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. 
• Alopecia: hair loss, oftentimes at the hairline and/or at the part line. 
• 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.
• Miscarriage & Recurrent Pregnancy Loss (RPL): women with PCOS have a 20-40% higher risk of having a miscarriage as compared to women without PCOS, and some experience multiple miscarriages, ie: Recurrent Pregnancy Loss (RPL).  
• 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. 

For more information on PCOS and Infertility & RPL scroll to the bottom of this page where I have posted some recent research articles on treatments. For more in-depth information on Infertility and RPL see my webpage here. 

Most providers will make a diagnosis of PCOS by using the Rotterdam Criteria. 

A women must have only 2 of the 3 criteria mentioned below: 

1. Oligoovulation OR anovulation

• 1-3 yrs after first period: menstrual cycles < 21 days or > 45 days apart. 
• > 3 yrs after first period: menstrual cycles < 21 days or > 35 days apart OR you are having less than 8 cycles per year.
• > 1 yr after first period: menstrual cycles > 90 days apart. 

2. Clinical and/or Biochemical Hyperandrogenism (affects 60-90% of pts) 

• A diagnosis of "clinical hyperandrogenism" will be made if you have:  significant acne, alopecia (hair loss) and/or hirsutism (hair growth). 
• A diagnosis of "biochemical hyperandrogenism" will made if you have high androgens in your blood when we receive your laboratory results. 

3. Polycystic Ovaries (diagnosed by ultrasound on Cycle day 5 if you meet one of the following criteria: 

• You have at least one ovary with a total volume equal to or greater than 10 mls (hint: L x W x D = sum x 0.52 = total volume.  Ovarian total volume is reported in either mls or cc's. However, there cannot be a  dominant follicle nor a cyst present in the ovary making it larger. 
• You have a total follicle count of > 20 in one ovary. Only follicles that are greater 2 mm and less than 9 mm in size in counted to meet this criteria. 

You may view or download the American Society of Reproductive Medicine (ASRM) 2023 International Guidelines for diagnosing and managing PCOS by clicking the button below. 

Special Note: 

The Rotterdam Criteria recommends AGAINST doing an ultrasound to diagnoses PCOS in women until they are 8 yrs past their first period. However, many providers choose to do an ultrasound, which I will also want to do for you. 

The reason is because your HPO-axis has not yet had time to fully mature, and oftentimes there will be many follicles present in one or both ovaries. Younger women are also more likely to have large ovaries and irregular menstrual cycles. Thus, most experts agree to give a diagnosis of "LIKELY PCOS" until the pt is beyond 8 years past her first period, and monitor her over time. 

Your appointments at MyCatholicDoctor 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 and provide you with education about normal healthy reproduction and oftentimes about a condition I suspect you may have after we have talked a while.
I will order a pelvic ultrasound which I will ask you to schedule on day 5 of your next menstrual cycle. I will order a series of laboratory tests. Click the "laboratory tests" button below to learn more.
You will be asked to begin charting your menstrual cycles using the Creighton Model System (CrMS). Please choose a Fertility Care Practitioner (FCP)  by clicking the "Fertility Care Practitioners webpage" button below to learn more about scheduling an Introductory Session to get started. 

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 a "progesterone challenge".  You will be given 200 mg of bioidentical progesterone to take for 10 days at bedtime. A "withdrawal bleed" should ensue approximately 3-6 days after  the progesterone is stopped. If a bleed does not occur, we may try another challenge with 400 mg of progesterone for another 10 days.  

Please consider joining me as I pray for you here.

Second Appt:  You will be asked to return to the office in 2 mos for a follow-up appointment to review the results of your imaging and laboratory tests. Together we will also review your Creighton Model System (CrMS ) chart to look for specific biomarkers which will help me make a diagnosis. 

Please upload an image of your CrMS chart two days prior to all follow up visits and send to me via the portal. 

Please add the length of your post-peak phase and your mucus cycle score (MCS) to the R-hand margin of the chart. Your Fertility Care Practitioner (FCP) will calculate your MCS for you. 

During this appointment, you may be asked to begin some supplements and/or medications. We will also discuss drawing a full set of hormone panels. We will make a decision if you should have a peri-ovulatory estradiol panel, a post-Peak estradiol & progesterone panel, or both panels. 

 Hormone Panels: 

• Peri ovulatory estradiol panel: start on CD8, go to the lab EOD for an estradiol draw, until you have one draw post-peak. 
• post-Peak estradiol and progesterone panel: P+3, 5, 7, 9, and 11. See Handout #3 on the the Patient Handout webpage 
• Hormone panels require 2 mos of CrMS charting AND the patient must be able to confidently identify her Peak day.

Many patients will be asked to consider working with a dietitian or a nutritionist to help optimize your reproductive health. Oftentimes I may also recommend a mental health appointment to help with anxiety, depression and/or disordered eating habits. 

Third Appt: You will return to the office in 2 mos to review the results of your hormone panels as well as the biomarkers on your CrMS chart. Most often at this time I will have made one or more more diagnoses to identify the root cause of your symptoms. Together we will discuss a treatment plan, which will be implemented. 

Follow Up Appts: You will return to the office every 2 months. During this time, I will conduct a comprehensive medical interview to ensure your symptoms have resolved, and to ensure you are responding well and not having any negative responses to the management plan. Depending on the individual patient and your individual diagnosis, I may need to monitor your progress with serial laboratory tests and/or serial imaging. 

After 6-9 months: If medical management has not been successful AND we have not identified yet any other root cause for your problem, you may wish to move forward with a diagnostic laparoscopy. However, this would be your personal decision after we discussed benefits vs risks for your individual case. All surgeries present risks, which can sometimes be serious.  Oftentimes, we will have identified additional medical conditions which are treatable with supplements and/or medications. On occasion, I may come to know a surgical evaluation will be of benefit to you earlier on in this process, and an expedited surgical referral will have been recommended. NaPro surgeons typically book out 5 mos to 18 mos. At any time, if you feel you would like an expedited surgical referral, please feel free to discuss this with me. 

Please review my laparoscopy page. You will notice NaPro surgeries are done very differently as compared to laparoscopies done by mainstream medicine surgeons. We use a near contact approach and a near adhesion-free technique", which has been described as pelvic surgery of the pelvis.  

At any point in time, if a diagnosis has been made, treatment initiated, and/or you are satisfied with the medical management we have implemented, you can schedule annual or biannual visits, per your choice.