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Polycystic ovary syndrome

Polycystic ovary syndrome also known as Stein-Leventhal syndrome is a disorder in which the ovaries are enlarged with cysts, with levels of male hormones may be high. PCOS is a term used to describe a common endocrine disorder (syndrome) that occur in about 6% of women.

Symptoms

The most common symptoms are:

  • Cystic Ovaries – Cysts are fluid filled sacs that are found on the outside part of the ovary. Cysts are a common occurrence in many women, but in PCOS there are an increased number of small cysts in most (but not all) women. These cysts are seen during an ultrasound test. Some women (about 20%) have many cysts in their ovaries, but do not have PCOS.
  • Hirsutism – an excessive amount of body hair growth compared to other women in your ethnic community, since women of different racial backgrounds can have very different amounts of body hair normally.
  • Anovulation – The monthly release of an egg in the middle of the menstrual cycle is called ovulation. When something prevents that release, it is called anovulation. Women who do not ovulate have missed periods (oligomenorrhea), and sometimes stop having menstrual periods completely (amenorrhea).

What other problems can women with PCOS have?

  • Obesity – Often, there is a period of rapid weight gain at or around the time menstrual periods become irregular. The trend may then continue for years.
  • High blood pressure
  • Acne
  • Alopecia – This term refers to thinning or loss of hair on the scalp.
  • Abnormal cholesterol – Common abnormalities are an elevation in triglycerides and lowered amounts of good (HDL) cholesterol.
  • Infertility – Impairment or absence of ovulation naturally makes conception difficult.
  • Acanthosis Nigricans – A cosmetic skin condition usually affecting the groin area, underarms, and base of the neck. It usually is a visible sign of the presence of excess insulin.
  • Abnormal bleeding – When women do not ovulate on a regular basis, the lining of their uterus (endometrium) is exposed to constant estrogen, without the monthly progesterone to cause shedding and thinning of the lining (menstrual periods). In time, this situation can cause the lining to become excessively thick and unstable, leading to erratic bleeding problems. If left untreated over a period of years, the risk for cancer of the uterus increases.

PCOS treatment options

Problems Oral Contraceptives Progestins Diet Insulin Sensitizers Anti-Androgens Calcium & Vitamin D
Irregular Periods Yes Yes Yes Yes No Yes
Anovulation
(infertility)
No No Yes Yes No Yes
Metabolic
(cardiovascular)
(obesity)
(diabetes risk)
No No Yes Yes No No
Hirsutism
(excess hair)
Hair Loss
Acne
Yes No No Yes Yes ?

A woman who doesn’t have increased body hair may be given a progesterone-like drug such as synthetic progestin. It will protect the endometrium.

Anti-androgen drugs

  • Spironolactone (Aldactone) is a drug that blocks the production of male hormones. It can be used to reduce unwanted body hair. There are however side effects to this drug. Side effects may or may not include: frequent urination, fainting (low blood pressure), tender/painful breasts, irregular vaginal bleeding. Please note that Spironolactone may not be safe for a developing fetus. It is suggested that while on this treatment that you eiher abstain from intercourse, or use reliable birth control methods.
  • Cyproterone acetate (Androcur)
  • Finasteride (Proscar or Propecia)

What causes PCOS?

For many years, it was believed that PCOS was simply an internal problem of the ovaries, such that they overproduced the hormone testosterone. Although this is still sometimes the case, obstetricians and gynecologists have learned in the last 10 years that PCOS is a condition that often involves other parts of the body, and can be quite complex. One of the most common and important relationships they have discovered is the one between PCOS and Insulin Resistance. Insulin resistance appears to be the underlying cause of many, if not most, instances of PCOS. The relationship is strongest amongst the heaviest women. Other abnormalities in function of the brain and ovaries can be found in some women as additional contributing factors to PCOS.

Insulin Resistance (IR)

To understand insulin resistance, it is necessary to first understand what insulin does in the body. The primary role of insulin is to signal the cells of the body to allow glucose (sugar) to enter from the blood. This activity occurs intensely after a meal, but also occurs at a much lower level at all times. Normally insulin is very efficient at moving sugar into cells as it enters the bloodstream. However, the cells of some people are resistant to the signal to allow sugar to be transported inward. We say these people have Insulin Resistance.

In order for the body to keep tight control on blood sugar levels, the pancreas must either compensate for the resistance to insulin by increasing insulin secretion, or allow blood sugar levels to become elevated (diabetes). In almost all cases, that insulin resistance is a characteristic that a person has from birth. It’s severity varies widely. When it is more severe, it can be detected in childhood. Insulin Resistance may result in a kind of ‘burn-out’ of the pancreas (from overwork), and is the primary reason for development of Adult Onset Diabetes (Type II diabetes). In women, insulin resistance can take on another face; which is PCOS.

How does Insulin Resistance cause PCOS? Insulin is a hormone that affects many different organs of the body: The brain, kidneys and liver are examples. Recently we have discovered that insulin also affects the ovaries. Excessive insulin stimulates the hormone factories of the ovaries to produce higher levels of testosterone than normal, resulting in many of the well known problems with hair and acne. Insulin may also disrupt the communication between the brain and the ovary independent of an effect by testosterone. Not everyone with PCOS has IR, and vice-versa; but as severity of obesity increases, the relationship becomes very strong. Even women of normal weight can have insulin resistance, so all women should be tested for IR.

The insulin response of the body to the consumption of sugar/carbohydrates can be assessed through an Insulin-Glucose Tolerance Test.

What are the consequences of Insulin Resistance?

  • Higher Risk of Gestational Diabetes
  • Higher Risk of Elevated Blood Pressure During Pregnancy
  • Higher risk of Developing Type II Diabetes
  • Accelerated Cardiovascular Disease
  • Higher Risk of Heart Attacks

PCOS diet: nutrition basics

Most of the diets around are used for short periods of time, with short term goals. Women with PCOS caused by insulin resistance need to develop eating habits that promote health for their entire life. The guiding principle of food choices, similar to that for Type II diabetics, is food choices that have the least effect on stimulating insulin release. Simple sugars are rapidly absorbed by the gut, and are the worst offenders. Their consumption should be severely limited (candy, regular sodas, table sugar, fruit juices with added sugar, cereals with added sugar, alcohol, and of course most desserts). Carbohydrates are the food category that get converted into sugar by digestion; but not all carbohydrates are the same. There are two basic groups.

Starches:
Foods like potatoes, rice, cereals, bread, pasta. These foods should be limited, meaning small potions, and not consumed at every meal. Less processed starches (whole wheat/multigrain bread, whole wheat pasta, brown rice, whole grain cereals) are better choices, but still require limitations.

Non-Starches:
Fruits and vegetables are the vast majority in this group. Vegetables, and to a lesser degree fruits, should be the foundation of everyone’s diet, especially those with insulin resistance, and should be present at every meal. Fruit juices are less preferred than fruits themselves, and should be consumed in moderate amounts.

Fats:
Like carbohydrates, there are different kinds of fats. Goals should be to minimize saturated fats and cholesterol. The simple way to accomplish both goals is to limit consumption of animal products (meat and dairy). The percentage of your daily calories that come from fat should be about 30%. Learning how to read food labels is very helpful in keeping track of fat calories. I am often asked which oils are best; the answer depends on what they are used for:

  • General use (no heat): Olive Oil, Flax Seed Oil, and Walnut Oil
  • Low heat cooking: Olive Oil or Walnut Oil
  • High heat cooking: Canola Oil (high oleic acid variety) or Walnut Oil (more expensive)

Proteins:
I prefer that most dietary protein is supplied from non-animal sources. I do not think it is necessary, from a health point of view, to be a strict vegetarian, but I think that the extent of our meat consumption in the U.S. is clearly excessive from a health, environmental, ecological, and animal welfare perspective. Among the meat sources of protein, I advocate fish over land animals (cow, pig, lamb, chicken, turkey) and crustaceans (shrimp, lobster, crab). Protein deficiency in the U.S, regardless of diet, is very rare, and should not be a concern of the average person.

What can I drink?

This question requires us to separate what you want from what you need. Soda consumption in the U.S. is very high, especially among the young. This is unfortunate, and I think we are beginning to see the consequences. Sodas satisfy taste, but have negative health value. Water is best, is what we require, and is under-consumed by almost everyone. Milk is OK, Tea is OK, Juice drinks (without high fructose corn syrup or ‘concentrated grape juice’) are OK, Coffee is OK. Water consumption should be at least one half gallon per day (64 oz), and filtered water is recommended.

What if I have PCOS and wish to be pregnant?

If a woman who has PCOS wants to become pregnant, she may be given a variety of hormones to stimulate the ovaries to release her eggs. These hormones include Clomiphene citrate, follicle-stimulating hormone and a gonadotropin-releasing hormone. If this treatment is not successful, surgical interventions may be considered to remove any scar tissue.

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