but not a great drug. Of course some with say that it works and
others will not because that is the truth. It is about 30% effective
in establishment of pregnancy. The drug is a good first line therapy.
It is relatively easy, safe, and cheap. The chance of twins is
about 5%. Over 70% of pregnancies established on clomiphene are
in the first 4 cycles of use.
INSULIN
AND INSULIN RESISTANCE
Becky: I have PCOS and my insulin level is 11. Is that
enough of a resistance to be able to take metformin?
Dr.
Thatcher: A fasting insulin level of 11 is not considered
elevated by most. While some use 10 as a cut off level, many,
many individuals have levels this high and are otherwise normal.
Most who are overweight will have levels over 10. Almost all experts
consider a level of over 20 as abnormal. I personally use 14,
but there is no hard fast rule.
When
the fasting insulin level is elevated, that is called hyperinsulinemia.
Hyperinsulinemia is a marker of insulin resistance, but it is
not the same as insulin resistance. There are a variety of tests
that are used to measure insulin resistance. One test is the insulin
level obtained during a glucose tolerance test.
Also, what is insulin resistance anyway? Insulin resistance can
be thought of as deafness. The best way to explain insulin resistance
is that the organs that use insulin grow increasingly hard of
hearing, in order to compensate and keep the lines of communication
open the pancreas, where insulin is made, starts to speaks loud
and louder. Insulin resistance is deafness not to sound but to
the action of glucose and insulin.
Now,
when to be treated. This is a very controversial topic. Insulin
resistance is clearly linked to increased risk of developing of
type 2 diabetes. Insulin resistance is also clearly related to
abnormal ovarian function and increased levels of androgens. However
insulin resistance is not a disease as such. Some advocate a trial
of insulin altering drugs in almost all those who do not ovulate.
Others reserve therapy for those that have clearly been shown
to be insulin resistant. Pregnancies have been reported after
use of insulin altering drugs, such as metformin, when the insulin
levels are completely normal. This is a decision that is best
made in cooperation with an individual physician well versed in
PCOS and insulin altering drugs.
BREASTFEEDING
AND FERTILITY
Janet: We have one child who is 17 months. I nursed him until
he was 14 months. We have been trying to get pregnant since he
was 6 months old, right around the time my menstrual cycle returned.
That is almost a year now. I am wondering what affect the nursing
would have had on my fertility, and if that would be part of a
reason we are having such a hard time getting pregnant this time?
Last time it was really quick.
Dr.
Thatcher: I would say yes, this is why you are not pregnant.
One should expect a 6 month gap after feeding is completely discontinued
before any concern. That is, unless you are using breastfeeding
as a contraception. Then it always seems to occur immediately.
Also, see the comments posted earlier.
METFORMIN
USE IN DIABETES AND INFERTILITY
Theresa: I would like to know about metformin being used to
help with fertility in women with PCOS? I was told four years
ago I had PCOS and I am also a type two diabetic and have been
told I will need insulin injections instead of metformin. I am
on diabex (500mg) three times a day. Any information you have
would be a great help.
Dr.
Thatcher: I am not trying to evade the question. I do not
like to give contrary information, and there are many "right
ways." Having said this, I believe Metformin to be a foundation
of the treatment of type 2 diabetes, regardless of pregnancy desires.
The first evidence that metformin was useful for infertility came
form the accidental finding that diabetics using metformin began to have regular cycles and get pregnant. We are hopeful that diet,
exercise, and insulin altering drugs will be able to keep the
thousands off insulin. You may also want to check out the American
Diabetes Association site which has a load of good information.
HOW
LONG CAN EMBRYOS REMAIN FROZEN?
Robin: I recently gave birth to my son, Brett. He was a
product of IVF with ICSI. I have about 9 frozen embryos. My question
is: What are my chances of conceiving another child/children,
with the frozen embryos? IS there a life span if they are frozen?
Can I go a natural cycle, or do I need to do Lupron again? The
infertility was due to male infertility.
Dr.
Thatcher: Not trying to pass the buck, but these are questions
that should be easily and best answered by your IVF center. Success
rates with frozen embryos are center specific. It is never quite
as good as fresh, but the fact that it appears that it was primarily
a sperm issue, should get you quite good chances of success -
if your cycles are regular and especially if you ovulate on your
own. Many centers do transfers with any form of stimulation or
suppression. It's very easy, you monitor the cycle and stop by
the first transfer. No one knows how long viability remains for
frozen embryos. There have been successful pregnancies after 10
years. All agree the quicker out of the freezer the better, but
this is largely for other reasons than the health of the embryo.
WILL
FERTILITY DRUGS BE NEED FOR A SECOND PREGNANCY?
Anna: I have PCOS and now I'm pregnant with my first child,
with help from Clomid. My questions for you are: Do I have a chance
to conceive without help from medicine in the future?
Dr.
Thatcher: Sometimes
a second pregnancy will follow the first without any additional
help. It largely depends on whether ovulation will more likely
or more frequently occur. You should not think that you are either
infertile, or that you might not need additional therapy. The
fact that you became pregnant after clomiphene suggests that your
ovulatory disturbance was not too severe. If you do not want to
become pregnant and have stopped breastfeeding, I usually suggest
oral contraceptives. Do not wait, but try to become pregnant the
first month off the pill. The miscarriage rate may be slightly
increased, but so is the pregnancy rate. Try to keep weight down
and exercise up. This will go a long way toward improving fertility.
DOES
CLOMIPHENE / PCOS CAUSE BIRTH DEFECTS
Anna: Is there an increased risk for birth defects for
my baby since I've got PCOS?
Dr.
Thatcher: There have tens of thousands of pregnancies on clomiphene.
The rate of birth defects does not appear to be increased. Birth
defects occur in about 1% of all pregnancies.
I
strongly believe that there is an increase risk of miscarriage
with PCOS. There is also an increased risk of pregnancy induced
hypertension (pre-eclampsia, toxemia) and gestational diabetes.
Each of these can cause major problems with pregnancy. I do not
know that PCOS itself has any DIRECT link with birth defects.
In the past PCOS patients have been so poorly studied in this
area that a conclusion cannot be made.
EXERCISE
IN PREGNANCY
Tara: Can you do sit ups while you are pregnant (1st trimester)?
Dr.
Thatcher: I am not sure of the answer to this specific question,
but I generally would not recommend it. I usually advise to change
from strength and aerobic conditioning to mobility and flexibility.
Yoga is excellent. Exercise is important in pregnancy, but aggressive
exercise may shift the needed blood flow, thus nutrient supply,
to skeletal muscle and away from the uterus. There are several
good books on exercise in pregnancy available.
ABNORMAL
FETAL ULTRASOUND
Michael K: Our doctor has informed my wife and myself that
our baby (24 weeks) has dilated kidneys. They have sent us for
a fetal echocardiogram which was negative and have now done an
amniocentesis. The results should be back this week. On Monday
9-25-00 we had another sonogram and one of the kidneys has gotten
better. He has explained to us what might cause this and what
might have to be done, early delivery if the problem gets worse.
I was just looking for another opinion on what might cause this
and what our options are.
Dr.
Thatcher: This is too important a topic for Internet consultation.
If you do not feel your questions have been adequately answered
seek a consultation with a specialist in maternal-fetal medicine.
You physician should be very willing to refer you. All my best
to you.
DELAYED
OVULATION
Lisa: Any idea what is going on here? I had fairly regular
cycles of 32-34 days. I charted temps for one cycle just before
starting to try conceiving (IUI) and it looked picture perfect.
Even had the small temp dip before ovulation. Then the next cycle,
when I was going to try I had a 52 day cycle with no ovulation.
Then this cycle I am on day 23 with no ovulation so far (am using
OPKs and temping) but have had lots of clear egg white cervical
mucus for over 12 days so far. Any ideas?
Dr.
Thatcher: The average cycle length is 28-29 days. The farther
one deviates from the norm the greater the likelihood of poor
egg quality, lack of ovulation. Delayed ovulation is also associated
with an increased risk of miscarriage. The rate of infertility
is very high when cycles are over 35 days and I do not even recommend
testing for ovulation, just progressing with therapy. At 32-34
days you may be somewhat borderline for normal ovarian function.
Then too, there could be other problems such as male and anatomic
factors. Still my first thought with the above scenario is that
there may be an ovarian/ovulation problem.
RECURRENT
PREGNANCY LOSS
Laura: Can you send me info regarding ''rejecting the fetus?'
I have been having miscarriages (8 of them) over the past 7 years.
I live in Edmonton Alberta Canada, and the doctors here don't know
why. I went to Florida for a vacation and went to a hospital with
another miscarriage. The doctor said that I reject the fetus.
The doctors in Edmonton don't agree, and say it's very unlikely. But
it's some hope for me. Can you help?
Dr.
Thatcher: My list of reasons of miscarriage in the first trimester
in order of occurrence and with percent of occurrence follows.
This is only my own estimate. 1) Endocrine/genetic 70% 2) anatomic/
structural 2O% 3) inherited genetic 5% 4) other including infection,
immunologic, and chronic maternal medical problems 5%. Your case
is much too complicated and I have much too little information
about the pregnancy losses to even guess at a cause or quote a
statistics for the risk for an additional pregnancy. I am not
a large proponent of the immunologic causes (rejection) of pregnancy
loss. I am sure that it occurs, but I believe it is very uncommon.
I mostly favor hormonal causes related to egg quality and structural
causes that are usually diagnosed by ultrasound and hysteroscopy.
METFORMIN
WHILE BREAST FEEDING
Jenine: I am currently 8 months pregnant. I have PCOS and
conceived while using Metformin. I've been on it throughout my
pregnancy and thankfully I've had an uneventful pregnancy. I want
to know if it is ok to stay on the met while I breastfeed or should
I go off it until I stop breastfeeding. What are the dangers of
staying on Met to the baby while breastfeeding? Thank you so much!
Dr.
Thatcher: Metformin is released in breast milk. Most recommend
not using Metformin while breastfeeding, although there is no
specific research studies that Ii know of indicating that it will
be of harm.
CLOMIPHENE
USE
maddie: I quit ovulating for six months and my RE could
find nothing wrong with my reproductive system. He concluded that
my being overweight was the reason for my non-ovulation. He put
me on Clomid which worked but I did not like the side effects.
I am stopping the Clomid this month and hoping to conceive naturally.
Is there any reason to think that since I ovulated on Clomid,
my cycles might return to normal?
Dr.
Thatcher: Not impossible. Usually clomiphene is effective
only in its cycle of use. Sometimes its effects will hold over
until the next and it is not unusual for a pregnancy to occur
in the first month or two after clomiphene is stopped.
Unfortunately,
the nest step up from clomiphene is usually the injectable medications.
Some report the side effects are less than clomiphene, but they
are certainly more costly, and more risky.
In
my experience, those that are overweight do not ovulate and have
a normal hormone values by our usual diagnostic testing are often
insulin resistant. You might benefit form metformin, or at least
a trial. I know you do not want to hear this from anyone, but
lifestyle improvements in diet (that's not the same as dieting)
and increased physical activity (that's not the same as strenuous
exercise) can be very helpful.
WHEN
DOES PCOS START?
Carlene: I am 21 years old. I have had irregular periods
all my life. Then I got on the birth control pill in December of 99. I got off
of it in April because of weight gain. Since then my periods have
stayed regular, except for this month where I just have a lot
of spotting. My mother says I may have PCOS because since getting
off the pill, I haven't gotten pregnant yet. My mother had one
child at 19 and then had trouble having any more. She got on Pergonal
and was able to conceive after that with no trouble. My sister
had a cyst on her ovaries removed. Does any of this indicate to
you that I may have PCOS?
Dr. Thatcher: We believe that PCOS is inherited. This means
you may have had the gene for PCOS since before birth.
It sounds like your mom could have easily had PCOS and it sounds
like you may too. The chance of passing from mom to daughter
is probably about 50%. PCOS can also be inherited through the
dad's side, but there is probably no clue that it is there other
than an increased risk of diabetes in some. The genetics of PCOS
is an important area of present research. If you are concerned,
you may want to see a physician who specializes in PCOS.
METFORMIN
AND BIRTH DEFECTS
Theressa: Will metformin (diabex 500mg) cause birth defects?
I take metformin for type two diabetes and I also have PCOS. (6Yrs)
Dr.
Thatcher: There is a clear relationship between how well the
blood sugar levels are controlled and the risk of birth defects
and overall complication in pregnancy outcome. Blood sugars must
be normalized before a pregnancy is attempted.
Metformin is listed as "pregnancy category B" by the FDA. This
indicates there is no known relationship with birth defects, but
also that it is not proven to be safe. If you have type 2 diabetes
and are using metformin, it may be reasonable to continue because
pregnancy often worsens insulin resistance. Pregnancy planning
clearly needs some advanced thought and conversation with your
endocrinologist and possibly a maternal fetal medicine specialist.
REGULATION
OF MENSTRUAL CYCLES BY METFORMIN
Robin: I haven't been officially diagnosed with PCOS, and
I'm neither overweight or have excess hair or diabetes, but I've
been prescribed metformin and it made me have a normal cycle for
the first time in 16 months (I did not respond to Clomid). My
question is: when the metformin is working for me, do you think
it's possible that I have a mild case of PCOS?
Dr.
Thatcher: The experts can't agree with what PCOS is. SO sure,
you could have it. The largest single cause of lack of
ovulation lies along the PCOS spectrum. It seems that about 50%
of those with PCOS are insulin resistant and insulin resistance
leads to lack of ovulation. Often insulin resistance will be missed
on the routine lab testing for PCOS. I pay considerable attention
to the ultrasound appearance of the ovaries. I bet there is an
increase in small follicles (cysts) less than 10mm., or an increase
in the size of the ovary. The fact that your cycles have regulated
is great news. Hopefully a pregnancy is not far behind.
IS
THERE A GENERIC METFORMIN
Theressa: Could you please tell me is there any difference
between Metformin (Diabex) and Metformin (Glucophage)? I have
read a lot about women being told to try Glucophage to help them
get pregnant. I am on Diabex and would also like to conceive my third baby.
Dr.
Thatcher: Diabex is another brand of metformin. Glucophage
is a brand of metformin. Generics are on the way and will lower
cost of the medication use.
METFORMIN
USE IN PREGNANCY
Donna: I just found out that I am pregnant. I've been on
glucophage for 2 months. I would rarely have periods, so I expected
that the glucophage would help with periods. I was very surprised
to find out that I had conceived so soon. My question is do you
think it is safe to stay on the medication while pregnant?
Dr.
Thatcher: There is very limited information on this. One study
has shown a decrease in the rate of miscarriage in a relatively
small group of patients. Another study also reported no problem
when used during pregnancy. In the future, metformin may be widely
used in pregnancy, but its use can not be universally recommended
at present. We just do not know the risks. Hopefully this issue
will be cleared up in the near future. A decision should be made
in conjunction with advice form your obstetrician.
PCOS
GENETICS AND THERAPY
Ngaire:
I was diagnosed with PCOS several years ago. I have many classic
symptoms - weight gain, excess hair, insulin resistance, annovular
periods etc. My OB suspects that I have always had it but that
the development of the symptoms was triggered off by my first
pregnancy, as until then, I had no symptoms other than irregular
periods. I have three children, the last of which required clomid
to induce ovulation as I have had less than a period a year since
the birth of my second son 5 years ago. With each pregnancy my
symptoms get worse. I guess I have several questions - is it likely
that my PCOS is indeed getting worse with each pregnancy? Is there
any alternative to drugs (eg metformin) to control it? We are
wishing to get pregnant with our last child but I am reacting
negatively to the clomid dose required to induce ovulation (50
mg). So are there alternatives to this? As I am now 33. We wish
to conceive fairly quickly - is there anything else we can do?
And possibly most importantly - my mother is into alternative
medicine and has suggested that I could restore my cycles with
the use of 'natural' progesterone cream as suggested by Dr. John
R Lee. What are your thoughts? I would appreciate any answers
you could give me. Thanks. Ngaire
Dr.
Thatcher: I would agree with your OB that you may have always
had PCOS. It is a genetically based disorder. I am not sure about
whether it was your pregnancy, or equally likely was that it was
age and often weight that brings PCOS to the surface. Since PCOS
can be altered by environment, I would strongly suggest that you
encourage the very healthiest lifestyle in your children. They
may not be able to escape the gene(s), but it is possible to alter
their consequences by the changing the environment. Hopefully
this indirectly answers a part of your questions.
I would concentrate on establishing and maintaining the healthiest
possible lifestyle. Maximize nutrition (without dieting); increase
physical activity without stressing yourself. Small investments
can pay major dividends.
Metformin
may be a good alternative, especially since you state that you
are insulin resistant.
I
am very cautious about recommending supplements. It is not that
they may not work, in fact, it is that I have too much respect
for them to idly prescribe herbs and supplements without a firmer
scientific basis of their positive actions, and most importantly
possible negative actions.
DELAYED
OVULATION AND THE LUTEAL PHASE DEFECT
Candy: I have been using the basal thermometer for temping
this cycle and have discovered (along with charting all babymaking
encounters for the past 5 months, as well as cervical mucus) that
I am not ovulating until cycle day 19. However my period begins
on day 27 or 28. Am I looking at a luteal phase defect and if
I am, what is my first choice of treatment? I am almost 38 and
do not want to just try for another year after trying for almost
6 months now. Could the problem be in the first half of the cycle
if signs point to the fact that I am ovulating or is it more likely
that the problem is just too short of a luteal phase and therefore
implantation is unlikely? What questions and information should
I take to my doctor? Thank you.
Dr.
Thatcher:
I do not believe in the luteal phase defect as such. I believe
that most defects of the luteal phase are in fact defects on the
follicular phase. This may seem to be splitting hairs, but it
puts the emphasis back on the developing follicle and egg and not
the resulting corpus luteum and progesterone production. Good
luteal phases follow good follicular phases. Conversely, if ovulation
is delayed, the luteal phase is often inadequate. Yes, I think
that implantation could be less likely because I believe egg quality
is decreased.
Depending
on a more complete history, you might be a candidate for clomiphene
therapy. Hopefully it would promote a more timely ovulation. The
good news is that a late ovulation, is miles above no ovulation
and you might need just a little help to push you over the top.
WHY
MAKE THE DIAGNOSIS OF PCOS?
Kendra: I have not been diagnosed with PCOS and do not
have some of the more definitive symptoms. However, I have struggled
with acne (present on the paternal side of the family) and increased
periareolar hair growth. The hair growth was alarming to me and
happened over a three year period. I am not over weight for my
height and I have regular monthly menstrual periods. I have never
used birth control pills. I asked my OB-GYN if I could have PCOS. She informed
me that since I was having regular periods she doubted that I
had PCOS. She further explained that in my case periareolar terminal
hair growth was familial. She checked my testosterone and DHEA
level (both results were WNL). I asked my mother if she had hair
growth on her chest and she does not. Should I have a LH:FSH ratio
done? Is a pelvic ultrasound indicated? If I am having regular menstrual
periods, does this mean that I am ovulating monthly? Thank you
for responding.
Dr.
Thatcher: The strictest diagnosis of PCOS requires both hyperandrogenism,
either by clinical signs or hormonal determination and anovulation,
which usually translates into irregular cycles. The principle
skin signs of hyperandrogenism are excessive hair growth (hirsutism)
and acne. Adult acne is a reasonable reliable indicator of hyperandrogenism;
hair around the nipples (periareolar) is not unless accompanied
by hair in the middle of the chest and lower abdomen. It seems
that in your case there may be mild "clinical" hyperandrogenism
without laboratory confirmation. This occurs in at least 50% of
cases. If so, it sounds like it came from your dad's side
of the family. I would not be at all surprised that the ovaries
were also at least mildly polycystic on ultrasound scan.
Oral
contraceptives may help the acne by reducing luteinizing hormone
and decreasing androgens. Even though your laboratory values are
normal, there may be an increased sensitivity of the skin to androgens,
and reduction may be of benefit.
It
is possible that you may not be ovulating despite regular cycles.
This is most important if fertility is an issue.
Whether
you have PCOS is in some ways unimportant. The reason to make
the diagnosis is most importantly a way to explain of a clustering
of signs and symptoms and identify health risks. We direct therapy
not at PCOS, but at its signs and symptoms. Of course the diagnosis
of PCOS also may identify with a long-term outlook toward possible
metabolic consequences.
The
fact that you have regular cycles and do not have a weight problem
probably removes many of the risks associated with PCOS. It may
be of academic interest to determine the LH/FSH ratio, but it
probably would not affect anything written. As a part of good
health maintenance it may be prudent to have a lipid profile,
fasting glucose and maybe insulin level. If there is a strong
family history of type 2 diabetes even a glucose tolerance test
with insulin levels. This may identify the risk of diabetes and
possibly heart disease and promote life-style changes, even medical
intervention that might allow a longer and healthier life.
METFORMIN
AND WHEN TO START OTHER FERTILITY THERAPY
Kris: I am 26 and have recently been diagnosed with PCOS.
I have a 16 month old daughter that was conceived with fertinex.
I have been having regular though light periods since April, but
have not ovulated. I am taking 1500mg of glucophage a day. How
many cycles should I wait before adding fertility treatment to
the mix? My doctor is in a hurry, but I would like to get my system
in order first and see if I ovulate on my own.
Dr.
Thatcher: I usually will try clomiphene challenge in the 5th
or 6th month of metformin. Some individuals who have been previously
clomiphene resistant will ovulate and become pregnant on the metformin-clomiphene
regimen, when neither alone is sufficient.
It
is usually the patient and not the physician that is in a hurry.
If you are making positive lifestyle alterations and are feeling
better, plus starting to have regular cycles, what's the rush?
At 26 and with one successful pregnancy, your chances for another
pregnancy are very high. The drug companies will make sure that
there is plenty of gonadotropins whenever you might need them.
PCOS
AND GETTING OLDER
Vicki: I've never actually been diagnosed with PCOS. But
after reading what I have on the subject, I'm really starting
to wonder whether this may have been the cause of all my past
fertility problems. My question to you is that since I'm now no
longer trying to conceive (I had a tubal ligation done after our
last child), and if indeed I am correct on my assumption and this
is PCOS, how will it continue to affect me as I get older? I am
now 33.5 years old. (shortened version of question)
Dr.
Thatcher: First, I agree that a good case could be
made for your diagnosis of PCOS. One of the most pressing issues
about PCOS is that there are its long term consequences. We virtually
know nothing about this at present and the scattered reports tend
to be conflicting.
There are several things we think we know for sure. PCOS is clearly
associated with an increased risk of type 2 diabetes. Continued
vigilance on fasting glucose levels, possibly even insulin levels
may be a reasonable idea. Much of type 2 diabetes is weight related.
It has been difficult to separate out the adverse effects of weight
from other medical conditions.
PCOS patients also tend to have abnormal lipoid profiles and yearly
monitoring with lifestyle, and possible medical intervention when
appropriate. There is a real question about heart attacks and
heart disease. It seems that the risk with PCOS should be much
higher than it actually is. This is still an issue that requires
a considerable amount of research. Both diabetes and heart disease
may be preventable in part and successfully treated when identified
in the formative stages.
There
is a clear association of PCOS with cancer of the uterine lining
(endometrium). This is markedly reduced and possible reversed
with cycles regulation or regular bleeding. Others cancer such
as ovarian and breast do not seem to be increased. Childbearing
and oral contraceptive use is protective against ovarian cancer.
Family history is most important issue with breast cancer. Routine
mammogram and self-examination are strongly suggested. Colon cancer
risk rise with obesity.
Cycles
tend to become more regulate after age 35. It is possible that
the menopausal transition is easier with PCOS. Hip fracture and
osteoporosis are very significant health risks to postmenopausal
women. Bone density is greatest and fracture risk appears reduced
with PCOS.
StorkNet:
Our deepest gratitude to Dr. Thatcher for taking so much time
to talk with us. He tells us that he would like to come back again
in a couple months. We will be contacting him so please save your
questions and watch for announcements. Much more information about
these subjects is available in Dr. Thatcher's books, listed above.
Click on the book covers. Thanks to our StorkNet members, as well.
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