PCOS: Diagnosis and Treatment

Polycystic Ovarian Syndrome (PCOS) is an endocrine disorder which affects about 6-10% of women who are of reproductive age. 1 PCOS is hard to diagnose and therefore frequently missed by health care professionals. If a woman has less than eight menstrual cycles per year, there is an 80% potential chance she has PCOS.

Although 10% of women with PCOS are lean, insulin resistance and weight issues are normally characteristic of PCOS. PCOS is diagnosed by 3 main features (3):

• hyperandrogenism (high levels of masculinizing hormones)
• anovulation (lack of ovulation)
• polycystic ovaries (diagnosed by transvaginal pelvic ultrasound)

Common diagnostic laboratory measures include but are not limited to:

• C-peptide (measures insulin output by the pancreas)
• Glycosylated hemoglobin A1C (measures the previous 3 month blood sugar average)
• Fasting glucose level (levels above 100 can be indicative of insulin resistance)
• Fasting insulin (levels above 10 can be indicative of insulin resistance)
• Oral glucose tolerance test
• Total and free testosterone
• DHEAS sulfate
• FSH (follicle stimulating hormone)
• LH (luteinizing hormone)
• Cholesterol panel (total, HDL, LDL, triglycerides)
• C-reactive protein (measure inflammation in the body)

Two of the most common laboratory measures to check are a fasting blood sugar and glycosylated hemoglobin A1C. Statistically, if the fasting blood sugar is over 100 and the Glycosylated A1C is over 5.5%, professionals only miss the diagnosis of PCOS in 1.5% of cases, as opposed to missing 15-20% of the cases of women with PCOS. 2

Commonly, there is a high triglyceride level coupled with a low HDL, and an elevated LDL cholesterol. Women with PCOS have a two-fold risk of myocardial infarction, equal to a woman of 70 years old. 1

Although oral contraceptives are frequently recommended and prescribed, they may actually worsen insulin resistance, cause glucose intolerance, increase triglycerides and increase cardiovascular disease. In addition, there is a 2-fold increase in cardiovascular events in woman with PCOS taking oral contraceptives versus normal women. 1 Since the hormone content of birth control pills is supra-physiologic, even at a low dose, it is pertinent to raise the question of their safety with regard to the development of insulin resistance, cardiovascular disease, and type two diabetes in women with PCOS. 2

Treatment:

Weight loss significantly improves androgen levels and fertility. Even a 5% loss of body weight is enough to improve clinical symptoms of PCOS. A carbohydrate controlled diet with protein, monounsaturated and omega three rich fats at each meal and snack, individualized according to the patient, can significantly calm down insulin resistance leading to weight loss.

It is important to include omega three rich foods and/or supplements as needed. The 3 types of omega three fatty acids are:

• Alpha Linolenic Acid (ALA)- richly found in ground flax seed
• Eicosapentaenoic Acid (EPA)
• Docosahexaenoic Acid (DHA)

Both EPA and DHA are found in fish and fish oil. 1 tablespoon per day of ground flax seed is recommended to achieve 2 grams of ALA per day, and between 500-1000 mg. each of DHA and EPA is recommended to help with symptoms of PCOS. If an individual consumes fish several times a week, a supplement may not be necessary.

A drug given with PCOS is Metformin or Glucophage. Metformin in an insulin-sensitizing drug which lowers insulin resistance and can assist with lowering the appetite and weight, and normalizing hormone levels. Dosing is usually 500 or 850 mg. given once or twice a day. Side effects of Metformin can include: gas, bloating and diarrhea, which can be exacerbated by a high carbohydrate diet. If the patient is compliant with a carbohydrate modification, and slowly transitions onto the drug from once to twice a day, these symptoms are minimized or nonexistent.

Another class of drugs known as TZD’s are commonly prescribed. Experts in PCOS do not recommend these drugs due to increased weight gain, and an increase in fractures in women prescribed them.

Exercise and daily activity are extremely helpful with lowering insulin resistance and assisting with weight loss.

Although PCOS can be a challenging condition to diagnose and treat there are many pharmacologic and non-pharmacologic treatments available. A lifestyle including a balanced carbohydrate controlled diet along with omega three rich fats, and daily exercise has been shown to be extremely successful in treating PCOS. Metformin is the drug of choice in helping to lower insulin resistance, cardiovascular symptoms and assisting with hormone balance.

1. Nestler, John. Update on Polycystic Ovarian Syndrome. Presented at the American Diabetes Association 54th Annual Postgraduate course. 2/23/07.
2. Baillargeon, Jean-Patrice. Sex Hormones and Diabetes. Presented at the American Diabetes Associaton 56th Annual Postgraduate course. 2/7/09.
3. The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Hum Reprod 2004; 19:(1): 41-47.

Susan B. Dopart, M.S., R.D.
2336 Santa Monica Blvd. Ste. 201
Santa Monica, CA 90404
310-828-4476
www.susandopart.com