Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB Medcast. I'm Melanie Cole. Today, we're talking about a modern approach to women with polycystic ovary syndrome. Joining me is Dr. William Hurd. He's a professor, reproductive endocrinologist and infertility specialist at UAB Medicine.

Dr. Hurd, thank you so much for joining us today. As we're updating a previous episode you and I did together, how has our understanding of the underlying causes of PCOS evolved? How does it impact the current approach to diagnosis and treatment?

Dr William Hurd: The causes still are being determined. And since it's a syndrome, there are thought to be definitely several different causes. The most well described one is insulin resistance, which is thought to increase androgens by the ovary, and then that puts people into polycystic ovary syndrome. But there are certainly a large percentage of people with PCOS who are not insulin resistant, so there are more than one causes. The other causes are less well understood.

Melanie Cole, MS: Well, if they are less well understood, and there are so many women that suffer from this, speak about diagnostic criteria, the most up-to-date criteria for it, and how do they differ from previous guidelines? Because notoriously, it had been difficult to diagnose.

Dr William Hurd: The guidelines still remain a little bit nebulous. There are several different criteria, but the one most commonly used throughout the world is the patient should have two out of three of the following symptoms or signs. The first is signs of anovulation or oligoovulation, which is irregular periods or no periods. The second is clinical or laboratory evidence of elevated androgens. And the third, which is the most difficult to really describe is polycystic ovary morphology on ultrasound. The reason this third one has changed so much is because ultrasound has gotten much, much better. So, the better and more accurate ultrasound is, the easier it is to see small follicles.

The traditional criteria was 12 or more follicles on one or the other ovary, from 2 to 10 millimeters in size. And it turns out that almost every teenager has well more than this and most people into their 20s do. So, many people now are using the criteria of 20 or more follicles on at least one ovary. And this really brings up the next thing.

Most or many teenagers have irregular periods, signs of elevated androgens such as, acne and PCO morphology on ultrasound, so the diagnosis is made with caution. In teenagers, and we recommend that they're told that you might outgrow this or this might be a problem later in your life.

Another thing about the diagnostic criteria that's important, I think, to remember is obesity is not part of the diagnostic criteria. And at least a third of the people with polycystic ovary syndrome are not obese. So if you're just looking for the obese woman with signs of elevated androgens, you're going to miss a lot of the people with PCOS.

Melanie Cole, MS: Well, that leads me into the next question, Dr. Hurd. How important is this idea of really listening to your patients, even if they are teenagers, which we all know can really elevate what they're feeling, what they're thinking, but there are other disorders that could be included or confused for. Tell us how you listen to your patients in order to make this differential diagnosis.

Dr William Hurd: Every patient comes in with a different concern or one of several possible different concerns, and it is really important to ask them, is it the increased hair that's a problem? Is it not getting pregnant, infertility, which is a common problem with these women? Is it weight gain or a fear of weight gain? So, it's really important to talk, especially to the younger people. Nowadays, people go online and, as my patients say, they consult Dr. Google before they even come in. So, they have a preconceived idea of what they might have and what it's going to turn into for them. So, it really is important to ask them what are the symptoms that you're having and what are the symptoms that concern you the most?

Melanie Cole, MS: Now, what's changed, Dr. Hurd, in treatment options once we have definitively diagnosed this? And speak about the different treatment options out there, how they have evolved over the years and how that concept of reproductive planning comes into play when you're thinking about management and considering both fertility goals and long-term health considerations.

Dr William Hurd: We do a standard workup just to make sure there's no other conditions that look like PCOS, but part of the standard workup is to make sure there are not any medical problems associated with PCOS. And the main ones of those are diabetes, metabolic syndrome, which is related to PCOS, but it's a combination of multiple problems more common in the obese patient, including hypertension, diabetes and hyperlipidemia. And then, the long-term problem we worry about is endometrial hyperplasia and even cancer-related to the long-term estrogen without a cyclic progesterone.

So with that kind of thing in mind, what we really do is try to figure out how can we preserve the patient's health and fertility until she is ready to get pregnant. And it depends on what her conditions are. So, basically, the number one treatment for irregular periods and clinical signs of increased androgens and lowering the risk of endometrial hyperplasia is a oral contraceptive with progestins or an intrauterine device with progestins. Both of those are commonly used and very important to avoid some of those things. Then, the other cornerstone of treatment for those women who are obese is getting that treated effectively.

Melanie Cole, MS: So, I think one of the most important aspects of this syndrome is this multidisciplinary approach because, as you mentioned, there are fertility considerations and overall health considerations. It could be teenagers, it could be women in their reproductive years or older. How do you collaborate with other healthcare providers to really optimize the care of women with PCOS?

Dr William Hurd: Yeah. This is especially important in younger women, but really women of all ages with PCOS. We take care of the gynecologic problems and we advise people about the other treatment approaches. But it's really important to make sure the women with metabolic syndrome, hypertension, diabetes, et cetera, are seen by a primary care physician, either internal medicine or family medicine, to deal with these on an ongoing basis.

And then, the thing that's really changed the most is we're getting better treatments for weight loss. So, we try to connect our patients who are overweight or obese with weight loss programs, who are now using much more sophisticated medical treatments in addition to increasing physical activity and watching the diet intake.

Intro: This is so interesting and how this has really evolved into something that women are no longer, hopefully, as afraid or hesitant to discuss with their doctor. You're speaking to other providers. What would you like them to know about managing women, their comorbid conditions that may or may not be associated with, and I'm so glad you brought up obesity is not necessarily part of that diagnostic criteria, but it can be involved.

Melanie Cole, MS: And so, as you said, there are so many specialists involved. What would you like other providers to take away from this updated episode, Dr. Hurd, to really know to take forward to their patients?

Dr William Hurd: I think any physician who feels comfortable with managing women with PCOS can easily do it as long as they're aware of the importance of a progestin-containing contraception while they're not trying to get pregnant. And watching for the other comorbidities that go along with PCOS. Nowadays, there are more and more weight loss programs that we can send these people to. So, I think unless the practitioner feels real comfortable with that area of medicine, it's probably a good idea to refer these patients to weight loss programs. And then finally, the patients who are attempting to get pregnant most commonly are sent to either a reproductive endocrinologist or gynecologist to do a lot of fertility work.

Melanie Cole, MS: Thank you so much, Dr. Hurd, for joining us today and updating this very important episode. For more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.