Polycystic Ovarian Syndrome

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General info	Tests	Treatments
PCO sites	Hirsutism sites	PCO articles

Prediction of the Effect of Metformin Treatment in Patients with Polycystic Ovary Syndrome

Symptoms?

A lack of periods (or too many)

Periods that are too heavy (greater than 1 pad/tampon soaked through in 1 hour)

Hirsuitism (dark hairs on your neck (beard), chin (sideburns), breasts, lower abdomen, and other areas)

You gain weight on a low fat diet without cheating

Acne

Mood swings/depression associated with eating or your hormones

Infertility

Relatives with Type II Diabetes or infertility problems

Possible thyroid problems, but this is not confirmed. (See Polyglandular Deficiency Syndromes for more info.

Congenital Adrenal Hyperplasia can mimic PCOS. This is where the adrenal glands overcompensate for not having enough cortisol produced in the body. Once the adrenals kick in, they make androgens (like testosterone) like PCO does, for example: purplish stripes on the abdomen. The Magic Foundation and Medhelp have more information.
Thyroid problems can mimic PCOS. Have your doc check your T3/T4/free T4 levels.

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General info
The first symptoms that one recognizes are generally acne, hirsutism and not getting your period. The lack of periods are to due anovulation or not ovulating, the rest are due to an overbalance of male hormones. The anovulation might be due to insulin resistance.
This problem occurs when your body becomes resistant to the insulin you are producing, making your body produce more of it. This starts off a chain reaction in that the extra insulin works on the ovary to produce more male hormone. Those male hormones cause the lack of periods and hirsutism. This process can start at any age. Some women noticed it or see it in their daughters at puberty, younger than that, or some don't see it until their later 20's/early 30's.
If you are concerned you or a relative or friend has it, have your doc run tests. Your doctor may not think its a problem, but researchers like Dr. Nestler at VCU and Dr. Glueck at the Jewish Hospital in Ohio have shown that there are lifelong consequences, like higher rates of diabetes and heart problems. It is linked to higher breast cancer rates, higher cardiovascular problems and risks of type II diabetes. Once you have been tested, your doctor may want you to just go on the pill or take Provera or Prometrium for the symptoms. While this can help, and has worked well for a good number of women, there is controversy about the pill causing or making IR/diabetes worse. This was recently proven wrong in a 2002 study (see my PCOS articles page). However, there is another method that is getting success: treating IR by using anti diabetic drugs such as Metformin (most popular), Avandia, or Actos. If the doctor is not in favor of using Metformin, and you are, see if they will accept medical journal or medical book articles talking about its efficacy. Do NOT use popular magazine articles. Your credibility and your chances will be much better if you give them their own authoritative information. If you are seeing a ob/gyn, a reproductive endcrinologist or endocrinologist would have greater experience and probably will be more familiar with IR.
A couple of concerns that have come up are in regards to Metformin losing its effectiveness. I've heard about it from women on almost all the email lists and newsgroups I'm on. The diabetics I've spoken to on alt.support.diabetes (Feb./March 2002 said that either you are losing your ability to produce insulin (one article said that medications only last 5 to 7 years on average or that there need to be changes in the diet and exercise (stricter diet, more exercise). So, that being said, whether or not you want to use Metformin as an 'ace in the hole' to have a baby, or whether you want to stay on it, its pretty much up to you. article
If you need birth control, you can use the pill and Metformin at the same time. While only one doctor I've heard of says you can't take them together, there is no scientific evidence to prove this. Actually a study was done with Metformin and Dianette, a European birth control pill, and Metformin enhanced the pill (again, see my PCOS articles page).
Endometrial hyperplasia is something you need to be aware of. When you don't get your period, the lining builds up and builds up. This can cause endometrial cancer or uterine cancer. The FDA approved in 1999 a new dosage of 200 mg of Prometrium to help treat this. You can also use the pill to help control this.
PCOS depression can come from several things: hormone imbalance, self image problems (being fat and hairy). Several ways and ideas proposed to relieve this, outside of drugs are: exercise; buying new things such as clothes, hairstyle, or something that has to do with a favorite interest; joining clubs; refocus on your goals in life; be flexible; get organized; drop negative self talk and be positive; get plenty of sleep and eat right.
Thanks to BJ Lewis, I have a list of larger women's fashion places: Fashion Avenue, Article on Fashion Retailers, Timeless beauty, Shapely intimates, Bigger Babewatch. The National Association to Advance Fat Acceptance is a place to go to for support for larger women. If you are trying to concieve, Fertility Plus has a FAQ and Support for you. Stephie suggests the following tips.
Your doctor may have first suggested that in addition to the pill, losing weight and exercising, if you are overweight would cure the problem. It will definitely help you to lose the weight, whether or not it will really 'cure' or 'fix' the problem is an unknown. As for diets, I would check out the low carbohydrate/high protein diets, because they may better work for how your body processes certain carbohydrates. Extra carbohydrates causes your insulin to rise. Since you already have extra insulin, this is only going to exacerbate the problem.

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Tests:
If you want to know what your doctor is looking for during exams, this page gives you a chance to look up several different types of regular screening exams by your doctor. Some of the more specific exams, such as both male and female infertility checks are here.
The tests that I would use to check for PCO include the following: FSH, LH, prolactin, T4, T4, free T, total T, progesterone, SHBG, HbA1C, 17-hydroxyprogesterone, dexamethosone challenge test (for adrenal androgens), vaginal ultrasound of the ovaries, fasting glucose and fasting insulin, the ratio of insulin to glucose. Note that it is possible to have normal levels of blood hormones and still have PCOS. Also make sure to note whether or not you are on any medications that can affect the results: SPECIFICALLY the birth control pill and where you are at in your menstrual cycle at the time of the tests. I would also add what you ate and when you ate it for insulin/glucose type tests. When you want to do an insulin resistance test, the best on is the 'clamp' test. Its so expensive that a 5 hr GTT is a lot better. It usually takes until the 3rd or 4th hour to see a drop in the glucose level. The current tests we have are not as sensitive as they could be to really prove one way or another whether you are or are not.
Dr. Leon Speroff (see my Dr. Speroff page for background info, Pg 512): The upper limit of normal in fasting insulin is 10 to 20 mL. The ratio of glucose to insulin that is less than 4.5 is IR.
If your HbA1C is tested, > 9 is bad, 7-9 is average, and < 7 is great. The glycosated hemoglobin test is used to measure control of sugar over several months.
Your C Peptide levels are also an indication of how well your insulin has been used.
Your doctor may suggest an ultrasound to look at the ovaries. Here is an excellent look of ovaries with the cysts. Not all women have the cysts, and even if you don't have them, you still might have PCO.
These are your normal hormone levels. Some other blood tests results are here.
Checking the thyroid is also very important in PCOS. Its not a rare complaint, and can also cause problems in infertility. The tests needing to be checked are the T4 and T3. An explanation with values can be found here.

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Treatments:
The best treatment to prevent diabetes and help IR is diet and Exercise. It was proven to beat Metformin in a head to head study (New England Journal of Medicine 2002;346:393-403). I know its a dirty word, but more muscle helps you to process insulin better, and your cardiovascular risks go down. At least briskly walking 2 miles a day (30 min) can start you on the road to help. The Greater Salt Lake Clothing Company we have exercise clothes to fit us. Fear of Fat is a great article that I thought talked about weight issues. Although its not on exercise per se, I include it here due to the perceptions that many overweight women have about how people look at them.
There is also the pill that works with irregular periods and hirsutism problems. Its use is controversial by PCOS women, because some say it makes IR worse.
The previously mentioned Metformin, or any anti diabetic drug, can help you use your insulin better. Metformin has several years of history being used in PCOS women to regain monthly periods and fertility. In some people, weight loss occurs. Hair problems may or may not change. Its use is controversial in women without diabetes, as it is an off-label usage for insulin resistance.
If you have an HMO, or/and are thinking of getting one or dealing with one for Metformin with PCOS, here are some ways to find out about them:
1) In writing, with a signed return receipt and a date to respond by:
a) ask to have a copy of the contract they have with the doctor
b) ask if they offer or deny financial incentives to deny tests, treatments, specialist visits, hospital visits.
c) ask if they maintain doctor prescribing and visit patterns
d) ask if they have access to your medical records and what do they do with them
e) ask if they can terminate you for 'failed relationships' with doctors
f) ask to gain a copy of ALL records (in writing and verbal) of your dealings w/them
g) ask about credentials of people making the medical decisions to pay for treatment
h) ask if the people in g) have seen them or are violating law by making medical decisions w/out seeing patient
i) ask for a copy of the "Evidence of Coverage"
j) try the following websites: HMO HARDBALL, Citizens for the Right to Know, Patient Advocacy.

Melissa, a truly wonderful person, tracked down a list of herbs to try.
For the hirsutism, the easiest thing is to shave, wax or pluck. IGIA, Braun, and Epilight don't appear to help. Surgi Hair-Stop by Ardell in WalMart's cosmetic dept. supposedly does. Dr. Leon Speroff confirmed that shaving doesn't make the hair grow out thicker or more course (pg. 545). Lasers reputed to work the best are Alexandrite lasers. Vaniqa (prescription creme) slows the growth of unwanted hair. Its applied b.i.d. or twice a day. It takes 8 weeks to 6 months before you see an improvement, and if you don't see any by then, stop it. For the acne, a number of products are reputed to work: Proactiv, Clear by Design, Accutane (prescription), Alpha-Hydroxy Oil free gel, Acne clearer: Alque Glycolic, Dermablend, Physicians formula, Clinique, Estee Lauder's, Almay Clean Skin, Revlon, Mary Kay, Vincent Longo, Almay, and one online cosmetic group: Scarlett Cosmetics. An anonymous donor said that the incidence of hypertriglyceridemia is 1 patient in 4 on Accutane therapy. You should have weekly or biweekly fasting blood lipids taken before and following-up with treatment, to know whether or not you are affected. If you take alcohol, the results are messed up and you have to wait for 36 hours to do it again. Liver enzyme elevation has been a problem, as have glucose control problems, with new cases of diabetes have been diagnosed, although no official relationship to the drug has been established. If you are a vigorous physical exerciser, elevated CPK levels have been found; any clinical significance is currently unknown.
Clomid is normally given to women who don't ovulate and are trying to concieve. There are articles that say it helps to use Metformin with it or that Clomid only works for a few ladies. From different lists, I've seen a number of Clomid resistant women that Metformin or the combination of Metformin reputedly helped. (Human Reproduction 2001 Aug;16(8):1625-31, Effects of metformin on ovulation rate, hormonal and metabolic profiles in women with clomiphene-resistant polycystic ovaries: a randomized, double-blinded placebo-controlled trial). Acupuncture may or may not work.

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PCO specific sites

American Infertility Association

The Polycystic Ovarian Syndrome Association - National Organization

PCOS from Midwives of Washington

Polycystic Ovarian Syndrome

The Menopause Doctor's PCOS page

OBGYN.net - PolyCystic Ovarian Syndrome (PCOS) Pavilion

England's Polycystic ovary syndrome

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Hirsutism

What You Can Do If You Have Excess Hair / AAFP Patient Information Handout