Amanda Wilde (Host): This is Check-up Chat with EvergreenHealth. I'm Amanda Wilde. In this episode, we'll focus on PCOS, a hormonal condition that can have long-term consequences. We'll talk about causes, symptoms, and treatment with Dr. Semonti Hossain. Dr. Hossain specializes in Obstetrics and Gynecology at EvergreenHealth. Doctor, thank you so much for being here for this conversation.

Semonti Hossain, MD: Thank you for having me.

Host: First, what is PCOS?

Semonti Hossain, MD: So, PCOS stands for polycystic ovarian syndrome, and it's one of the most common, if not most common endocrinopathy, so endocrine disorder in women, which often catches my patients off guard because they think of thyroid as a common, or diabetes. But actually, PCOS is more prevalent than that. But women don't seem to talk about it too much because they don't know about it, or the symptoms sometimes can be masked or misleading and confused for other conditions. And women need to talk a little bit more openly about their reproductive organs, so it often gets missed.

Host: Well, what are the symptoms?

Semonti Hossain, MD: The actual diagnosis for PCOS, I go by a criteria called the Rotterdam criteria, where there's three symptom clusters. And if you have two out of the three, you meet the diagnostic criteria for PCOS. But if you have one, you know, it makes you think that it's suggested that you might develop it or maybe you're resolving it.

So, let's go into the three symptoms. Number one, the most common symptoms my patients present to me with is amenorrhea or oligomenorrhea, which is a fancy word for fewer periods. You're not ovulating, and you have prolonged space in between periods. So oftentimes, I'll hear women come in saying they haven't had a period in six months or four times a year. So, that clues me in, maybe this patient is PCOS.

Number two, as the name suggests, we're looking for polycystic ovaries on ultrasound. And so, you typically do a transvaginal ultrasound, so a probe that is inserted in the vagina. The reason being is that probe can then really come up nice and close to the ovaries, and we can see multiple cysts on the ovaries. There's specific sonographic criteria for this that's not really relevant for you, but something that myself or the radiologists look at. But we look for 2 to 9 millimeter cysts, many of them, about 12 of them on each ovary. It's pretty obvious when you see it. In medical school, we learned about this feature called a string of pearls sign, because the cysts aligned on the periphery of the ovary, and it looks like a string of pearls. So, that clues us in of a sonographic feature of PCOS.

And the last symptom of PCOS is symptoms of elevated testosterone or hyperandrogenism. So, sometimes women will report hair on their chin or chest or male pattern hair loss or balding or darkening of some parts of their body, like the back of their neck or their underarms. These are suggestive of elevated estrogen or insulin resistance. This is a little harder to ascertain because some ethnic groups may have them naturally. So, I also like to kind of support this with a laboratory test. Oftentimes, we'll order a lab blood testosterone level. And if it's a little elevated, that clues me into elevated androgens.

So if you have two out of these three, you meet the criteria. but if you have one, you don't quite meet the criteria, but you can still keep it in your differential.

Host: When you see these suspicious findings in these three areas, how do you determine the diagnosis is PCOS?

Semonti Hossain, MD: Most of the time, patients come to me with the irregular periods, so they're already slam dunk meeting that criteria, but there are many other causes of irregular periods, and that's also part of my PCOS workup is to rule out other rare causes. Usually, I assess for the other two symptoms. So, we order an ultrasound and I order a blood testosterone to support the diagnosis of PCOS. But then, I also order a series of hormonal tests to rule out other causes. So, I order a prolactin level, a thyroid level, DHEAS, and a hemoglobin A1c and lipid; and those two are mainly not for diagnostic purposes, but just since I know it can be associated, those metabolic syndromes or abnormalities in your like metabolic syndrome-- I guess for a lack of better words-- is associated with PCOS, I want to just see if the patient is pre-diabetic or has high cholesterol. So, that's kind of how we initially-- we do a data gathering visit where we're like, "Okay, this looks kind of like PCOS. Let's do some of this testing, gather our data and then revisit and see if you meet the diagnosis or not." And then, over the course of the next few days, we get the results and we meet again, and then we confirm the diagnosis.

Host: So, where does PCOS, where will we see the impact? It sounds like it disrupts ovulation. What about fertility?

Semonti Hossain, MD: Yes. So, first of all, PCOS impacts menstruating women because it's a menstruation abnormality. So, it's not something we consider in our pre-pubertal adolescents or children or then after menopause, it's not an active issue. It's really when you're menstruating years. So when you have irregular cycles, the kind of way I think about it is backtracking a little bit, I see the menstrual cycle as a vital sign in a woman. So if your blood pressure's normal or heart rate's normal, we also got to be looking at regularity in your menstrual cycle. So, that's a vital sign because if you are not menstruating regularly, that's indicating that there is some sort of hormonal disruption inside your body. And hormonal disruptions has longstanding effects on every organ because every organ has receptors for hormones. And my menopausal or perimenopausal patients recognize that because when they lose their estrogen, they have a series of symptoms, not just one isolated symptom. So when I notice a patient's having irregular or spaced out cycles, it's really important to know if it's PCOS or not because of long-term consequences. There are some long-term consequences.

One is if you're not shedding your cycle period regularly or endometrial lining regularly, that puts you at a slightly higher risk for endometrial cancer. I don't think this is like a scientific explanation, but the way I think about it is your body is not getting rid of that lining, and so that lining can build up over time and then can turn abnormal. And endometrial cancer is a cancer diagnosis. We'll see it in some of our 30 or 40-year-old patients, and that's pretty distressing to have that diagnosis.

Number two, as you noted, it's an ovulation disorder. So every month, our ovaries ovulate and that triggers or, as part of a whole hormonal cascade, that allows for a regular monthly cycle. So if you are not ovulating, you are not going to be able to get pregnant if you would like to get pregnant. So, one way I talk about it with my PCOS patients who are wanting to get pregnant is a non-PCOS patient is ovulating 12 times a year, so they have 12 reasonable chances to get pregnant. A PCOS patient might only be ovulating three to six times a year, and in an unpredictable pattern, you don't know when you're going to ovulate. It can really markedly decrease your fertility because you don't know when you got pregnant or when you can get pregnant. Alternatively, you can accidentally get pregnant and not realize you're pregnant because you know yourself to miss periods. So, that's kind of feeds into my treatment discussion as you talked about fertility, as my first question is, would you like to get pregnant or not? Because if you want to consider fertility, then we have a whole discussion about how to optimize your health for fertility, how to reverse some of the effects of PCOS medications we can give to elevate and improve ovulation. And then, if you're wanting to pause on pregnancy and not try for pregnancy this year, then we talk about actually initiating combined oral contraceptive pills, which has been shown to be the best treatment to regulate your cycles until you're ready to have kids.

Host: How do you know the treatment's working?

Semonti Hossain, MD: Well, the good thing is you can see your periods, so my patients will let me know if they're having regular monthly periods. It's not going to be immediate. For some women, it is immediate and that's great. They'll message me and say, "Hey, Dr. Hossain, I did have a period this month and it's been working." Some of my patients, it won't happen immediately. So, I usually give them a three to six-month trial period. And I don't hear back from them, which makes me think that they're having regular monthly periods again.

Host: So, your typical patient is a menstruating patient. Do other women also have PCOS? You mentioned you don't really see younger women or postmenopausal women, but can you still have those cysts in your ovaries at a later age?

Semonti Hossain, MD: Typically not. PCOS is a syndrome that manifest as abnormal menstrual cycles. And when we're in menopause, our ovaries are basically dormant. So, it essentially is treated if you think about it that way. For the same reason, we don't see PCOS manifest in kids who haven't had periods yet because their ovaries aren't active at that point.

That given, it's not just about ovulation and regular monthly cycles, PCOS is also associated with other metabolic disorders, which has even stronger implications on a woman. So number one, I talked about the higher risk of endometrial cancer. Number two, these patients have a higher risk of diabetes and insulin resistance, so always screen them for diabetes. They're almost often pre-diabetic. Last statistic I've read was I think 50-80% can be pre-diabetic.

Another thing about PCOS, which is interesting, is it's associated with obesity. So, we're seeing it rise, get higher and higher in the U.S. as our obesity epidemic continues to rise. Eighty percent of women with PCOS have obesity. And so, one of our first treatments, actually even before the birth control pills in our fertility discussion, is weight loss if you're in the 80% category. As little as 10% weight loss can result in regulation of your cycles. We suspect that the excess fat and adipose tissue in the body secretes extra estrogen. Estrogen is the hormone that our ovaries secretes. And so, when your brain sees the extra estrogen from your ovaries and the fat tissue, it gets a little confused and it messes up the cycle.

Host: So, losing weight and the treatment options that you have mentioned, how successful are these approaches to dealing with PCOS?

Semonti Hossain, MD: Pretty successful. And it really depends. If a woman is significantly obese, yeah, you're going to see results from weight loss. But for my moderately obese to non-obese patients, I don't see much of an impact.

That given, you know, lifestyle interventions, it's hard, it's hard to do. So, I don't see an immediate effect. It usually takes years and it relies on patient motivation. So, it's hard to really assess. It's not as clear as medications. If I were to start them on pill, the effect is immediate. But the weight loss, it's more of a long-term, consistent effort.

One interesting thing I wanted mention was now with the introduction of these GLP modulators with Ozempic, these kinds of medications we're seeing, you'll see this on papers or the news that patients who are taking Ozempic are suddenly getting pregnant. And that's, I believe, due to reversal of their PCOS because they're losing weight, their cycles regulate, and they ovulate again.

Host: It's interesting to hear that people can really be proactive in treating their PCOS with lifestyle changes like that. That's a big one.

Semonti Hossain, MD: Yeah, it is. But it can also be a challenging one. I mean, I think patients know, you know, weight loss has significant impact on the body in a good sense. And so, I like to do a little bit of both instead of, you know, just saying, "Let's try." Unless some of my patients really want to stick to lifestyle modification first, I like to start them on the pill, but also encourage parallel lifestyle modification to help or maybe using a medication like Ozempic if they qualify for it.

Host: Dr. Semonti, thank you so much for explaining PCOS so clearly.

Semonti Hossain, MD: You're welcome. Thank you so much for taking the time to ask. You know, this is something I see so commonly in patients, and honestly, I don't have the time to delve into this regularly with them. So oftentimes, I'm sending them links and videos. So, being able to share this information here makes my job easier and lets me share something to my patients as well.

Host: That wraps up this episode of Check-up Chat with EvergreenHealth. Head on over to our website at evergreenhealth.com for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.