Episode Transcript
Courtney Collen (Host):
Hello and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Women’s. I’m your host, Courtney Collen, with Sanford Health News. We want to start new conversations about age-old topics from fertility to managing stress, healthy living, and so much more.
“Her Kind of Healthy” is designed to bring you honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.
On this episode, we are talking about polycystic ovary syndrome, or more commonly referred to as PCOS. And joining me for this conversation is Dr. Keith Hansen, who is a specialist in fertility and reproductive medicine at the Sanford Fertility and Reproductive Medicine Clinic in Sioux Falls. Dr. Hansen, welcome. Thanks for joining me.
Dr. Keith Hansen:
Thank you, Courtney. I appreciate it.
Courtney Collen (Host):
Well, let’s dive right in. Polycystic ovary syndrome: What is it? Tell me about some of the warning signs symptoms, how it’s diagnosed.
Dr. Keith Hansen:
Well, polycystic ovary syndrome is the most common metabolic endocrine abnormality in women. And it does have a number of different presenting symptoms that can occur. One of them is it can cause infertility because a lot of these gals are either only ovulating once in a while or not ovulating at all. And of course, if you don’t make an egg, then you can’t get pregnant.
Other symptoms that they can have include irregular periods or no periods, primarily because they’re not ovulating or only ovulating once in a while. They can also have very heavy periods because the endometrial lining gets so thick that it can cause heavy bleeding. Then if it goes on long enough, they can even get what’s called the endometrial hyperplasia in the lining of the uterus and that can even develop into endometrial cancer. So we have to be aware of this and treat these patients early so that hopefully that doesn’t present.
They can also come in with symptoms like what we call hirsutism, which is where they have excess hair growth on their face, like a mustache and beard, hair on their chest, hair on their abdomen. And if it gets really severe, they can even have what’s called virializing symptoms, which is like balding in a male pattern and other type, increased muscle mass, lowering of their voice and those kind of things. But that usually is in the more severe cases of polycystic ovary syndrome.
These patients are also at higher risk of other metabolic abnormalities. One thing is diabetes is also very common in these individuals. Increased weight and obesity can be an issue. And also they can have problems like sleep apnea and a number of other later-in-life conditions like heart disease and other cardiovascular abnormalities because of things like lipid abnormalities and glucose intolerance.
So it’s a wide spectrum of abnormalities that these patients can present with and it also depends on what stage of their life is as to what their primary symptom will be.
Courtney Collen (Host):
Let’s talk about how it’s diagnosed. How would you diagnose a woman with PCOS?
Dr. Keith Hansen:
That’s a great question. Polycystic ovary syndrome, PCOS, is diagnosed by a number of different factors. And the way we diagnose the disease has evolved over time. The most, some of the more recent studies are put forward, or the most recent diagnostic criteria are put forth by the Rotterdam criteria, or they had a consensus and came up with criteria. There are other ones, but these are basically that the patient has to have two out of three things and no what are called the endocrine mimics or diseases that can mimic polycystic ovary syndrome.
The two out of the three things is she has to have either irregular or no periods, because of the fact that she’s not ovulating a lot or she’s not ovulating at all; she has to have some evidence of elevated androgens, be that increased blood tests that show elevated testosterone or other androgens, or clinical evidence like a mustache and beard and chest hair and more male pattern increased hair growth; or polycystic appearing ovaries on ultrasound. But she only has to have two out of the three of those things. OK.
And then we have to rule out other endocrine diseases that can mimic that, such as late-onset congenital adrenal hyperplasia, where the adrenal gland is abnormal and it mimics polycystic ovary syndrome, but the treatment for it is totally different. We’ve got to rule out other conditions like hyperprolactinemia thyroid dysfunction and other endocrine and other endocrine type of diseases that can mimic polycystic ovary syndrome.
Courtney Collen (Host):
Are certain women at a higher risk for PCOS?
Dr. Keith Hansen:
Yeah, there are women that are at higher risk. And first, just so you’re aware, there are really two major categories of polycystic ovaries. There’s the obese polycystic ovary syndrome and then there’s the thin polycystic ovary syndrome. So just because a woman is thin doesn’t mean she can’t have polycystic ovary syndrome. And yeah, there are in a family, when there’s a family history of things like diabetes, women where their mothers and their grandmothers had polycystic ovary syndrome it’s thought that the male equivalent may be diabetes and male pattern balding may be a sign of the male kind of polycystic ovary syndrome.
Other things that are known to do it are if a girl has early onset of puberty, that can be a sign that she may later develop polycystic ovary syndrome and such.
Courtney Collen (Host):
As a specialist in fertility and reproductive medicine, let’s talk about pregnancy and PCOS. How does this diagnosis affect a woman’s fertility?
Dr. Keith Hansen:
It definitely can affect her fertility because, you know, before she’ll be able to get pregnant, she has to make an egg. Women who have polycystic ovary syndrome usually will not ovulate or will have a decreased frequency of ovulation, meaning that they have less chances of getting pregnant. So what we try to do in reproductive endocrinology is try to improve their ability to ovulate so that hopefully they’ll ovulate more and be able to get pregnant.
And there are a number of ways we can do that. One of the ways is to try to help through diet and exercise. If the person is overweight, sometimes by losing weight, even 3 to 5% of their body mass, they can actually improve their ability to ovulate, or they may even start ovulating on their own. So that can be very helpful.
One of the other big areas are drugs to try to help them ovulate. Like letrozole, which is an aromatase inhibitor. It basically decreases the amount of estrogen that’s made, or clomiphene citrate, which is what’s called a selective estrogen receptor modulator, which kind of tricks the body into thinking estrogen levels are lower so then they make more hormones to stimulate ovulation. The letrozole is the one that has really been – recently there was a large study showing that it works better than clomiphene citrate in women with polycystic ovary syndrome.
So a lot of times we try to treat them with letrozole to try to get them to ovulate and, and then we watch them closely. The biggest risk with letrozole is there’s about a 1 in 10 risk of having a multiple baby, like a twin or even more, ovarian cysts, which can be very uncomfortable, but it means it’s working because the cyst is, means that she’s developing follicles.
Courtney Collen (Host):
And does that go away eventually?
Dr. Keith Hansen:
Oh yeah. They’ll resolve, but they’re kind of there forever, not temporarily.
Courtney Collen (Host):
But it’s working.
Dr. Keith Hansen:
But it’s working, just doesn’t feel very good. And then it can cause things like hot flashes and they sweats and mood swings and some fool is making their hormones go crazy. Yeah, and then, hopefully once we get them ovulating, that can help them to get pregnant usually.
In the old days, we used to always say in women with polycystic ovaries, we’d say, let’s get you ovulating for six months or six cycles, and then if you’re not pregnant, then we’ll do a sperm count.
Well, in women with polycystic ovaries, we can get like 80-to-90% of them to ovulate with letrozole or with other method, other oral medications. But if the group that doesn’t get pregnant, that group, the most common reason for them not to be pregnant is something wrong with a guy. And so now we’ve pretty much changed where we now just say, look, why don’t you get a sperm count right up front to make sure there’s not something wrong with the male side of this too. It saves some time too. You don’t want to have somebody go on medicine for six months and then find out there’s no sperm.
And then if letrozole or CME don’t work, there are a number of other options. Like there’s shots, we can do human menopausal genotropin shots. The problem with those, though, is they have a very high rate of multiple babies. It’s like 30 to 40% of time, and that’s how you can get like quads and septs. And so we try to avoid that one if we can.
There’s also the option of in vitro fertilization. There’s also, sometimes what we’ll do is if we put the patient on birth control pills and just shut her ovary down for a little bit and let everything, all the hormone levels kind of get back down to normal, then stop it, then many times they’ll start ovulating on their own. Or will respond better to the medications. Probably better to say, respond better to their medications. Then if that doesn’t work, there’s a number of other combinations of medications we can do to try to help them.
And then finally, there’s even surgical options. We can go in and do what’s called an ovarian drilling, which basically the ovary, all the eggs are on the outside and the stroma is on the inside. And the stroma is what makes all the hormones the androgens, which then go out to the eggs, which then make estrogen. Well, one of the problems with polycystic ovaries is they make a lot of androgens. And so theca cells inside the ovary are just cranking out the androgens a lot. So if you can somehow lower those levels, like with a birth control pill or with surgery, get rid of some of those theca cells, then the androgens will drop and then the ovaries will be more responsive to therapy.
In fact, the very first studies that were done in polycystic ovaries back in like 1930 or 1940s by Dr. Stein Leventhal at Rush University, they actually had eight women with classical polycystic ovary syndrome. They wanted to study the ovary. So they went in and did a big incision, took a big chunk out of the ovary, and then went and looked at it under the microscope. Well, they sewed the ovary up and sewed the gal up. And lo and behold, all eight of these women who had never had a period for a long time started to have regular periods and every single one of them got pregnant.
And so it became what’s called an ovarian wedge resection, where we go and take out a big chunk of that internal part. But of course, you have to sacrifice some of the eggs, and then a lot of those gals will start to ovulate.
Then Clomid came along probably in the fifties. Yeah, exactly. In the fifties. And it kind of replaced the ovarian wedge resection. But it still can be very helpful in women who don’t respond to medications. And now we don’t do the big wedge resection anymore. We go in and we have a catheter, a little insulated needle, and we put the needle tip into the ovarian stroma and fulgurate the inside or, you know, burn the inside, fulgurate it, and it destroys part of the stroma. So, it’s kind of like taking it out, but not actually having to take it out. And then a lot of those gals will start to either ovulate on their own or will respond a lot better to medications and such. So there are a lot of different options available.
Courtney Collen (Host):
The options that you have and the advancements in medicine, just hearing some of these things – amazing. Incredible. What is it like to be able to provide this type of care to help of course, women or families grow?
Dr. Keith Hansen:
Oh, it’s wonderful. It’s very helpful. It’s very nice to be able to help people achieve what they want. Their dream, a little baby to keep them awake at night.
(Laugh)
Courtney Collen (Host):
Yes. Once a woman is pregnant, but she is living with PCOS, are there any complications or risks to her or baby moving forward?
Dr. Keith Hansen:
One of the big concerns is does she have diabetes or is she at higher risk of developing gestational diabetes later on in pregnancy? And so they want to monitor her very closely for that. So there are some other data showing possibly earlier deliveries in some of the gals with polycystic ovary syndrome. So we do like them to be very monitored very closely by their OB/GYN during pregnancy and watch and make sure that they hopefully don’t get any of those complications.
Courtney Collen (Host):
Yeah, that was my next question, what the care journey looks like. A woman comes in, you help her hopefully achieve pregnancy or at least get to ovulation and go from there. Do they stay with you in the clinic through pregnancy or can they go back to their OB/GYN, continue that care seeing you when needed? Talk about what that looks like.
Dr. Keith Hansen:
Yeah, we usually, once they’re pregnant, we like to send them on to see their regular obstetrician so they can be observed very closely and watch throughout the pregnancy and get through their prenatal care.
Courtney Collen (Host):
Would that be considered high risk if they were, if they came in with PCOS?
Dr. Keith Hansen:
No, it just makes it just sort of like alerts the OB to watch for things like diabetes and other potential issues.
Courtney Collen (Host):
Any other concerns for women who are diagnosed with PCOS or what it might lead to? Any other issues it might cause?
Dr. Keith Hansen:
Well, just a couple things. It’s really hard to diagnose it during adolescence and actually menopause. And the reason is because a lot of the symptoms of polycystic ovary syndrome are similar to the symptoms of puberty and the symptoms of menopause. And so, like irregular periods, they’re common at both ends of the spectrum. Acne is often a sign of androgens. Well, in teenagehood you know, acne is a real common finding. And so it’s really difficult to make the diagnosis at that point.
Now the nice thing about menopause is usually you have that history before of what their periods were like before they started. Puberty is a lot harder. In fact, they suggest that you don’t make the diagnosis of polycystic ovary syndrome until she’s a little bit older. Some people argue maybe even into the 20s before you say that it’s actually polycystic ovary syndrome.
But did you say she’s at risk for developing it later in life? There are some new guidelines coming out that say, you know, we had talked about making the diagnosis based on irregular periods, elevated androgens or hirsutism, elevated androgens and polycystic appear ovaries on ultrasound. They actually now are also saying that if we, there’s a level called AMH or anti-malarial hormone, which is a blood test that reflects how many eggs are in or how many follicles are in the ovary. And when that’s elevated, that’s often a sign of polycystic ovaries. But they’ve now adapted that for inclusion in the criteria where we can now use that as making the diagnosis of PCOS. We don’t have to rely on the ultrasound so much.
In terms of diagnosis, of course, the hard part is what does this do for women after they go through, had their kids, and they’re starting to approach menopause? Well one of the things we worry about is the hirsutism, getting a mustache and beard and hair growth. So, one of the big questions is, can you suppress the ovaries? And the answer is yes.
One of the ways we can suppress the ovary is the birth control pill. Now, of course, you don’t want to give that to somebody if they’re at high risk, but it does work really nicely at keeping those theca cells not producing a lot of androgens. And there are other options, but there are things we want to do to help out with those cosmetic issues because those are not a lot of fun.
The other one is we worry about developing diabetes. In fact, the new recommendation is that women with polycystic ovaries should probably get a glucose tolerance test every two to three years. And not just the hemoglobin A1C or a fasting sugar, but a full blown glucose tolerance because it can diagnose glucose intolerance a lot easier and better. It’s more sensitive for diagnosing that than a fasting sugar or a hemoglobin A1C. Also lipid panels, because they can, once again, insulin resistance increases the risk of lipid abnormalities.
High blood pressure is something we want to keep a watch on and make sure that they keep that under control. We also worry about developing endometrial hyperplasia and cancer. We don’t want them to get endometrial cancer. And so we want to make sure that they’re either ovulating on their own or getting some form of progesterone to prevent the development of endometrial hyperplasia or cancer. And there’s a number of ways we can give progesterone.
The other thing is, we can’t forget about sleep apnea. There are studies showing that women that have polycystic ovary syndrome see a higher risk of sleep abnormalities, specifically sleep apnea. And new recommendations are that if a woman feels like she is tired during the day, unless she has a baby at home, snores, ever woke up gasping for air or had any issues that might suggest sleep apnea, that you get a sleep study. So, yeah. So there are a lot of things that we want to monitor for sure throughout the life cycle.
Courtney Collen (Host):
Is there a connection, Dr. Hansen, between PCOS and insulin resistance?
Dr. Keith Hansen:
Well, there definitely is a connection between polycystic ovary syndrome and insulin resistance. In fact, it’s hard to know though – is it the chicken or the egg? Is it part of the process that results in the polycystic ovary syndrome or is it a result of the polycystic ovary syndrome? But we do know that they’re both interconnected. In fact, we know that that’s probably why they’re at higher risk of developing glucose intolerance and later in life, getting diabetes mellitus.
In fact, a lot of these gals will come in and will have other signs of insulin resistance. Like they’ll have what’s called acanthosis nigricans, which is darkening of their skin around the base of their neck or under their arms or in their inner thighs and then skin tags. Then elevated androgens are a result of the insulin resistance. So they’re kind of all tied together. And that’s why, you know, weight loss through diet and exercise and such can actually improve the way the ovary works is because it improves insulin sensitivity.
Courtney Collen (Host):
What do you recommend to patients as far as lifestyle, diet? You about diabetes being a concern later, potentially cancer. Are there lifestyle or diet changes that you recommend for women who are in your care?
Dr. Keith Hansen:
Well, you know, the healthy lifestyle is a really good idea. I mean, diet and exercise are very helpful for everybody who’s trying to get pregnant. We do like the gals to make sure they’re taking a vitamin with folic acid because that’s been shown to lower the risk of neural tube defects, which is amazing. And then also, a lot of people will go on their supplements, like myo-inositol is thought to be very helpful at improving insulin resistance and improving how people feel that have polycystic ovary syndrome.
Another one that has some data is cinnamon. People say that cinnamon actually can be very beneficial. And then one of the things that’s kind of hard is whether or not to use metformin. You know, it wasn’t that long ago, like maybe 10 years ago, where if you had polycystic ovaries, we automatically started you on metformin because it improves insulin resistance. And so, we got everybody on it, but it does have some side effects, primarily GI you know, like urgency to have diarrheal stools and nausea and vomiting and those kind of things. At one point we were giving pretty much anybody with PCOS, we’d give them metformin, then it kind of went back to say, well just give it to them if the person has diabetes or glucose intolerance. And that makes sense too.
And then if it also, now it’s kind of swinging back a little more that it might be beneficial for women to help them ovulate because there are some women with polycystic ovaries that if you give them metformin, they’ll actually start ovulating better and they can get pregnant because it improves their insulin resistance and improves their hormonal profile. It’s not as good as Clomid, not as good as Letrozole, but it does have a lower risk of multiple babies.
Courtney Collen (Host):
Does PCOS ever go away?
Dr. Keith Hansen:
Well, that’s a fascinating question, and the answer is no. The PCOS though, you know, is kind of one of those diseases as a woman ages, her ovaries may start actually ovulating on their own. So what’ll happen is she won’t ovulate when she’s in her 20s and maybe 30, 35, and then all of a sudden she’ll start having regular periods and be able to get pregnant because she’s finally ovulating. So as the ovaries start to kind of tune down, they’ll start to work a little better. So that’s one thing that does change.
But one of the hard parts is, you know, even if you go in and like, let’s say if a gal said, I’m tired of this PCOS, I’m going to have my ovaries taken out. She still has all the other problems, though. She still has the insulin resistance, she still has a higher rate of glucose intolerance, lipid abnormalities, high blood pressure and risks going forward. Then on top of it, she has the risk of having her ovaries taken out at a young age, which increases the risk of cardiovascular events. And we really don’t like to take the ovaries out of somebody until they’re, you know, in their 60s because of the risks that are associated with that.
And so, most people do not argue to take the ovaries out in somebody with polycystic ovaries syndrome. So it’s kind of one of those conditions where it’s more of a total body metabolic endocrine imbalance. So you can’t remove it and it doesn’t seem to get totally better over time. Wish it did.
Courtney Collen (Host):
Let’s say, Dr. Hansen, a woman is listening or a loved one of a woman who might be showing symptoms or have concerns that a lot of this sounds very familiar, at least some of those early warning signs we talked about. What might she do? How does that care journey begin and who does she talk to? Who does she reach out to?
Dr. Keith Hansen:
That’s a great question. I think one of the first persons they could talk to is their family medicine physician or their OB/GYN, whoever they’re seeing. And then, they evaluate them and start the journey. And then if they have any issues, of course they can always send them on to us. Or when they’re, you know, want to get pregnant and they want it to us to help them, we can do that. But that’s probably the first person to talk to.
Courtney Collen (Host):
Good start. How can we support a friend or loved one who might be diagnosed with PCOS? And specifically because we are at the fertility and reproductive medicine clinic, you know, if they’re trying to get pregnant we want to be able to support our friends or loved ones who are on that journey, that fertility journey. What would you recommend that we do? Or what can we do for them to show our support?
Dr. Keith Hansen:
Being supportive of the individual and helping them realizing that they have this endocrine condition and have to go through a lot of different types of therapies possibly, I think that can all be very helpful. You know, lending an ear so that they can chat with you and discuss their options and stuff if they want. The biggest thing is polycystic ovary syndrome is a very common endocrine metabolic abnormality, affecting a large number of women. And it can have some very devastating effects upon their reproductive and endocrine and their metabolic condition.
However, there are a lot of things they can do to help keep it under control, both when they’re trying to get pregnant and when they’re not trying to get pregnant. I think one really important issue that I forgot to mention earlier, when a person with PCOS is not trying to get pregnant, they still need to be treated. They should not, you know, say, oh, well I’ll ignore it. All I want to do is get pregnant. And then I don’t mind not have their baby and then say, “oh, I don’t mind having a period once every year.”
Because then if they don’t, they could go on to develop endometrial hyperplasia cancer. Some of these gals can have terribly heavy periods to the point where we have to give them blood transfusions and do emergency surgeries. They want to be treated. Sure. And some of the treatments that are good for, while you’re like, let’s say you’ve had your baby and you want to wait a year or two, which is a good idea to let your body build back up, you know, then the birth control pills are very good. They’ll keep everything kind of suppressed for us, and probably make it easier to get the woman to ovulate afterwards and prevent endometrial hyperplasia, cancer, and then there’s other progesterone agents that can also prevent the endometrial hyperplasia, but they don’t suppress the ovaries as well as the birth control pills do. Don’t ignore it, diet and exercise.
Courtney Collen (Host):
Dr. Keith Hansen, thank you so much for your time and all of your insight and expertise on polycystic ovary syndrome and all that you do here at the Sanford Fertility and Reproductive Medicine Clinic. Thank you.
Dr. Keith Hansen:
Thank you, Courtney.
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Posted In Gynecology, Pregnancy, Sioux Falls, Women's
