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There are many causes of irregular bleeding or absence of menstrual
periods. Common causes include Polycystic Ovary Syndrome(PCOS), uterine masses (such as polyps or fibroids), bleeding disorders,
elevated prolactin levels, thyroid disease, intrauterine infection,
overgrowth of the uterine lining, diabetes, and may others.
A thorough evaluation usually involves a physical exam, blood
work and a pelvic ultrasound in order to distinguish among the
causes. Having the accurate diagnosis is crucial to correct
the underlying cause. Treatments may be as different as removal
of an intrauterine polyp or medical suppression of a benign
tumor of the pituitary gland (in the base of the brain) that
is overproducing a hormone called prolactin.
The most common cause of irregular menses or absence of menses
is Polycystic Ovary Syndrome. At least 1 in 20 of the reproductive
age women in the Southeast has Polycystic Ovary Syndrome. Common
problems associated with PCOS include increased unwanted hair
growth, acne, and easy weight gain/difficulty losing weight.
What confuses many women and their doctors is the fact that
although the majority of women with PCOS are overweight at least
25% of women with PCOS are thin.
Dr. Williams has a research
interest in PCOS and has received grant funding to study this
problem. Our clinic sees a large number of women with PCOS,
probably the most in the region. No clinic in our area has more
specialized training and experience in helping women with PCOS
to become pregnant.
PCOS is the most common hormonal disorder of reproductive-age
women; it affects approximately 5% of the population
or one in twenty women. Despite this, PCOS remains largely unknown,
even by the women who have the syndrome. PCOS is characterized
by irregular menstrual periods; unwanted hair growth; being
overweight (in more than half of the cases) difficulty in becoming
pregnant; oily skin and/or acne.
Doctors Williams and Bateman have a large population of PCOS patients. They are actively involved with research relating
to PCOS. Ongoing studies including: inducing ovulation with
metformin and/or Clomid; an ongoing National Institutes
of Health (NIH) sponsored study, where Dr. Williams is a co-investigator
looking at the effect of acupuncture on PCOS.
The name "polycystic ovaries" is somewhat of a misnomer
and a nonspecific term. Women with PCOS have enlarged ovaries
with tiny asymptomatic cysts seen on ultrasound. It also happens
that 25% of normal women have ovaries that appear polycystic
in ultrasound appearance, so the diagnosis cannot be made by
ultrasound appearance alone.
PCOS Runs in Families
It does appear that a predisposition for PCOS can be inherited,
but the genetic patterns remain unclear. A daughter is estimated
to have as high as a 50% risk of developing PCOS if her mother
was affected. The exact cause of PCOS has eluded investigators
for decades but research indicates that excess insulin production
is likely to be a key factor in many women. The majority of
overweight women with PCOS seem to have a cellular signaling
mechanism for the hormone insulin that does not work efficiently,
so that higher levels of insulin are required to achieve a normal
response.
The excess insulin in PCOS also stimulates the ovaries
to produce an overabundance of male-type hormones (for example,
testosterone), referred to as androgens. All women produce androgens,
but women with PCOS make too much. The excessive androgens and
other hormonal irregularities of PCOS lead to the lack of ovulation
(resulting in irregular or absent menstrual periods), excessive
unwanted hair growth, acne, oily skin, and increased risk of
cardiovascular disease, elevated cholesterol, adult-onset diabetes
and diabetes during pregnancy, and cancer of the uterine lining
(endometrial cancer). Women with PCOS have diminished fertility
mainly because their ovulation is rare and unpredictable.
You have probably heard of the hormone insulin in connection
with another disease: diabetes. In fact, the abnormal insulin-signaling
mechanism involved in PCOS appears to be similar to the underlying
cause of adult-onset diabetes. Many scientists think that PCOS
belongs on a spectrum of insulin problems, with PCOS on the
mild end and adult-onset diabetes on the severe end. Studies
have shown that a large portion of women with PCOS have other
family members with adult-onset diabetes mellitus. Women with
PCOS need to realize they are predisposed to becoming a diabetic
as they age.
Because PCOS affects one in twenty women, it is a very common
cause of decreased fertility. In fact, PCOS is the most common
hormonal cause of infertility. Women with PCOS often visit their
doctors to report irregular bleeding. If a woman with PCOS goes
a few months without a menstrual period, her endometrium may
build up to point where irregular bleeding occurs from overgrowth
and breakdown of the tissue.
This bleeding can be heavy and
require hormonal medications or, in severe cases, hospitalization
with blood transfusions, or a surgical procedure called dilation
and curettage (D&C). Women with PCOS who have no had a menstrual
period for a prolonged period of time will be at greater risk
of developing cellular changes in the uterine lining called
hyperplasia, which can progress to endometrial cancer if left
untreated. When ovulation does occur, the subsequent menstrual
flow is often very heavy due to the thickened lining.
You can see that decreased fertility with PCOS is important,
but it is only one of many concerns that need to be addressed.
If you suspect you have PCOS, you should be evaluated. Blood
tests are necessary to help establish the diagnosis and rule
out confound diagnoses, such as diabetes. The diagnosis of
PCOS is largely made clinically, through your medical history
and a physical exam. A pelvic ultrasound is also commonly
used to establish the diagnosis. For most women with PCOS,
the most effective long-term treatment does not require a
doctor's help and can be done at home.
For most overweight women with PCOS, the most effective treatment
and the only true cure is losing weight. A likely theory is
that excess weight triggers PCOS by raising insulin levels
to a threshold where they stimulate the ovaries to make more
male-type hormones, enough to interfere with the normal menstrual
cycle. The excess insulin is a powerful hormone, and it encourages
the body to preserve its fat stores. This leads to a vicious
cycle of insulin-promoting weight gain and excess fat increasing
insulin levels. If you have PCOS and have found it extremely
difficult to lose weight, you are not alone.
If a woman is
obese, losing as little as 5 to 10% of her body weight
has been shown to be enough to allow resumption of normal
ovulation and menstrual cycles in many women with PCOS. Because
diabetes and PCOS are similar in their underlying mechanisms
of disease, many reproductive endocrinology clinics are encouraging
women with PCOS to try a modified diabetic diet to promote
a natural reduction in insulin levels. This means decreasing
your intake of simple sugars and carbohydrates, while consuming
more protein and non-starchy vegetables.
If you believe you have PCOS and you are overweight, you should
plan an effective weight loss and exercise program. Being overweight
alone or in combination with PCOS is correlated with reproductive
problems, including infertility, miscarriage, and pregnancy
complications.
If you are in the minority of women with PCOS who are not above
the normal weight ranges for your height, unfortunately weight
loss is not the treatment for you.
Metformin, Clomid and gonadotropins are the common
medical therapies for inducing ovulation regardless of weight.
Which therapy to be used or what combination needs to be individualized
for each woman.
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