Polycystic Ovarian Syndrome

PCOS is the most common hormonal problem in women of reproductive age, affecting approximately 9% -13% of women (some experts think as much as 21%). Although PCOS is most commonly seen in younger women, it can also present for the first time in women who are in their 40s and 50s. We also know this condition runs in families. There is a 20-40% chance of a PCOS-patient having a mother or sister who is also affected. 

The cause of PCOS remains unclear, but experts do agree that Polycystic Ovarian Syndrome is a very complex condition which is most likely caused by both genetics and environmental factors. 

Many women will have no symptoms at all or very mild symptoms. However, some more common symptoms are: 

• Irregular menstrual cycles and/or long cycles: abnormally long cycles can increase your risk of endometrial hyperplasia (thickened inner lining of the uterus) and endometrial cancer. 
• Acne: more severe than typical, may be on face, back, upper chest. 
• Hirsutism: hair growth on upper lip, chin, nipples/chest or abdomen. 
• High insulin levels: most often go undetected. High insulin levels put you at high risk of developing diabetes. 
• Infertility: PCOS accounts for ~ 27% of infertility cases.
• Recurrent miscarriage: 70-80% of PCOS-Infertility cases are due to "ovulatory dysfunction". 
• Pregnancy problems: higher risk of ectopic pregnancies, gestational diabetes, pre-eclampsia and premature birth. 
• High cholesterol: puts you at risk of heart attack and stroke. 
• Sleep apnea: puts you at risk of heart attack, stroke, and sudden death. 
• Psychological problems: depression, anxiety, eating disorders and/or disordered eating are all more prevalent in PCOS pts. 

Mainstream medicine providers and NaPro providers generally agree that in order to make a diagnosis of PCOS, the woman must have at least two of the following three signs/symptoms confirmed via a medical work up: 

1. Irregular menstrual cycles and/or long cycles. 
2. Hyperandrogenism: clinical or biochemical signs of high androgens. Clinical signs are: hirsutism, hair loss and/or significant acne. Biochemical signs are: high blood levels of androgens, ie: testosterone, DHEAs and/or androstenedione.  
3. Polycystic ovaries diagnosed via ultrasound or laparoscopy. Polycystic ovaries have a classic appearance. Volume is enlarged (> 10 cm), the surface is often smooth and white, and the ovaries contain multiple immature follicles often situated peripherally (see US image below). 

Your appointments at Natural Women's Health with me will be one FULL HOUR in length. Generally speaking, NaPro appts will follow a typical protocol as outlined below. However, every individual is different and your situation may warrant a more expeditious process. Please know, the Creighton Model Charting is very important. Your CrMS chart will help direct me to what diagnostic tests and imaging tests should be done and what treatment plan would be most appropriate. 

First Appt: I will take a comprehensive medical history, a pelvic ultrasound will ordered which should be done on day 5-7 of your next menstrual cycle. I will also  order FSH/LH and estrogen labs, which must be done on day 3 of your next menstrual cycle.  Please begin charting your menstrual cycles using the Creighton Model System (CrMS). Please choose a Fertility Care Practitioner by clicking the "Fertility Care Practitioner webpage" button below to find out how to schedule your first Introductory Session. 

Note: An exception is made for patients with a pre-existing diagnosis of PCOS and who are not having periods or who are having only 1-2 periods a year. In such a situation, I will offer you either a 200 mg progesterone injection which will be given at the first visit and then repeated every third day for a total of three injections. This protocol is called a "progesterone challenge" test, and will often bring on a  period within a few days to a week. A second option is to prescribe 200 mg if progesterone to be taken by mouth for the next 10 days. 

Once your period begins, you will then be asked to continue oral progesterone on days P+3 through P+12 each month. The dose will be adjusted according to your unique estrogen and progesterone levels to help prevent endometrial hyperplasia, which can lead to endometrial cancer (click the "laboratory tests" button below, with atten to the "third visit orders" in the table. 

Second Appt: You will be asked to return to the office in one month for a follow-up appointment to review your lab results of your imaging tests. Together we will review your Creighton Model Chart and look for specific biomarkers in your menstrual cycle. Please upload an image of your CrMS chart two days prior to all follow up visits and send to be via the portal. 

A full GYN physical examination will be preformed (unless you have had a recent full well-woman exam) and oftentimes I will order additional laboratory and/or imaging tests to guide your medical management. 

Third Appt:  You will be asked to return to the office one month later to review the results of your laboratory and imaging studies. At this time, we will consider ordering the progesterone and estrogen panels, which will be specificity timed to your CrMS chart. Click the "Laboratory Tests" button below for more detail.  You may be asked to start medications and/or perhaps make an appointment with another specialist such as a dietician, a sleep specialist and/or a counselor. 

Follow Up Appts:  You will return to the office every two months to monitor and/or make adjustments to your medications and treatment plan. 

After 6 months, if medical management has been unsuccessful you will be referred to Dr. Naomi Whittaker, MD who is a NaPro surgeon. You will undergo an evaluation. Dr. Whittaker will require that you have two full months of CrMS charting to submit to her office staff, prior to scheduling your initial appt. She will review your Creighton Model Charting as well as the lab and imaging results and medical management you have received during your time working with me. Together you will formulate a surgical treatment plan.