Bob Underwood, MD: Polycystic ovarian syndrome, or PCOS, affects millions of women worldwide. Yet, its complexities are often overlooked. The symptoms can range from irregular cycles to hormonal imbalances, and the impact on fertility can be significant. Despite its prevalence, many women struggle to get the proper diagnosis and care.

This is Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Bob Underwood. Today we're joined by Dr. Nancy Fay, OBGYN with the Carle Health and expert in women's health issues.

She's going to guide us through the latest understanding of PCOS, it's challenges and the most effective ways to manage it. We'll explore how lifestyle, diet, and medical treatments can make a profound difference for those living with PCOS, and discuss the latest research that's offering hope for better outcomes.

Thanks for listening as we dive into the complexities of this condition and how it affects the lives of so many women. Dr. Fay, it's so good to have you join us today to talk about polycystic ovarian syndrome. Thank you for joining us.

Nancy Fay, MD: Very good. Nice to be here.

Bob Underwood, MD: Let's just start by talking about a brief overview of what is polycystic ovarian syndrome. Why is it important to our listeners?

Nancy Fay, MD: Well, PCOS, or polycystic ovarian syndrome, is the most common metabolic disorder in women, and depending on person's ethnicity, it's about a 10 to 13 percent incidence in reproductive age women, with the highest incidence in the Mediterranean Asian, Indian population. There's numerous symptoms associated with PCOS.

Typically women have less than regular cycles. Some obvious sign of excess male hormones, whether it's blood work or extrafacial hair, acne, that sort of thing. But in order to diagnose it, other endocrine disorders have to be ruled out.

Host: So kind of a diagnosis of exclusion in some ways.

Nancy Fay, MD: Correct. People have to have normal thyroid functions, their prolactin needs to be normal, and they have to be two to three years out from their first menstrual period before this is something that can be diagnosed, and some teenagers may not be able to be diagnosed until they're in their early 20s.

Host: So, since we've talked about that, and it is a diagnosis of exclusion, are there any particular tests involved once you've really looked at thyroid, prolactin, and some of the other things? Any other tests that you might be looking at to make the diagnosis?

Nancy Fay, MD: Certainly there's clinical history and on exam women who have elevated male hormones, but when there's not clinical suspicion in terms of extra facial or abdominal, chest hair or severe acne, we a lot of times will do blood work to measure levels of the different male hormones which can originate either from ovarian or adrenal gland sources. We do test for ovarian reserve as well because women, based on the international guidelines on PCOS from 2023, an elevated anti mullerian or AMH hormone test is also diagnostic, which is a blood test of PCOS. And we do ultrasound to visualize the ovaries to see if they look polycystic.

However, one has to be in their 20s before an ultrasound showing a polycystic ovary is significant given that much younger women, teenagers, will have ovaries that look polycystic at that age just because of having a high reserve given their young age.

Host: Right. So the age of the patient can determine the finding based on ultrasound and what that image would look like. That makes total sense. Is there discomfort for the patient with polycystic ovarian syndrome?

Nancy Fay, MD: That is a variable finding. Not all of the research suggests that women have pelvic pain associated with PCOS. However, in this patient population who have PCOS, they have a much higher incidence of developing, not the tiny excess number of egg follicles we see on the ovaries, but larger cysts, which can cause pain and occasionally rupture, which clearly causes pain for that patient. So there is an association with it, but it's not part of the classic, diagnostic criteria for PCOS.

Host: So how does PCOS impact a woman's fertility? Are there potential reproductive challenges associated with the condition?

Nancy Fay, MD: I would say the majority of women, but not all, with PCOS have some form of ovulatory dysfunction in that they either do not ovulate consistently or at all. So they lack progesterone and their body just produces constant estrogen which can lead to bleeding problems, irregular, heavy, random cycles, and because they don't ovulate, clearly they can't conceive, or they have a higher incidence of multiple miscarriages due to low progesterone levels.

Host: Interesting. And is this hereditary in any component?

Nancy Fay, MD: It is hereditary in one sense that it is a much higher incidence within a given family of PCOS. There is no bona fide specific gene that has been linked. It's probably a multi factorial polygenic kind of inheritance, but it is common in women with PCOS to have a mother or a paternal aunt on both sides of the family with a history of that and or Type 2 diabetes or insulin resistance.

Host: So what are some treatment options that might be available for managing PCOS? How do these vary based on independent patient needs?

Nancy Fay, MD: Well, it sort of depends on whether the patient is wanting to conceive today versus, they want their cycles regulated versus, and sometimes this is all together, wanting to manage their extra hair growth or acne. For the younger woman not currently wanting to be pregnant, either if they need contraception; combination birth control pills, patches or rings will regulate the period, provide the missing progesterone that they are not producing, and it does suppress ovarian male hormone production, which results in the acne or excess facial hair.

In that setting, with the combination hormonal contraceptives, if that's not enough to manage the male hormone side effects, we'll typically add another drug called spironolactone, which blocks the male hormone at the level of the hair follicle, which does improve both the acne, as well as the extra hair growth.

Now, for women who don't necessarily want to regulate the cycles, but want to get rid of chaotic, heavy bleeding; progesterone only types of birth control, a Mirena, Kyleena, the number of hormonal IUDs will work to provide the missing hormone. And one of the biggest issues for people is unopposed estrogen in women with PCOS for a lifetime can increase the risk of uterine cancer and any of the hormonal contraceptives will help this.

For the other category of women who are wanting to be pregnant, and those patients who have significant insulin resistance, maybe are pre diabetic already; those that are pre diabetic and have significant insulin resistance, a lot of times we will start them on metformin, which is an insulin sensitizer, which for some women, is enough to help regulate their cycles and help with ovulation. But many women will need additional medication like Clomid or letrozole to actually induce ovulation in order to conceive.

And they will probably need help with either OBGYN or reproductive medicine specialists to help in that regard.

Host: It's all great to know information and you know, all the different categories that have to be considered depending on the needs of the patient and the desires of the patient. What about lifestyle changes? Are there any diet modifications or anything like that, that can play a role in managing the symptoms of PCOS?

Nancy Fay, MD: Yes, and many women with PCOS have an increased incidence of weight gain, obesity, some to extreme levels and some are more minor. The best management for this category of patients is the lower carbohydrate diet just because eating carbs will bump a person's insulin up even more. Other things that help with insulin resistance is increasing activity.

I mean, people groan when I say that. I don't mean they have to be running marathons, but really just increasing the number of steps per day and actually strength training and weightlifting is actually very helpful with insulin resistance and just losing 5 to 10 percent of their body weight; that seems like a lot, but sometimes they don't have to get back to completely normal BMI, and it will definitely help their cycles and help fertility, and also help with having a healthy pregnancy as well.

Host: Now, all of those things are quite relevant. And of course, increased activity and changes in diet affect your health in so many ways. PCOS being just one of the many ways that a patient's going to benefit, I think.

Nancy Fay, MD: Correct.

Host: So what should our listeners know about seeking care for PCOS at Carle Foundation Hospital?

Nancy Fay, MD: Well, certainly, being a very, very common problem, first step would be making an appointment to find out, make the diagnosis to see if they have it, and depending on where they are in their life plans and reproductive history, managing all of this at an earlier rather than later time, it would be super helpful.

First step is making an appointment to get an exam and figure out what's going on, and then the appropriate management plan, depending on that specific patient's history.

Host: Absolutely. Anything else you'd like to add as we kind of finish up today?

Nancy Fay, MD: I think for someone with PCOS, the best way to manage is a sort of lifespan management; doing something to help with cycles today, but also prevent them from developing Type 2 diabetes, which they have an increased incidence of later in life. And prevent the uterine cancer and all of the other things associated with potential other metabolic abnormalities that women may have with PCOS.

Host: I'll tell you what, I always learn a lot when I get to speak with experts like you. So, thanks helping us all become a little smarter today in understanding PCOS. Thank you so much for being on.

Nancy Fay, MD: Well, thank you. It was my pleasure.

Host: And for our listeners, if you'd like more information and to get connected with one our providers, please visit carle. org. That's C-A-R-L-E.org. Also, for a listing of Carle providers and to view Carle sponsored educational activities, head on over to our website at carlconnect.com. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Bob Underwood.