Polycystic Ovarian Syndrome and Insulin Resistance
Polycystic ovarian syndrome (PCOS) is a metabolic disorder that is estimated to affect approximately 10 percent of reproductive aged women. In fact, it is the most commonly identified fertility obstacle in women.
PCOS is a syndrome rather than a specific disease. Even the world's experts cannot agree on a single definition. Most experts would agree that a minimal requirement for this diagnosis would be an absence of regular ovulation. Other symptoms might include increased hair growth, acne, and weight gain. However, there are women who will have few if any of these symptoms.
There is a clear link between insulin resistance and PCOS. Insulin resistance is a condition in which the pancreas (abdominal gland that makes insulin) must secrete much higher amounts of insulin in order to keep blood sugars in the normal range. Through a variety of mechanisms, this results in higher male hormone production by the ovary, often causing anovulation, weight gain, and the other symptoms listed above.
Southeastern Center for Fertility and Reproductive Surgery and PCOS
We were one of the first centers in the nation to begin testing for and treating PCOS. Our reputation has brought invitations to lecture on this topic at both local and national levels.
Autumn Galbraith, our Women's Health Nurse Practitioner, is particularly interested in the area of PCOS. We believe that aggressive and ongoing management is important for optimal reduction of long term health risks and maintenance of favorable cosmetic features such as weight management and hair reduction. We are experienced in the use of hormones, antiandrogens, weight loss medications, lifestyle modifications and support groups to achieve long term success in managing PCOS.
A clinical workup for PCOS should include a careful history and physical exam. It is important to assess for blood pressure, body mass index, ovarian features and other skin and hair distribution irregularities. In addition, lab values obtained from bloodwork is a hallmark of establishing a PCOS diagnosis. Further evaluation may be necessary to rule out other causes of PCOS symptoms.
Treatment of PCOS depends greatly on the patient goals. Please choose which treatment goal is of primary importance to you at this time:
This questionnaire is an assessment of your possible need for further evaluation for a disorder called Polycystic Ovarian Syndrome (PCOS). If you have one or more "yes" answers, it would be advisable to follow up with a medical provider who specializes in the evaluation and treatment of PCOS.
- Do you have irregular/infrequent menstrual cycles?
- Do you have excess hair growth on your upper lip, chin, lower abdomen or inner thighs?
- Do you have darkening &/or thickening of the skin on the back of your neck, armpits, or under your breasts?
- Do you have recurrent cysts or "boils" in the groin area?
- Is your waist circumference >35 inches?
- Do you or another family member have a history of diabetes?
- Have you had trouble achieving pregnancy?
Clients with PCOS often require medication and specialized behavioral changes to achieve improvement in their healthcare. If you have one or more yes answers to the above questionnaire and would like further evaluation, our center would be happy to speak with you.
Fertility and PCOS
From a fertility standpoint, the goal of treatment for PCOS is inducing regular ovulation. Weight loss and exercise are often helpful, but medications are the cornerstone of therapy. Anti-estrogens such as Clomiphene, Tamoxifen and letrozole will induce ovulation in 90% of patients, although only 40-50% will actually conceive. For those patients who do not ovulate or conceive with oral therapy, low dose injectable hormones are extremely effective. Finally, surgical therapy for PCOS remains a viable option and is a preferred method in certain individuals.
It is common to incorporate insulin-sensitizing medications such as metformin to the above therapies. These medications have been shown to assist in ovulation induction and to decrease the risk of miscarriage and gestational diabetes in women with insulin resistance.
Long-Term Risk Reduction
Studies have shown that women with PCOS have a 40% chance of developing diabetes later in life. They are also more likely to develop heart disease, high blood pressure, elevated cholesterol levels, and endometrial cancer.
PCOS patients also have great difficulty with weight control, acne, increased hair growth and other skin complaints. While some of these symptoms are mainly cosmetic, others can increase the risk for other health problems.
Treatment for women who are not pursuing pregnancy often includes birth control pills. These hormones protect the lining of the uterus and decrease the risk of endometrial cancer. Metformin is used to regulate high levels of insulin that many PCOS women have. Anti-androgens are incorporated for hair and acne complaints, and to reverse some of the other detrimental biochemical changes of PCOS.
Weight loss is an important part of PCOS management. Modified exercise and diet plans are crucial as the metabolic activity of these patients is different than the typical dieter. Certain weight loss drugs can assist with the often-frustrating plateaus of weight loss that PCOS patients hit. Goal setting and reward planning are also vital to success in achieving a healthy weight.
Finally, careful monitoring of associated health issues are important for long term PCOS management. Among the recommended areas of monitoring are blood pressure, blood sugar, lipids, uterine lining status and body mass index.
Laparoscopic Ovarian Diathermy (aka Ovarian Drilling) & Ovarian Wedge Resection
Laparoscopic ovarian diathermy is a surgical procedure used as a treatment to induce ovulation and regular menses in women with polycystic ovarian syndrome (PCOS).
This procedure is performed via laparoscopy, which is an outpatient surgical procedure in which a telescopic instrument is placed through the umbilicus and two or three very small incisions are made in the lower abdomen to hold and treat the ovaries. Using electrocautery, the ovarian cortex is entered and the underlying ovarian tissue is cauterized. The number of cauterization points is dependent upon the size of the ovary. This procedure can also be performed with laser; however over the years I have found this to be less effective than treatment with cauterization.
The main underlying reason for the effectiveness of this treatment is that cauterization of the ovarian stromal tissue decreases male hormone production, thus allowing the follicles to grow in response to the woman's FSH hormone. Other mechanisms may be operative as well but are probably less important.
Ovulation and pregnancy rates - At least 2/3 of women will ovulate spontaneously after this procedure is performed. Most of the remainder can be made to ovulate with Metformin or low doses of ovulation induction agents such as Clomiphene or Femara.
Pregnancy rates are the same or perhaps slightly better than those achieved with oral ovulation induction medications, and approximate 50%. Miscarriage rates are no higher after these pregnancies than after pregnancies conceived in a normally ovulating (non-PCOS), woman.
Potential risks and complications - We will discuss this with you in detail at the time of your office visit. Laparoscopic surgery poses few risks in the hands of an experienced surgeon. The risk of laparoscopic surgery is probably lower than the risk of driving your car.
Adhesion formation is possible after laparoscopic treatment of the ovaries. However, I have found this to be quite uncommon in my patients following this procedure, and the majority of them have conceived, indicating that if any scar tissue formed, it was too little to significantly effect the ability to conceive.
Why you should consider having this procedure - Generally, ovarian diathermy is not routinely performed because it is typically easy to help women with PCOS ovulate using less invasive and costly oral medications. However, women who fail to ovulate with these medications are good candidates for the procedure. Many women cannot afford these medications and ovarian diathermy is an appropriate option for them as well. Finally, women who have decided to discontinue infertility treatment but who would like to leave the option for pregnancy open should consider this procedure, since women with PCOS generally would not ovulate on their own without intervention.
Other factors to consider - Not all women will ovulate or conceive with this procedure, however the risks are few. In addition, it could improve response to injectable medications and help prevent hyperstimulation syndrome in any subsequent injectable Menotropin or IVF cycle.
Although no data has shown this, it is possible that destruction of portions of the ovary could cause menopause to come slightly earlier than it otherwise would in women who have this operation. Early in this history of this procedure, over aggressive treatment of the ovaries did lead to some cases of ovarian failure. I have never seen this in clinical practice.
Bilateral Ovarian Wedge Resection (BOWR)
Bilateral ovarian wedge resection is an extremely old but very effective procedure for helping women ovulate who have PCOS. The principals are the same as those described above. In this procedure, however, a more standard sized incision is made through the abdominal wall and the operation is performed through this incision by cutting out a "wedge" of ovarian tissue and then sowing the ovary closed again. The reason for having this operation rather than laparoscopic ovarian diathermy is primarily financial, in that it is not considered experimental whereas some insurance companies still consider ovarian diathermy to be experimental. However, the laparoscopic procedure has been validated in thousands of patients all over the world and is by no means experimental. A second reason for having bilateral ovarian wedge resection is for women who have extremely high hormone levels and therefore an androgen secreting ovarian tumor must be ruled out. This cannot be performed with the laparoscopic diathermy procedure.