Specialists in Reproductive Medicine & Surgery, P.A.
Craig R. Sweet, M.D.
Board Certified in Reproductive Endocrinology & Infertility and Obstetrics & Gynecology
Dedicated to excellence in reproductive medicine

Introduction:
    A common endocrine disorder in reproductive age women can cause some obvious and distressing symptoms — from irregular vaginal bleeding and obesity, to excess facial or body hair and acne. The disorder is called PolyCystic Ovarian Syndrome (PCOS) and it affects about 6% of young women in the United States.

    Women with PCOS do not ovulate or menstruate regularly. Some also have ovarian cysts, darkening of the skin folds, acne and elevated lipid levels. Many also suffer from infertility. The long-term effects of PCOS can be even more serious — including hypertension, heart disease, gestational diabetes, adult-onset diabetes and uterine cancer.

     While not always the rule, the majority of those suffering from PCOS will be obese which increases the risks of stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems and colon cancers. Obese individuals may also suffer from social stigmatization and discrimination.

    PCOS has been recognized by doctors for many years— but all we generally could do, until recently, was deal with the symptoms of PCOS. In the past, we prescribed birth control pills, ovulatory medications and recommended procedures to remove the excess facial and body hair. In reality, we were only treating the symptoms rather than the disease.

    While it has long been thought that PCOS was caused by the ovaries producing an excess of male hormones, it wasn’t known why they produced this hormone imbalance. Now, recent studies have shown that PCOS, and the hormone problems that result from the condition, are often a result of Insulin Resistance (IR) and Glucose Intolerance (GI).

    We now believe that many women with PCOS become resistant to the hormone insulin, which is normally responsible for carrying the sugar glucose into the cells. As the cells become more insulin resistant, sugar levels increase in the blood, eventually causing glucose intolerance, along with many of the problems we commonly see in adult-onset diabetes. In fact, PCOS may be a very early type of adult-onset diabetes. It is the excess insulin that is apparently responsible for directly stimulating the ovaries to produce an excess of male hormones, throwing the entire system out of balance.

    PCOS is usually diagnosed by a thorough medical history and physical exam. Transvaginal ultrasonography and blood tests may also assist in making the diagnosis. Depending upon the age of the patient, an endometrial biopsy (biopsy of the lining of the uterus) also may be necessary to make certain that pre-cancer uterine changes have not already begun.

    It is also important to realize that not all women with PCOS have IR/GI. A number of medical illnesses including thyroid disease, adrenal disease, as well as adrenal, pituitary and ovarian tumors can produce the signs and symptoms of PCOS. With appropriate evaluation, the cause of PCOS can be identified and treatment can begin.

    It is not difficult to diagnose the IR/GI using a modified glucose tolerance test. Following the patient’s 10-12 hour fast, baseline blood work is obtained, including insulin and glucose levels. The patient then drinks 75 grams of glucose (GlucolaŽ ). Two hours later, insulin and glucose levels are repeated and the study completed. By examining the baseline and stimulated insulin and glucose levels, the diagnosis can be made.

    When the diagnosis of IR or GI is made, treating with insulin-sensitizing medications, such as metformin (GlucophageŽ), troglitazone (RezulinŽ) and rosiglitazone (AvandiaŽ) may reduce both the short and long-term consequences of PCOS. These medications are FDA approved for diabetics but seem to hold tremendous promise for those patients with the early signs and symptoms of diabetes such as the PCOS patient. These medications and a number of other new drugs are currently awaiting FDA approval specifically for the treatment of PCOS.

    As a reproductive endocrinologist, I see numerous patients with PCOS every day. Some come to see me because of infertility and others because of abnormal uterine bleeding or other hormone imbalance problems. Up to 40% of the women with infertility don’t ovulate regularly, and many of these will eventually be diagnosed with PCOS.

    What is so exciting for the infertile patient is that I may not have to use ovulatory medications such as clomiphene citrate (ClomidŽ or SeropheneŽ) or the more powerful injectable medications to induce ovulation and pregnancy. Simply prescribing the insulin-sensitizing agents often induces ovulation and pregnancy. This treatment has an additional bonus by being very cost effective, between $40 and $120 per month.

    Since ovulation may occur on its own with appropriate medical therapy, the risks for multiple pregnancy are substantially reduced compared to the use of ovulatory agents. With fewer multiple pregnancies, the overall costs are reduced. Preliminary data also seems to indicate that by reducing the insulin and glucose levels, we may even reduce the number of miscarriages and potentially, the number of malformed infants, both substantial benefits.

    For the PCOS patient who is not concerned with fertility, the insulin-sensitizing agents will reduce male hormone levels, assist in weight loss and reverse or minimize many of the signs and symptoms of the disorder.

    As with any medical treatment, there are potential complications. GlucophageŽ can cause gastric upset, although fewer than 5% of the patients will have to stop the medication because of this problem. RezulinŽ can result in slight fluid retention resulting in weight gain and occasionally elevates the liver enzymes. As a precaution, blood work must be done on a regular basis during treatment. AvandiaŽ may cause slight weight gain, swelling and a mild anemia. One area of concern is that AvandiaŽ seems to elevate the LDL cholesterol levels, which is less than ideal with respect to cardiovascular risk. All medications require normally functioning kidneys and liver.

Some Additional Thoughts:
   My practice, Specialists In Reproductive Medicine & Surgery, P.A., has been diagnosing and treating patients with PCOS/IR/GI with tremendous success. We are currently a national testing site for a new insulin-sensitizing agent. You may learn more about this study by reviewing the Ongoing Studies link here on my web site. We have also drafted a proposal to initiate a multi-center study on a group of infertile patients who may have very subtle insulin resistance.

    If you have a history of irregular menstrual bleeding, you may be a candidate for testing for PCOS/IR/GI. It is suggested that you seek a qualified physician for consultation. By bringing the endocrine system back into equilibrium, the long-term risks of PCOS, including hypertension, cardiac disease, skin problems, adult-onset diabetes and uterine cancer will be reduced.

•   http://www.pcosupport.org/ (Excellent, Polycystic Ovarian Syndrome Association, Inc.)
•   http://support-group.com/cgi-bin/sg/get_posts Polycystic Ovarian Syndrome (PCOS) Bulletin Board)
•   http://www.geocities.com/CollegePark/Union/4195/pcos.html
•   http://dmoz.org/Health/Conditions_and_Diseases/P/Polycystic_Ovarian_Syndrome/ (multiple links)
•   http://www.pitt.edu/~kerst9/pcopage.htm (nice review)
  
      Being able to treat PCOS, rather than just treating its symptoms, is a significant step forward, and an encouraging development for patients with this common and potentially devastating disorder.