PCOS: Overlooked and Under-Treated

A recent report revealed that there are so many cases of polycystic ovary syndrome (PCOS) in the US that costs for diagnosis and lifetime treatments are estimated to be $8 billion a year.

If you have PCOS, obviously you’re not alone. It’s estimated that PCOS affects one woman in seven (estimates go as high as 15-20% of reproductive-age females), and, sadly, most go undiagnosed for years.

The most common PCOS symptoms are irregular periods, a disruption in metabolism leading to weight gain, and elevated levels of the male hormone testosterone. All of these frequently result in infertility. Untreated PCOS is also linked to obesity, diabetes, acne, and heart disease.  

When I was in med school, PCOS was quite uncommon. Now you see articles in magazines and experts on daytime talk shows trying to explain a condition no one really understands. At least today there’s hope for affected women, who find themselves becoming overweight and infertile, growing facial hair, and getting acne.  

The average woman sees five doctors before being diagnosed with PCOS. Most don’t actually even make it to five doctors and millions more go undiagnosed because they have limited or no access to the US health care system.

This diagnostic delay is a good example of a serious flaw in the specialized education of doctors. Ovaries, infertility, and irregular periods are considered the purview of obstetrician-gynecologists. Obesity, excess facial hair, metabolic syndrome, and cholesterol are internist territory. PCOS requires that an obstetrician-gynecologist think like an internist…and vice-versa.

And it’s only been recently that the two groups of physicians sat down and started discussing what seems to be a near-epidemic of PCOS.

What causes PCOS?

The situation is further complicated by the absence of straightforward tests to make a clear-cut diagnosis, not helped by the fact that doctors are uncertain what triggers PCOS in the first place. There appears to be a genetic predisposition. PCOS is common in sisters and mothers, and brothers of PCOS patients have high levels of pre-testosterone DHEA, though it’s harmless to them.

Some researchers attribute the explosion of PCOS to hormone disruption caused by the massive amounts of toxic chemicals in our environment, which can trigger PCOS in genetically susceptible women.

The underlying problem in PCOS begins when the ovaries develop fluid-filled sacs called cysts and begin to secrete an excessive amount of the male hormone testosterone. This in turn disrupts menstrual regularity and ovulation and leads to infertility. It’s the testosterone that also causes excessive facial hair and acne.

To complicate matters, women with PCOS develop resistance to the blood sugar-lowering hormone insulin, a situation similar to Type 2 diabetes that leads to high levels of glucose (sugar) in the blood, weight gain, high cholesterol, and even more testosterone production.

To compensate for insulin resistance and high blood sugar, the body produces even more insulin, which in turn produces even more male hormone, like a snowball rolling downhill out of control. After years of elevated glucose and cholesterol levels, women with untreated PCOS become susceptible to heart disease and high blood pressure.

In short: High levels of insulin lead to pre-diabetes, diabetes, and obesity. High levels of testosterone lead to irregular periods, infertility, facial hair, and acne.

Helpful treatments, conventional and alternative

I recommend that any woman experiencing a combination of irregular periods (with or without infertility), unexplained weight gain, and/or new facial hair ask her doctor about PCOS.

The standard diagnostic tests for PCOS are:

• Blood tests that check for evidence of elevated male hormones (testosterone and androstenedione).
• Tests to check for insulin resistance (fasting blood glucose and triglyceride levels).
• Vaginal ultrasound to look for cysts.
• Tests for levels of cholesterol and other hormones (estrogen, progesterone, and thyroid and adrenal hormones).

However, and this is a big however. If you have all the clinical findings of PCOS, but your tests are normal, you should assume you are pre-PCOS and begin treatment with diet, exercise, and natural remedies. Start with nutritional counseling along with weight reduction and exercise.

Every woman who has PCOS should work with a nutritionist. There’s probably no endocrine disorder, except perhaps for diabetes, whose outcome relies so heavily on healthful eating. Our nutritionists Becca and Olivia have lots of experience with PCOS patients. From them you’ll learn what type of PCOS you have.

The four types of PCOS

• Insulin resistance PCOS. This is by far the most common, occurring in 70 per cent of women with PCOS.
• Adrenal PCOS. Triggered by an episode of severe and protracted stress.
• Inflammatory PCOS. Caused by chronic inflammation.
• Post-pill PCOS. This type can occur after you stop taking birth control pills.

Treating PCOS

Often, women with PCOS will see improvements in their overall health and well-being by wholeheartedly embracing a healthy lifestyle. It is well-established that junky foods make matters worse with PCOS. Here are four steps to consider.

1. Immediately begin a weight-reduction program centered on eating a low-carbohydrate diet with protein, veggies, and fruit. You should eat as organically as possible to detoxify yourself, but this needn’t be the $100-a-bag approach from Whole Foods. Many groceries now carry organically grown produce, and with the money you’ll be saving by not purchasing prepared and processed foods, trust me you’ll come out ahead. If you need help with all this—including very practical and eminently usable advice on how to shop your local grocery for best results–set up an appointment with one of our nutritionists.

2. It’s essential you start a regular exercise program to burn off toxin-storing fat and to strengthen your muscles. This isn’t a question of vanity–it’s a medical necessity. You can hire a personal trainer or you can easily start on your own. Look for a workout that combines cardio, strength training, and stretching. The online choices are endless. Click here and choose one to get started.

3. Supplements. You need a good general multiple vitamin (like this one with iron) or, if you’re trying to conceive, a prenatal blend. There is no one-size-fits-all herbal protocol for PCOS treatment. One group of herbs may be useful for high levels of testosterone, another for pre-diabetes, and another for menstrual irregularity and infertility. For help, schedule consults with either of our herbalists, Caley Scott, N.D. or Parisa Samsami, D.C.

4. Conventional medicine emphasizes prescription drugs rather than nutrition, lifestyle changes, and herbal remedies. If you have insulin resistance or high blood sugar, expect a diabetes pill (Metformin or any of five others); facial hair or acne, a pill to block testosterone (spironolactone); irregular periods (often treated with birth control); infertility (clomid, letrozole); fluid retention (a diuretic); and obesity (an appetite suppressant). Be sure to ask your doctor to clearly explain all the possible side effects of any prescription drug she prescribes for you.

If your doctor remembers, she’ll give you a pamphlet on weight loss and you’ll most likely lose the pamphlet instead of losing any significant weight. Start on numbers 1, 2, and 3 above and check in with us if you need support.

Be well,

David Edelberg, MD