Fertility Chronicles is proud to present a special blog series, “From the Fertility Experts,” where leading fertility experts answer commonly asked questions from patients about their fertility health and treatment options. We hope this series can help patients navigate their personal fertility journeys.
Univfy guest blogger Dr. Shahab Minassian, an expert on PCOS, offers insights into the latest treatments for this condition. In addition to his work at the Reading Health System in West Reading, Pa., Dr. Minassian is a Clinical Associate Professor at Jefferson Medical College and at Drexel University College of Medicine, both in Philadelphia. Dr. Minassian shares the following preface and then answers to questions about PCOS.
The changes are gradual: Weight gain, excessive hair growth, acne, and a steadily worsening irregularity of menstrual periods. Meanwhile, fertility suffers.
The diagnosis, treatment, and health risks of Polycystic Ovarian Syndrome (PCOS) have afflicted patients and perplexed their physicians for decades. But recent advances have helped infertility specialists to better care for patients with the syndrome and turn to newer, more effective treatments.
Q: What is PCOS?
Dr. Minassian: The diagnosis of PCOS has been challenging ever since it was first described nearly a century ago, because PCOS patients can take on different profiles. PCOS experts have tried to broaden the definition of PCOS, so that patients in need could receive the appropriate treatment and counseling.
Women with PCOS may not have all of the symptoms of PCOS. Hirsutism (excessive hairiness), menstrual irregularities, and infertility are the most common. Polycystic ovaries can be seen on ultrasound in some but not all PCOS patients. Excessive weight is commonly seen, but a significant portion of patients are of normal weight. Insulin resistance is found in up to 70% of PCOS patients. In fact, Type 2 (adult-type) diabetes has been found in up to 7% of PCOS patients.
PCOS-related infertility can be caused by obvious problems such as a lack of regular ovulation. Lack of proper shedding of the uterine lining every month can lead to overgrowths of tissue and a risk for endometrial polyps, which can cause infertility or early miscarriages.
Q: How do you diagnose PCOS?
Dr. Minassian: Physical exams, laboratory tests, and imaging tests are essential for the diagnosis.
Common blood tests include androgen levels (or male hormones, such as testosterone, DHEA-sulfate, 17-hydroxyprogesterone, androstenedione, for example). In addition, vaginal ultrasound is frequently used to locate the polycystic appearance of the ovaries. This finding is called the “pearl necklace” or “string of pearls” sign, named for the string of small follicles in the ovary.
Q: Do you screen for diabetes, too?
Dr. Minassian: Diabetes screening is also critical. The AE-PCOS Society recommends that all women diagnosed with PCOS are screened with the two- hour glucose tolerance test (GTT), the most effective office-based test available for diabetes screening. Also recommended are a fasting lipid profile and liver enzyme blood tests to screen for “fatty liver.”
Q: Why is this screening especially important?
Dr. Minassian: Women with abnormal glucose testing are at risk for birth defects in their children, miscarriages, and gestational diabetes and should not undergo infertility treatments until their glucose levels are normalized.
How has PCOS treatment improved?
Dr. Minassian: The treatment of PCOS-associated infertility has noticeably changed in recent years. Medications for insulin resistance, or “insulin sensitizers,” have helped many patients. These medications lower insulin levels. Then, androgen levels drop, and menstrual cycles return.
Q: What medications do you use to treat insulin resistance?
Dr. Minassian: The most studied and prescribed medication is metformin. It is at least 75% effective for the return of cycles in women with PCOS and insulin resistance. Many patients will report some weight loss initially on this drug, but that is usually short-lived unless accompanied by lifestyle modification. Side effects of metformin can include gastrointestinal distress (diarrhea, loose bowels, bloating).
It is important to understand that metformin treatment has not been supported by the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction (ESHRE) as a primary infertility treatment, but they support its use if the patient has abnormal glucose levels. However, there is other evidence in the medical literature that supports the use of metformin as a primary medication or as an additional medication to be used with fertility drug treatments.
Q: How has the definition of PCOS evolved?
Dr. Minassian: In 1990, a National Institutes of Health conference defined PCOS as the finding of elevated androgens (male hormones that men and women both have but in differing amounts) and impaired (irregular) ovulation when other hormonal problems are ruled out. Then in 2003, The European Society of Human Reproduction and American Society for Reproductive Medicine (ESHRE/ASRM) added the finding of polycystic ovaries to the criteria and proposed that PCOS can be diagnosed even if a woman has regular periods. The AE-PCOS Society, a worldwide organization of PCOS specialists, has recently published its own diagnostic criteria, a blend of the NIH and ESHRE/ASRM systems, now accepted by many PCOS specialists worldwide.
To read the second blog of this 2 part series, please click here.