PCOS stands for Polycystic Ovarian syndrome and affects between 5-10% of women of reproductive age. 

The criteria for diagnosis has some variations but the most commonly used one involves the presence of irregular or absent menstrual periods in combination with excess androgens (male hormones) or evidence of them (male type facial/body hair) and possibly polycystic ovaries. It can be very mild to very advanced in severity, developing gradually as a teen or in your early twenties, usually in women with a family history of PCOS. The exact causes are unknown and are likely to be multifactorial including genetics and environmental factors.

Menstrual irregularity many times will present as a history of having periods every 2-3 weeks when they are actually having overflow bleeding and not normal periods. Women who chart their reproductive biophysical signs with evidenced-based fertility awareness based methods are able to bring to their provider very good medical information about their reproductive health, such as:

• if their vaginal bleeding is actually normal cycles 
• if they are producing appropriate amounts of cervical mucus, which is a reflection of follicular health
• if the postovulatory phase is normal or failing, laboratory levels of free testosterone, total testosterone, DHEA-S, and androstenedione will be elevated

Additionally, many women will develop insulin resistance, elevated glucose, and weight gain around the waist, though many women can be of normal weight or even underweight. Other conditions that can appear similar to PCOS must be ruled out such as non-classic adrenal hyperplasia and Cushing syndrome.

What are the treatment options available?

It is imperative to diagnose and treat PCOS, whether a young woman is considering pregnancy or not because PCOS is associated with:

• Hypertension
• High cholesterol
• Impaired glucose tolerance
• Cardiovascular disease
• Depression
• PMS
• Endometrial cancer

Unfortunately, many women are placed on chemical contraceptives such as the birth control pill in their teens to “control their periods” which merely mask symptoms and actually has the same side-effects as does PCOS. Treatment always starts with good nutrition and appropriate amounts of daily exercise. Because women with PCOS will push out larger amounts of insulin to keep glucose levels normal, women with PCOS (as should all people) eat a low glycemic breakfast with a fair amount of protein.

◻️ Replace the bowl of cereal, oatmeal, or bagel with a breakfast burrito, high protein yogurt (no sugar) with a measured amount of granola or fresh fruit, or leftover meat from dinner. Lunch should be balanced with proteins and healthy carbs. Have a mid afternoon snack such as nuts, cheese, and a small amount of fruit or vegetable. Aim for zero carbs at dinner but include a lot of fresh veggies. Then go into a 12 hour water only fast overnight to allow all of the hormones to reset—growth hormone, leptin, insulin, melatonin, cortisol, etc. These get dysregulated with any food including diet drinks or plain tea. 

◻️ Daily brisk walks of 20 minutes, while simple, have been shown to be very effective for everyone’s health. Do more and different types of activity if your schedule allows. All of this helps to reduce insulin resistance.

◻️ Myo-inositol (in a 40:1 ratio with d-chiro-inositol) 4 grams daily is usually the first supplement to be used for women with PCOS. It reduces insulin sensitivity and is safe in pregnancy. Most women tend to stop it when they have conceived. Additionally, metformin may be prescribed to help reduce the insulin levels which are toxic to the ovaries and ovulation. Progesterone may be prescribed to be taken at the correct time of the cycle because of the suboptimal levels of progesterone and to “counterbalance” the higher estrogen levels. The suboptimal progesterone levels lead to PMS and premenstrual dysphoric disorder. I use only bioidentical progesterone which is low cost and well tolerated. Most women with PCOS will need progesterone during pregnancy so they should NOT stop it when they have conceived. It will need to be weaned when it is certain that her body is making enough. Some women may take spironolactone to reduce testosterone but must know that it is a Category D (“dangerous”) in pregnancy. Many times the testosterone will reduce once insulin is reduced and progesterone is used to stabilize the post ovulatory phase of the cycle. 

There are many other medicines that can be added but these described above help most women, especially when diagnosed and treated early enough. Surgical wedge resection of the ovaries is also associated with great improvement of signs and symptoms of PCOS.

How can PCOS affect my fertility?

PCOS does affect fertility to different degrees. Like any disease process, the longer and the more severe it is, the more the side effects impact fertility. It is heartbreaking to have patient after patient come into the office in her mid 30’s unable to conceive after a few years of trying after stopping the birth control pill she has been on since her teens. The whole time the pill has been masking the disease – not treating the disease. 

How can telehealth be used to manage PCOS?

While age-appropriate pelvic exams, imaging, and PAP smears are indicated and have to be done in person, the lion’s share of PCOS is very effectively treated via telehealth. At MyCatholicDoctor, we are interested treating the person as a whole, and can teach teens and women how to chart their cycles in a medically meaningful way, appropriately order labs, imaging, and treatment, refer for surgery, and follow along to measure outcomes. Because many women with PCOS suffer from depression and PMS, MyCatholicDoctor has qualified mental health professionals to address their needs. Finally, since women with PCOS are at much higher risk for miscarriage due to poor progesterone levels, we can treat and follow progesterone throughout pregnancy via telehealth. Postpartum depression is more likely in women with PCOS and so that can be managed easily via telehealth as well. In this way, both the baby and mom are taken care of.

Author: Dr. Gretchen Marsh, Family Practice Physician and Fertility Provider with MyCatholicDoctor