Polycystic Ovarian Syndrome (PCOS) By Lisa Glickstein, Ph.D, Triplet Mom Originally printed in March, 2005 Polycystic Ovarian Syndrome (PCOS) is an extremely common cause of infertility. By some estimates, up to one in ten women has PCOS, and many of these women will experience infertility. In addition, women with PCOS have an increased incidence of multiple births. All of this adds up, for me, to a suspicion that I am not the only woman with PCOS in TMM!! Treatment for PCOS shouldn’t end when you have all of your babies. Read on to learn more and find out how to take care of yourself. What is PCOS? This inherited syndrome (cluster of symptoms) includes a dramatic appearance of multiple cysts surrounding the ovary. On ultrasound, this is sometimes called the “strand of pearls,” as the cysts appear white against the black background. The syndrome includes other symptoms as well, including missed or irregular periods, acne along the jawline, excess facial hair, male pattern baldness or hair thinning, darkened skin in the armpits and groin, and endocrine abnormalities, such as type 2 diabetes. The cysts actually consist of half-developed follicles. In a normal menstrual cycle, multiple follicles begin to grow. Finally, one becomes dominant, and suppresses the others from growing further. This dominant follicle ovulates. For reasons that are incompletely understood, this process is frustrated in women with PCOS – no dominant follicle appears and the cycle becomes “stuck” without ovulation or a period. The ovulatory phase of the menstrual cycle includes high production of estrogen and other hormones by the developing follicles. These hormones produce the acne, and hair growth and thinning characteristic of PCOS. Obesity worsens PCOS symptoms, but PCOS is often characterized by insulin resistance (a prediabetic condition), which can make maintaining or losing weight difficult. Even normal weight women with PCOS are at increased risk of developing type 2 diabetes. PCOS is a lifelong condition that should be monitored by your doctor long after you have your children. Treatment in the past was limited to the symptoms (e.g. acne topicals, laser hair removal, ovulation induction with hormones, hysterectomy), but based on new research, it is now possible to treat PCOS at its source. The most effective treatment plan will incorporate stress reduction, control appetite and weight, and address insulin resistance, with a goal of inducing ovulation and menstrual cycles. Why and how should I reduce stress? Stress elevates the hormones called cortisols (steroids) that your body produces. Cortisol primes your body to flee or attack – responses that were helpful to ancient man, but not as useful today. Over time, elevated cortisol has many negative effects on the body (including suppressing the immune system). One of these effects is the accumulation of abdominal fat (fat that surrounds your internal organs). This is the fat that gives you the pregnant look (as opposed to the usual fat on your hips and thighs or belly that is just under the skin), and is seen most often in men (the beer belly). Abdominal fat is associated with high cholesterol, blood pressure, and type 2 diabetes. Stress can be reduced by exercise (kind of a pretend attack or flee response), social interaction (MNO!), meditation or prayer, therapy, or medication (if related to depression or anxiety). Can I lose weight with PCOS? Yes! The newest research studies suggest that many of the hormones, like insulin, that regulate energy use in the body also act on the brain and on the ovaries. For ancient humans, food was scarce, and it didn’t pay to use energy for ovulation if there was not enough food to maintain body function. Conversely, it made sense to trigger ovulation when food was abundant. Therefore, weight and PCOS are linked. Eating carbs can cause a surge in blood sugar in women with insulin resistance, actually leading to increased appetite. Women with PCOS usually do better on a low-carb or modified carb diet. This type of diet better controls the secretion of insulin as well as the blood sugar levels. Famous examples include Atkins (the “new” approach which is low fat), and South Beach diets. Calorie control must also be practiced, of course. Weight Watchers is a comprehensive program that now includes a modified carb diet (called “Core”). Author Pamela Peeke, author of Fight Fat After Forty, suggests that women eat whole grain and unprocessed carbs (in bread, cereal, fruits and vegetables), avoid white pasta, bread, and rice, and avoid carbs at the dinner meal. Even taking sensible steps such as trading some carbs for protein (such as low-fat milk or yogurt, small amounts of cheese or nuts, or plain turkey or chicken) with meals and snacks can be helpful. Metformin (glucophage), a drug developed to treat diabetes, is helpful for women with insulin resistance. Glucophage has two mechanisms of action; it prevents some sugar from being absorbed by the intestines, and it increases uptake of sugar by muscle cells. The net effect is less sugar in your blood. Glucophage helps with weight loss by decreasing appetite and blocking your body from using some of the sugar you eat. It can cause moderate to severe intestinal distress if you take it without also modifying your diet. How can I get my body cycling again? Ovulation is a prerequisite for fertility, but is also important for other reasons. If your body does not cycle, it is important to find another way to shed your uterine lining at least 4-6 times per year. If the lining doesn’t shed, you could be at increased risk for uterine cancer. Finally, more normal ovarian function can reduce the other symptoms of PCOS, such as acne or hair growth. PCOS usually gets progressively more severe with age. Some of this is due to increased body weight. The ovary also develops a tough outer covering that reduces ovulation further, making symptoms worsen. “Ovarian drilling” is an older treatment that was designed to address this problem. By puncturing the covering and destroying some of the follicles, ovulation could be restored temporarily in some women. In the past, women with PCOS might have endured a D&C once or twice a year or alternatively had their uterine lining destroyed by heat, or frequently had a hysterectomy after they had completed their families. None of these are currently first line treatments for PCOS. The most common method to cause the uterine lining to shed is prescription birth control pills (BCP) or a 10-day course of progesterone. It is important to note that progesterone and BCP can cause mood swings and increased appetite. BCP are very useful for women with PCOS who are young and desiring birth control, and some formulations have been proven to reduce acne. Losing weight, especially in younger women, can dramatically restore cycles. Most importantly, Glucophage seems to act directly on the ovaries, in addition to its beneficial effect on blood sugar and insulin, appetite, and weight. Glucophage often restores cycles to women with PCOS, and should be considered as a first-line treatment for women with PCOS at any life stage, to address insulin resistance, weight, and restore more normal ovarian function.