   
PCOS Polycystic Ovary Syndrome - Anovulatory Androgen Excess
by Jeffrey Dach MD
Seventeen year old Alice has PCOS (Polycystic Ovary Syndrome). Alice came with her Mom into the office and told me her story. Alice has been overweight, borderline diabetic, and has facial hair and acne caused by elevated testosterone. At age 12, Alice started normal menstrual cycles, but her cycles began fluctuating and periods stopped at age 15. Her gyne doctor diagnosed PCOS (Polycystic Ovary Syndrome), and put her on birth control pills to regulate her cycles. The birth control pills caused adverse side effects of weight gain weight and elevated blood pressure (hypertension), so she stopped them.
Progesterone is the Most Logical Form of Treatment and Actually Works
Two months ago, Alice was switched over from the birth control pills to natural progesterone, taking a 100 mg capsule twice a day for 14 days on, 14 days off. The progesterone was successful, restoring a normal menstrual period, and a return to regular cycles.
BCP’s (birth control pills) are usually prescribed by the ob-gyne doctor to regulate cycles in the PCOS patient. This standard treatment is not the best one. There is a better more logical alternative that actually works called natural progesterone. Both John R Lee MD, and JeriLynn Prior MD advocate the use of natural progesterone as a far better alternative to birth control pills. After all, birth control pills (BCP's) are a chemical form of castration, and work by inhibiting ovulation.
This article will explain the cause of PCOS, and will describe the signs and symptoms of PCOS, including the clinical features of PCOS, and give you a simple questionnaire to determine if you have PCOS. This article will also explain why natural progesterone is the best treatment, and a much better choice compared to birth control pills.
PCOS was Rare When First Described in 1935, Now Quite Common.
When PCOS (polycystic ovary syndrome) was first described in 1935 by Stein and Leventhal, it was fairly rare.(55) Nowadays, it is quite common, involving 6 to 10 per cent of the female population, affecting 3.5 to 5 million women. (24) Why the increased incidence? Some believe that endocrine disruptor chemicals in the environment are to blame.(60A)
 Clinical Signs and Symptoms Of PCOS
Oligomenorrhea or amenorrhea (no periods), Anovulation (no ovulation)
Weight gain, obesity, Hirsutism (excessive hair growth, male pattern)
Insulin resistance (pre-diabetes), Acne, Male-pattern baldness, Multiple small ovarian cysts on sonogram, Acanthosis Nigrans (darkening of the skin at the nape of the neck and under arms)-indicator of hyperinsulinemia
Above Left Image: Obese Young Lady with PCOS, anovulatory infertility, acne and facial hair.
A Brief Moment for Definitions:
 Definition of ovulation: This is the when an egg pops out of the follicle in the ovary, and starts on the long trip down the fallopian tube to the uterine cavity where it can be fertilized to form a new baby. Ovulation causes high progesterone production by corpus luteum in the ovary. Menstrual Cycles are regular.
Definition of Anovulation: The egg doesn't’t pop out and there is no progesterone production. The cycles are irregular or absent.
Above Left Image: Typical hirsutism, with hair growth under the chin.
 How Do You Know If You Have PCOS?
This is the PCOS Questionnaire.(63)(64) and these are the Links to questionnaire articles:
1) PCOS Questionnaire
2) PCOS questionnaire
If you answer Yes, to 2 out of 3 of the following questions, this indicates high likelihood (80%) of PCOS.
Above Left Image: The bearded fat lady at the circus. She had PCOS.
Length of Menstrual Cycle, Variable Length
1) Between the ages of 16 and 40, was length of your menstrual cycle (on average) greater than 35 days and/or totally variable ?
Hair Growth (Male Pattern)
2) During your menstruating years (not including during pregnancy), did you have dark, coarse hair on your three or more of these sites? Upper lip? chin? breasts? chest between the breasts? back? belly? upper arms? upper thighs?
Obesity
3) Were you ever obese or overweight between the ages of 16 and 40?
Hormone Levels during the Menstrual Cycle with normal ovulation.
The green dotted line is progesterone which rises days 14-22.
The progesterone is absent in PCOS, because there is no ovulation,
and the green line stays flat on the chart, instead of rising
What Causes PCOS ?
The world’s greatest authority, Leon Speroff MD, says: “A question which has puzzled gynecologists and endocrinologists for many years is what causes polycystic ovaries. There is an answer which is appealing in its logic and clinical applicability. The characteristic polycystic ovary emerges when a state of anovulation persists for any length of time”
(1) Clinical Gynecologic Endocrinology and Infertility by Leon Speroff MD p.493
PCOS is the end result of not ovulating, (no progesterone production) for a long time (a few years), resulting in a vicious cycle which self perpetuates anovulation, causing increased testosterone production by the ovary. Insulin resistant diabetes and obesity aggravate the problem. As you might expect, PCOS is a major cause of infertility.
About 10% of patients thought to have PCOS actually have an underlying genetic enzyme defect in adrenal steroid synthesis called Non-Classical CAH. This can be diagnosed with a Cortrosyn stimulation test, and a 21-OH genetic test called CAHDtex from Esoterix. If present, treatment is successful with low dose adrenal steroid tablets (cortef, dexamethasone, prednisone) which restores fertility and reverses the acne. (see below discussion on non-classical CAH).
Oral Contraceptives for PCOS (BCP's)
Birth control pills are a chemical form of castration, which prevent ovulation. Lack of ovulation is the primary defect in PCOS, so birth control pills merely perpetuate the primary defect. Birth control pills can restore regular bleeding periods, however, this is artificial, and aggravate the underlying PCOS problem rather than solve it. In addition, birth control pills are known to worsen insulin resistance and diabetes. (2)
"PCOS may affect between 3.5 and 5.0 million young women in the United States, it arguably may be the most important general health issue affecting young women. BCP's (OCPs) are the traditional therapy for the chronic treatment of PCOS…… limited evidence raises the issue that BCP's (OCPs) may aggravate insulin resistance and exert other untoward metabolic actions that possibly enhance the long-term risk for diabetes and heart disease."
JeriLynn Prior MD Says:
“The fundamental problem with PCOS is not making progesterone for two weeks every cycle. This lack of progesterone leads to an imbalance in the ovary, causes the stimulation of higher male hormones and leads to the irregular periods and trouble getting pregnant. Progesterone is usually missing—replacing it therefore makes sense. “
John R Lee MD says:
"I recommend supplementation of normal physiologic doses of progesterone to treat PCOS. If progesterone levels rise each month during the luteal phase of the cycle, as they are supposed to do, this maintains the normal synchronal pattern each month, and PCOS rarely, if ever, occurs. Natural progesterone should be the basis of PCOS treatment, along with attention to stress, exercise, and nutrition.
If you have PCOS, you can use 15 to 20 mg of progesterone cream daily from day 14 to day 28 of your cycle. If you have a longer or a shorter cycle, adjust accordingly. The disappearance of facial hair and acne are usually obvious signs that hormones are becoming balanced, but to see these results, you'll need to give the treatment at least six months, in conjunction with proper diet and exercise." This is quoted from the The John R Lee Medical Letter 1999.(10)
Self-Medication Not Recommended
Some young women find out about progesterone on internet messenger boards, and then proceed on their own to buy it over-the-counter. The progesterone cream may successfully restores cycles in many cases. However, self - medication is not recommended. It is best to work with a knowledgeable physician. If you have PCOS and need a doctor to prescribe progesterone, you can find a knowledgeable physician on the ACAM or A4M doctor's directory.(65)(66) Always work closely with a knowledgeable physician.
Can PCOS be Treated with Natural Progesterone?
YES by Dr. Jerilynn Prior (3)
"Progesterone talks back to the hypothalamic and pituitary (brain) hormones that control the ovaries and stops them from stimulating the ovaries to make too much testosterone."
Dr Prior recognizes that the (BCP) pill, with its synthetic type of progesterone, does help women with PCOS to a certain degree.
But her goal for PCOS patients is, "to return the brain/ovary system to a normal balance. The goal of the BCP Pill is the opposite - it must suppress the brain-ovary system to prevent pregnancy."
To help her PCOS patients achieve a normal hormonal balance, she prescribes oral micronized progesterone (trade name Prometrium) which is a bio-identical hormone. Taking this natural progesterone for two weeks every month (called cyclic progesterone therapy) may help the brain to develop the normal cyclic rhythm that is missing in PCOS.
Interestingly, Dr. Prior believes there is another benefit of cyclic progesterone therapy. She explains, "most doctors don't realize progesterone antagonizes and inhibits the enzyme (called 5-alpha reductase) that is needed to make testosterone into dihydrotestosterone. Dihydrotestosterone is the powerful male hormone that talks hair follicles into making coarse hair and too much oil that causes acne." Above quote is attributed to Jerilyn Prior MD Web Site.(3)
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  WHAT MAKES YOUR OVARIES TICK Insights about Ovulation, Fertility, PCOS and more. (4)
Click Herer for an Interview with Jerilynn C. Prior, M.D. posted on the Virgina Hopkins Health Watch. Dr. Jerilynn Prior is a professor of endocrinology at the University of British Columbia. She is a pioneer in research involving women's menstrual cycles, ovulation, progesterone and bone loss.
Above Left Image: Polycystic ovary on ultrasound image.
Interview Quoted from Virgina Hopkins Health Watch:
JLML: How do you track your luteal phase with a basal temperature chart?
JCPrior: If you record your oral temperature every morning for an entire month using a digital thermometer, record the temperature in the evening before you go to bed, and record any illness or early or late rising, you can quantitatively determine which days of the cycle are high progesterone days. You can then take all of those daily temperatures from the beginning of one period until the day before the beginning of the next, and do an average of the temperatures. The point where your temperature goes above that average, and stays above it, is the beginning of the luteal phase. It will go back down when your period starts or just before. That's how easy it is to figure out your luteal phase length! That alone is valuable information for women who are having miscarriages that may be due to a short luteal phase.
JLML: I have found that women who are more aware of their cycles are often better able to self-treat for hormone imbalances.
JLML: What else can you tell us about anovulatory cycles? The other kind of ovulation disturbance I called “turned on.” The woman experiencing this kind of ovulation disturbance will complain of weight gain, acne, and hair where she doesn’t want it. The biology of this is less clear, but it relates to insulin excess and insulin resistance, which have effects both on the brain by increasing LH (luteinizing hormone) levels, and directly on the ovary. Excess insulin sits on receptors on the theca cells, the outer coat of the ovary, and makes them more responsive to the hormonal environment, and therefore they make more androgens [testosterone, male hormones].
JLML: Aha! So that's why a high sugar diet aggravates polycystic ovary syndrome. The excess sugar creates high insulin levels, which stimulate androgen production in the ovary, which suppresses ovulation.
JCPrior: The higher LH and the higher androgen levels set up a signal that inhibits the follicle from ovulating. Because each follicle grows and creates a lake of fluid around it, if it doesn’t burst and release its egg, a cyst is left. Therefore you get into a situation of high or normal estrogen levels, high androgens, and low progesterone. That condition is usually characterized by obesity, especially middle-of-the-body obesity, androgen signs such acne, oily skin, facial and breast hair, and head hair loss. Because estrogen tends to be higher with weight gain, these are the women who have a higher breast cancer and endometrial cancer risk. They may also have the worst PMS symptoms.
JLML: So this is yet another good reason to avoid sugar and refined carbohydrates such as white bread and pasta.
JCPrior: And it's another good reason to get plenty of aerobic or endurance-type exercise, which is one of the best ways of getting the insulin levels down and decreasing PMS. With turned on ovulation disturbances you need to correct three problems: The first is to bring progesterone into balance –and for this you use physiologic doses of progesterone. Next, you often you need to block the effect of the male hormone. There's a medicine called spironolactone which I use that blocks androgen action at the cell level. Finally, if a person has a family history of diabetes or is quite obese, then I may use a drug called metformin (Glucophage) that sensitizes the body to insulin and allows the insulin levels to go down.
JLML: I have found that supplemental progesterone, a good amount of exercise, and a low sugar diet, low simple carbohydrate and low fat diet with plenty of vegetables will often restore balance. The above interview posted courtesy of Virginia Hopkins Health Watch. (4)
Help for PCOS - Cyclic Progesterone Therapy
by Dr. Jerilynn C. Prior and Celeste Wincapaw (5)
Jerilynn C. Prior MD Says:
I use cyclic progesterone therapy as the heart of treatment for PCOS- anovulatory androgen excess.(6) Progesterone is the hormone made by the ovary after an egg is released.
The fundamental problem with PCOS is not making progesterone for two weeks every cycle. This lack of progesterone leads to an imbalance in the ovary, causes the stimulation of higher male hormones and leads to the irregular periods and trouble getting pregnant. Progesterone is usually missing—replacing it therefore makes sense. Progesterone talks back to the hypothalamic and pituitary (brain) hormones that control the ovary, and stops them from stimulating the ovary to make too much testosterone.
Taking progesterone for two weeks every month (called cyclic progesterone) may help the brain to develop the normal cyclic rhythm that is missing in PCOS. Progesterone also counterbalances the steadily high estrogen levels that the PCOS ovary produces even if you have no periods. Progesterone will prevent estrogen over-stimulation of the uterine lining (endometrial hyperplasia) and heavy flow. It may also interfere with the action of high estrogen on the breasts, therefore preventing tenderness and “lumpiness” and perhaps even the risk for breast cancer.
Finally, and most doctors don’t realize this, progesterone antagonizes and inhibits the enzyme (called 5-alpha reductase) that is needed to make testosterone into dihydrotestosterone. Dihydrotestosterone is the powerful male hormone that talks hair follicles into making coarse hair and too much oil that causes acne.
Useful Tools for Patients:
Protocol for Cyclic PROGESTERONE THERAPY patient handout sheet (6)
Menstrual cycle diary log sheet patient handout (7)
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Guidelines for Progesterone Cream Dosage for PCOS (8)
Early PCOS - 32mg from day 12-26
Advanced PCOS - 54mg from day 12-26 of your cycle
Severe PCOS with pain, 64mg of progesterone cream from day 5-26 , to address pain from endometriosis. Then try to wean back to a lesser dose or to extend breaks to fall into line with a day 12-26 cycle. Note, if you are using a regime day 5-26 in the first 4-7 months until symptoms settle, please be aware you are using a program suggested to enhance fertility. (8)
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Dr. Lam Progesterone Guidelines for Polycystic Ovary Syndrome (9)
Dr. Lam follows Dr John R Lee pioneering use of progesterone.
Apply 20 mg of progesterone cream during day 14 to 28 of the menstrual cycle. Adjust accordingly if for longer or shorter cycle. As the hormonal balance is regained, facial hair and acne, two commonly associated symptoms, will disappear. (9)
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Other treatable causes of anovulation
1) Low thyroid function (hypothyroid) causes menstrual irregularity, anovulation and infertility. Ovulation and fertility is restored by thyroid medication. Ovarian cysts also resolve.
2) Vitamin D deficiency is associated with anovulation. Resolves with Vitamin D.
3) Iodine deficiency causes ovarian cysts and anovulation, reversed by iodine supplementation.
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Other Useful Drug Treatments for PCOS:
Issue Drug Treatment
Infertility, anovulation: Clomid clomephine, induces ovulation.
Insulin Resistance: Metformin improves insulin sensitivity.(39)(39A)
Acne, Facial Hair: Spironlactone, Aldactone inhibits testosterone.
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PCOS—polycystic ovary syndrome.
Standard diagnostic assessments:
1) History may show: Variable or anovulatory menstrual pattern, obesity, hirsutism, and the absence of breast discharge.
2) Pelvic sonogram may show: 10 or more cysts in each ovary, 'string of pearls'.
The ovaries are generally 1.5 to 3 times larger than normal.
3) Labs may show:
Elevated DHEAs and free testosterone.
Ratio of LH to FSH is greater than 1:1, as tested on Day 3 of the menstrual cycle.
The pattern is not very specific and was present in less than 50% in one study.
Common assessments for associated conditions or risks.
1) Fasting biochemical screen and lipid profile
2) 2-hour oral glucose tolerance test (GTT) in patients with risk factors (obesity, family history, history of gestational diabetes) and may indicate impaired glucose tolerance (insulin resistance) in 15-30% of women with PCOS. Frank diabetes can be seen in 65–68% of women with this condition. Insulin resistance can be observed in both normal weight and overweight patients.
Lab tests for exclusion of other disorders that may cause similar symptoms:
1) Prolactin
2) TSH
3) 17-hydroxyprogesterone to rule out 21-hydroxylase deficiency (CAH).
4) Fasting insulin level or GTT with insulin levels (also called IGTT).
5) Fasting Glucose to Fasting Insulin ratio <4.5 is cheaper method
ICD-9 Codes: PCOS ICD-9 256.4 Amenorrhea ICD-9 626.0
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Non Classical CAH Congenital Adrenal Hyperplasia,
also known as Non-Classical 21 Hydroxylase Deficiency (NC21OHD)
Non-Classical CAH or 21 Hydroxylase Deficiency is the most common genetic disease known, occurring in 1% of New Yorkers, and up to 3% in ethnic groups such as of Ashkenazi Jews, Hispanics, Italians, and Yugoslavs.(68)
Ten per cent of patients with PCOS actually have Non-Classical CAH. The underlying genetic defect causes an enzyme deficiency in the adrenal gland which reduces the ability of the adrenal to make cortisol. Instead of making cortisol, the adrenal steroid pathways are shunted towards testosterone causing elevated testosterone and the typical symptoms of hair growth (hirsutism), and acne and there may also be menstrual irregularities, anovulation, and infertility.(69)(70)
What is the 21 Hydroxylase Enzyme?
This is a key enzyme in the adrenal gland which converts cholesterol into cortisol. In the Classical form of CAH, the 21 hydroxylase enzyme (21-OH) is severely deficient with resulting low cortisol levels. In the Non-Classical form however, the 21 hydroxylase (21-OH) enzyme is still working fairy well with only a slight reduction in activity, and cortisol levels are usually normal, while testosterone levels may be elevated to a variable degree. The Human Adrenal Steroid synthesis pathways and the adrenal enzymes involved can be understood on this chart from Quest Labs.(71)
How to Make the Diagnosis of Non-Classical CAH? Cortrosyn Stimulation
The most definitive diagnosis is done with a Cortrosyn Stimulation test (0.25 mg) which measures 17-hydroxyprogesterone (17-OHP) at 0 and 60 minutes after SQ injection of the Cortrosyn (ACTH).
This test in simple terms is described here:
First a preliminary (baseline ) blood test is done for various hormones including 17-OH, this is followed by a subcutaneous injection of 0.25 mg of a drug called Cortrosyn which is a form of ACTH which stimulates the adrenal glands to make more hormones. An hour (60 minutes) after the Cortrosyn injection, a post stimulation blood sample is drawn for lab testing for 17-OH and other hormones.
Patients with Non Classic 21-OH Deficiency typically show 60-min stimulated 17-OHP values between 1,500 and 10,000 ng/dl. This chart shows how the 17-OHP values cluster at three areas for normal (below 1,500), Non-Classical CAH (1500-10,000) and, and Classical CAH (above 10,000). (72) The Quest Lab testing algorithm is shown here.(73)
Genetic Testing for 21-OH Deficiency
Genetic testing is now available and very useful. This test shows whether or not there is a mutation in the CYP21A2 gene coding for the 21-Hydroxylase Enzyme.(74) The CAHDtex test by Esoterix is useful in showing the exact mutation in the CYP21A2 gene. (75) Once the exact mutation in the CYP21A2 gene is known, refer to this chart to determine the severity of the enzyme defect.(76) Genetic testing of other family members is usually recommended once a sibling is found with the mutation.
Clinical Presentation in Children
In children, the signs include premature onset of puberty, cystic acne, accelerated growth, and advanced bone age. Premature development of pubic hair may occur as early as 6 months of age (due to elevated testosterone). The severe cystic acne may be unresponsive to oral antibiotics and retinoic acid (Accutane).
Although the child may be taller than the other kids in early childhood, this early growth spurt finishes early (because of epiphyseal fusion), and final height ends up shorter than usual. Thus, these kids are tall children but short adults.
Another feature may be male pattern baldness in a female involving the top of the head and sparing the sides.
Teenagers and Young Adults - Major Cause of Infertility
Teenage girls may present with features of elevated testosterone such as facial hair (hirsutism), acne and menstrual irregularities or anovulation. Young adult females may present with the chief complaint of infertility. It has been generally recognized that infertility of undetermined cause in women may be reversed with glucocorticoid (cortef or prednisone) therapy, which most likely treats an occult Non-Classical CAH Syndrome. William Mc Jefferies MD successfully treated thousands of such cases ( The Safe Uses of Cortisol).(77)
Treatment of Non Classical CAH with Cortisol Restores Fertility
Oral tablets containing low dose cortisol sucessfully treat Non-Classical CAH and reverse the symptoms restoring fertility. The cortisol suppresses ACTH and reduces the testosterone production by the adrenal.
Dr. Maria New has followed a large group of 400 patients with Non-Classical CAH, and she treats them with 0.25 mg dexamethasone at the hour of sleep, and she notes it takes about 3 months for reversal of acne and infertility. Hirsutism takes longer to respond, about 30 months.
The cost for a dexamethasone tablet is $0.50, and the 3-month treatment cost is estimated to be $45. Compare this $45 dollars to the infertility treatment cost of $30,000 for one cycle of in vitro fertilization . Dr. Maria New says that many patients presenting with infertility actually have NonClassical CAH, and fertility could be restored easily with treatment with oral cortisol tablets such as cortef, dexamethasone, or prednisone. (69) Before you spend a fortune on in-vitro fertilization for infertility, it would be prudent to rule out Non-Classical CAH with a simple genetic test. For more information on CAH, see my article on this topic: A Commonly Missed Cause of Infertility, NonClassical CAH by Jeffrey Dach MD (78)
Jeffrey Dach MD
4700 Sheridan Suite T
Hollywood, Fl 33021
954 983 1443
www.drdach.com
www.jeffreydach.com
www.drdach.com
www.naturalmedicine101.com
www.truemedmd.com
Link to this article:
http://jeffreydach.com/2008/02/13/understanding-pcos-the-hidden-epidemic-by-jeffrey-dach-md.aspx
REFERENCES
(1) http://www.amazon.com/Clinical-Gynecologic-Endocrinology-Infertility-Editorial/dp/0781747953
The Clinical Gynecologic Endocrinology and Infertility: Leon Speroff MD
(2) http://jcem.endojournals.org/cgi/content/full/88/5/1927
A Modern Medical Quandary: Polycystic Ovary Syndrome, Insulin Resistance, and Oral Contraceptive Pills, The Journal of Clinical Endocrinology & Metabolism Vol. 88, No. 5 1927-1932
(3) http://www.pcosupport.org/newsletter/articles/article122707-3.php
Can PCOS be Treated with Natural Progesterone? Jerilynn Prior, PCOSA Today Newsletter
(4) http://www.virginiahopkinstestkits.com/priorovaries.html
WHAT MAKES YOUR OVARIES TICK, Insights about ovulation, fertility, PCOS and more.An Interview with Jerilynn C. Prior, M.D. FRCPC
(5) http://www.cemcor.ubc.ca/help_yourself/articles/challenge_pcos
Help for Anovulatory Androgen Excess (AAE)—Challenge PCOS! by Dr. Jerilynn C. Prior and Celeste Wincapaw
(6) http://www.cemcor.ubc.ca/files/uploads/Cyclic_Progesterone_Therapy.pdf
INFORMATION FOR WOMEN: CYCLIC PROGESTERONE THERAPY Protocol for treatment.
(7) http://www.cemcor.ubc.ca/files/uploads/Menstrual_Cycle_Diary_with_treatments.pdf
Menstrual Cycle Diary / Log Book / Calendar
(8) http://www.natural-progesterone-advisory-network.com/
what-is-the-guidelines-to-progesterone-dosage/
What is the guidelines to progesterone dosage for PCOS ? National Progesterone Advisory Network
(9) http://www.drlam.com/A3R_brief_in_doc_format/progesterone.cfm
Dr. Lam Progesterone Page
(10) http://www.virginiahopkinstestkits.com/pcos.html
What Your Dr. May Not Tell You about PCOS, Polycystic Ovary Syndrome (PCOS), A New Epidemic that Causes Infertility, Excess Hair, Acne and More By John R. Lee, M.D. and Virginia Hopkins
(11) http://www.townsendletter.com/Nov2004/phyto1104.htm
Townsend Letter, Phytotherapy for Polycystic Ovarian Syndrome (PCOS) by Angela Hywood N.D. & Kerry Bone, Townsend Letter message Boards
(12) http://pcos.meetup.com/217/
PCOS GROUPS and Message Boards, The Arizona Polycystic Ovarian Syndrome Meetup Group,
(13) http://search.yahoo.com/
search?p=pcos+message+board&fr=yfp-t-501-s&toggle=1&cop=mss&ei=UTF-8
Hundreds of PCOS Message Boards
(14) http://www.early-pregnancy-tests.com/vitex.html
Home Ovulation Tests, Pregnancy Test Kits, Basal Thermometers
Birth Control Pills
(15) http://www.sensible-alternative.com.au/polycystic_ovarian_syndrome.html
The Birth Control Pill is NOT the Answer. The birth control pill does absolutely nothing to improve insulin resistance, and can actually worsen it
(1). “They may, however, worsen insulin resistance and lead to deterioration of glucose tolerance.” Glucose tolerance deteriorated significantly, and two women developed diabetes” In 2003, the Journal of Clinical Endocrinology & Metabolism published an article called 'A Modern Medical Quandary: Polycystic Ovary Syndrome, Insulin Resistance, and Oral Contraceptive Pills'.
(2) The Pill has been standard treatment for PCOS, and yet, perversely, it appears to worsen the metabolic problem that is at the root of the condition. The authors say:
'...what has been lacking is a critical examination of whether oral contraceptives might...exert adverse metabolic effects with long-term consequences..'.
I propose that the Pill has made additional contributions to the epidemic of PCOS. The Pill is known to cause permanent hormone changes, even once it is stopped.
(3). Most doctors agree that it can take 1 to 2 years for normal menstrual cycles to resume after stopping the pill . The pill will cause a monthly bleed, but this is not a true period.
(16) http://jcem.endojournals.org/cgi/content/full/82/9/3074
The Journal of Clinical Endocrinology & Metabolism Vol. 82, No. 9 3074-3077. The Effect of a Desogestrel-Containing Oral Contraceptive on Glucose Tolerance and Leptin Concentrations in Hyperandrogenic Women Shahla Nader, Maggy G. Riad-Gabriel and Mohammed F. Saad
(17) http://jcem.endojournals.org/cgi/content/full/88/5/1927
Diamanti-Kandarakis, E et al. A modern medical quandary: Polycystic Ovary Syndrome, Insulin Resistance, and Oral Contraceptive Pills. J Clin End Met 2003.88(5): 1927-1932 CONTROVERSIES IN ENDOCRINOLOGY Evanthia Diamanti-Kandarakis, Jean-Patrice Baillargeon, Maria J. Iuorno, Daniela J. Jakubowicz and John E. Nestler
(18) http://www.ncbi.nlm.nih.gov/pubmed/16409223
Panzer et al. Impact of Oral Contraceptives on Sex Hormone-Binding Globulin and Androgen Levels: A Retrospective Study in Women with Sexual Dysfunction. The Journal of Sexual Medicine. 2006. 3:p.104-113
(19) http://www.eurekalert.org/pub_releases/2006-01/bpl-ocp121305.php
Birth Control Pill Side effects. Oral contraceptive pill may prevent more than pregnancy
New research indicates birth control pill could cause long-term problems with testosterone
(20) http://ditchthepill.org/
Ditch the Pill . org, very neative about BCPs
Jones, M.D. Medical Director, Women’s Health Institute
THYROID References
(21) http://www.ncbi.nlm.nih.gov/pubmed/16208308?dopt
Abstract Minerva Endocrinol. 2005 Sep;30(3):193-7. Relationship between insulin secretion, and thyroid and ovary function in patients suffering from polycystic ovary. CONCLUSIONS: The data obtained in our study enable us to support the close connection between ovary function, thyroid function and insulin-resistance. In all patients, in fact, albeit at different times, an improvement was obtained in all 3 pathologies.
(22) http://www.ncbi.nlm.nih.gov/pubmed/17302862
Thyroid disease and female reproduction. Poppe K, Velkeniers B, Glinoer D. Clin Endocrinol (Oxf). 2007 Mar;66(3):309-21
(23) http://www.ncbi.nlm.nih.gov/pubmed/15012623
High prevalence of autoimmune thyroiditis in patients with polycystic ovary syndrome.Janssen OE. Eur J Endocrinol. 2004 Mar;150(3):363-9. CONCLUSION: This prospective study demonstrates a threefold higher prevalence of Autoimmune Thyroid disorders in patients with PCOS
Prevalence of PCOS in Population
(24) http://jcem.endojournals.org/cgi/content/full/85/7/2434
A Prospective Study of the Prevalence of the Polycystic Ovary Syndrome in Unselected Caucasian Women from Spain. Our results demonstrate a 6.5% prevalence of PCOS, as defined, in a minimally biased population of Caucasian women from Spain. The polycystic ovary syndrome, hirsutism, and acne are common endocrine disorders in women. The Journal of Clinical Endocrinology & Metabolism Vol. 85, No. 7 2434-2438
Thyroid References
(25) http://www.ncbi.nlm.nih.gov/pubmed/8053991
Hypothyroidism presenting with polycystic ovary syndrome.Sridhar GR. J Assoc Physicians India. 1993 Feb;41(2):88-90. During a 30 months period, two women of primary hypothyroidism (2/13; 1.04%) presented with features of polycystic ovary syndrome (PCOS). In hypothyroidism, sex hormone binding globulin levels are decreased; increased conversion of androstenedione to testosterone, and aromatization to estradiol are present, all these being an exaggeration of biochemical changes characteristic of PCOS. Besides, metabolic clearance rates of androstenedione and estrone, the putative mediators of PCOS, are reduced. Hypothyroidism can either initiate, maintain or worsen the syndrome. Correction of hypothyroidism when present, would therefore form an important aspect in the management of infertility associated with PCOS.
(26) http://www.ncbi.nlm.nih.gov/pubmed/17954423
Precocious puberty and large multicystic ovaries in young girls with primary hypothyroidism.Sanjeevaiah AR, Sanjay S, Deepak T, Sharada A, Srikanta SS. Samatvam Endocrinology Diabetes Center, Bangalore, India.
(27) http://www.ncbi.nlm.nih.gov/pubmed/17917634
Mymensingh Med J. 2007 Jul;16(2 Suppl):S60-62. Vaginal bleeding with multicystic ovaries and a pituitary mass in a child with severe hypothyroidism.Mohsin F, Nahar N, Azad K, Nahar J. Department of Paediatrics, Bangladesh Institute of Research and Rehabilitation on Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh.
A seven year and ten months old girl presented with cyclic vaginal bleeding and a huge abdominopelvic mass. She had clinical features of hypothyroidism. The investigation results were consistent with the diagnosis of primary hypothyroidism with precocious puberty. She also had bilaterally enlarged cystic ovaries on CT scan of abdomen and CT scan of brain showed pituitary macroadenoma. After starting treatment with thyroxine, patient became euthyroid and her general condition improved. Treatment with thyroxine alone halted the cyclic vaginal bleeding, led to rapid resolution of the ovarian cysts and regression of the pituitary mass.
(28) http://www.ncbi.nlm.nih.gov/pubmed/2729396
Spontaneous ovarian hyperstimulation syndrome associated with hypothyroidism. Rotmensch S, Scommegna A. Department of Obstetrics and Gynecology, Michael Reese Hospital and Medical Center, University of Chicago, Pritzker School of Medicine, IL 60616. Am J Obstet Gynecol. 1989 May;160(5 Pt 1):1220-2.
(29) http://www.ncbi.nlm.nih.gov/pubmed/17954423?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Precocious puberty and large multicystic ovaries in young girls with primary hypothyroidism.Sanjeevaiah AR, Sanjay S, Deepak T, Sharada A, Srikanta SS. Endocr Pract. 2007 Oct;13(6):652-5.
(30) http://www.ncbi.nlm.nih.gov/pubmed/16864150
Primary hypothyroidism presenting as ovarian tumor and precocious puberty in a prepubertal girl.Campaner AB, Scapinelli A, Machado RO, Dos Santos RE, Beznos GW, Aoki T. Department of Obstetrics and Gynecology, Santa Casa São Paulo-Faculty of Medical Science, São Paulo, Brazil. Gynecol Endocrinol. 2006 Jul;22(7):395-8.
We report a case of a prepubertal girl with juvenile primary hypothyroidism presenting as ovarian cysts and precocious puberty. The 7-year-old female was referred to our clinic because of a pelvic/abdominal mass and vaginal bleeding. Besides these findings, on physical examination we noticed the thyroid gland globally increased and the presence of secondary sexual characteristics. Based upon the clinical profile and investigations, the patient was diagnosed with juvenile primary hypothyroidism due to autoimmune thyroiditis. The cysts and precocious puberty resolved spontaneously after the simple replacement of thyroid hormone. It is important to bear in mind hypothyroidism in cases of girls presenting ovarian cysts and precocious puberty in order to avoid unnecessary surgery on the ovaries.
(31) http://www.ncbi.nlm.nih.gov/pubmed/16995569
J Pediatr Endocrinol Metab. 2006 Jul;19(7):895-900.
Ovarian cysts in young girls with hypothyroidism: follow-up and effect of treatment.Sharma Y, Bajpai A, Mittal S, Ovarian cysts have been reported in girls with longstanding uncompensated primary hypothyroidism. Restoration of euthyroid state has been associated with resolution of these cysts; long-term follow-up of these patients is however lacking. Our study emphasizes the need to exclude hypothyroidism in young girls with ovarian cysts. A causal link between hypothyroidism and spontaneously occurring ovarian hyperstimulation syndrome is suggested by analysis of data from a patient with myxedema and review of data from animal research.
(32) http://www.jacemedical.com/articles/Sub-laboratory%20Hypothyroidism%20.pdf
“Sub-laboratory” Hypothyroidism and the Empirical use of Armour® Thyroid Alan R. Gaby, MD . Excellent revierw on subclinical hypothyroidism.
"Of 12 girls (ages 9-16) with severe and longstanding hypothyroidism, nine were diagnosed by pelvic ultrasound with PCOS. The cysts resolved rapidly after treatment with thyroid hormone. In another study of hypothyroid patients with PCOS, administration of thyroid hormone was associated with normalization of ovulation.23 These observations raise the possibility that sublaboratory hypothyroidism is a contributing factor in some cases of PCOS."
Lindsay AN, Voorhess ML, MacGillivray MH. Multicystic ovaries in primary hypothyroidism.Obstet Gynecol 1983;61:433-437. 23.
Ghosh S, Kabir SN, Pakrashi A, et al. Subclinicalhypothyroidism: a determinant of polycystic ovary syndrome.
Iodine and PCOS
(33) http://www.optimox.com/pics/Iodine/pdfs/IOD02.pdf
Orthoiodosupplementation: Iodine sufficiency of the whole human Guy. E. Abraham M.D.1, Jorge D. Flechas M.D.2 and John C. Hakala R.Ph.Our preliminary experience with I supplementation at 12.5 mg/day. Our findings in 3 patients with Polycystic Ovarian Syndrome (PCOS) confirmed the positive response observed following supplementation with 10 to 20 mg of potassium iodide by Russian investigators 40 years ago (62). Prior to I supplementation, those PCOS patients were olygomenorrheic, menstruating one or twice a year. Following I supplementation for 3 months, they resumed normal monthly cycles.
(34) http://optimox.com/pics/Iodine/opt_Research_I.shtml
Listing of Iodine publications at the Optimox Web Site.
(35) http://optimox.com/pics/Iodine/IOD-10/IOD_10.htm
Orthoiodosupplementation in a Primary Care Practice Jorge D. Flechas, M.D.
Iodine deficiency may cause the ovaries to develop cysts , nodules and scar tissue. At its worse this ovarian pathology is very similar to that of polycystic ovarian syndrome (PCOS). As of the writing of this article I have five PCOS patients. The patients have successfully been brought under control with the use of 50 mg of iodine per day. Control with these patients meaning cysts are gone, periods every 28 days and type 2 diabetes mellitus under control.
(36) http://cypress.he.net/~bigmacnc/drflechas/index.htm
HelpMyThyroid, George Flechas MD web site
Vitamin D and PCOS
(37) http://www.ncbi.nlm.nih.gov/pubmed/17177140
Low serum 25-hydroxyvitamin D concentrations are associated with insulin resistance and obesity in women with polycystic ovary syndrome. Exp Clin Endocrinol Diabetes. 2006 Nov;114(10):577-83. Hahn S et al. Insulin resistance (IR) and central obesity are common features of the polycystic ovary syndrome (PCOS). Vitamin D is thought to play a role in the pathogenesis of type 2 diabetes by affecting insulin metabolism. Subgroup analysis of lean, overweight and obese women revealed significant higher 25-OH-VD levels in lean women. Differences remained significant when women were divided according to their 25-OH-VD levels. Women with hypovitaminosis D (<9 ng/ml) had higher mean BMI, indices of IR and leptin levels compared to women with normal serum levels (all p<0.05). Analysis of vitamin D and biochemical endocrine PCOS features revealed a significant correlation only between 25-OH-VD and sex hormone-binding globulin as well as the free androgen index. In conclusion, in PCOS women, low 25-OH-VD levels are associated with obesity and insulin resistance .
(38) http://www.ncbi.nlm.nih.gov/pubmed/10433180
Vitamin D and calcium dysregulation in the polycystic ovarian syndrome.Thys-Jacobs S, Donovan D, Papadopoulos A, Sarrel P, Bilezikian JP. Department of Medicine, St. Lukes-Roosevelt Hospital Center, Columbia University, College of Physicians & Surgeons, New York, NY 10019, USA. Steroids. 1999 Jun;64(6):430-5.
Over the past 30 years, numerous studies in invertebrates and vertebrates have established a role of calcium in oocyte maturation as well as in the resumption and progression of follicular development. Polycystic ovarian syndrome (PCO) is characterized by hyperandrogenic chronic anovulation, theca cell hyperplasia, and arrested follicular development. The aim of this observational study was to determine whether vitamin D and calcium dysregulation contribute to the development of follicular arrest in women with PCO, resulting in reproductive and menstrual dysfunction. Thirteen premenopausal women (mean age 31 +/- 7.9 years) with documented chronic anovulation and hyperandrogenism were evaluated. Four women were amenorrheic and nine had a history oligomenorrhea, two of whom had dysfunctional bleeding. Nine had abnormal pelvic sonograms with multiple ovarian follicular cysts. All were hirsute, two had alopecia, and five had acanthosis nigricans. The mean 25 hydrovitamin D was 11.2 +/- 6.9 ng/ml [normal (nl): 9-52], and the mean 1,25 dihydroxyvitamin D was 45.8 +/- 18 pg/ml. with one woman with a 1,25 dihydroxyvitamin D <5 pg/ml (nl: 15-60). The mean intact parathyroid hormone level was 47 +/- 19 pg/ml (nl: 10-65), with five women with abnormally elevated parathyroid hormone levels. All were normocalcemic (9.3 +/- 0.4 mg/dl).
Vitamin D repletion with calcium therapy resulted in normalized menstrual cycles within 2 months for seven women, with two experiencing resolution of their dysfunctional bleeding. Two became pregnant, and the other four patients maintained normal menstrual cycles. These data suggest that abnormalities in calcium homeostasis may be responsible, in part, for the arrested follicular development in women with PCO and may contribute to the pathogenesis of PCO.
METFORMIN
(39) http://content.nejm.org/cgi/content/extract/358/1/47
Metformin for the Treatment of the Polycystic Ovary Syndrome John E. Nestler, M.D. N. Engl. J. Med., January 3, 2008; 358(1): 47 - 54.
(39A) http://www.ovarian-cysts-pcos.com/glucophage-metformin-pcos.html
PCOS and Metformin (Glucophage)
Diet and Weight Loss
(40) http://www.ovarian-cysts-pcos.com/pcos-book-res.html
The Natural Diet Solution for PCOS and Infertility Nancy Dunne, ND Bill Slater, MBA
(41) http://www.ovarian-cysts-pcos.com/PCOS-success.html#sec1
PCOS success stories by Nancy Dunne
Conventional Medical Diagnosis and Treatment of PCOS
(42) http://www.amazon.com/Clinical-Gynecologic-Endocrinology-Infertility-Editorial/dp/0781747953
Speroff on PCOS: Clinical Gynecologic Endocrinology and Infertility by Leon Speroff MD p.493
“A question which has puzzled gynecologists and endocrinologists for many years is what causes polycystic ovaries. There is an answer which is appealing in its logic and clinical applicability. The characteristic polycystic ovary emerges when a state of anovulation persists for any length of time” Should you have a sonogram to make the diagnosis of PCOS? “From 8-14% of normal women will demonstrate ultrasonographic findings typical of polycystic ovaries. Ultrasonography as a diagnostic tool for this condition is unnecessary, and we vigorously discourage its use for this purpose.”
(43) http://assets.cambridge.org/97805218/48497/excerpt/9780521848497_excerpt.pdf
Exerpt from Book: Introduction: Polycystic ovary syndrome is an intergenerational problem. Gabor T. Kovacs and Robert Norman Cambridge University Press 978-0-521-84849-7 - Polycystic Ovary Syndrome, Second Edition
(44) http://findarticles.com/p/articles/mi_qa3890/is_200407/ai_n9457295/pg_1
Hoyt, Karri Lynn "Polycystic Ovary (Stein-Leventhal) Syndrome: Etiology, Complications, and Treatment". Clinical Laboratory Science. Summer 2004.
(45) http://health.nytimes.com/health/guides/disease/polycystic-ovary-disease/overview.html
Polycystic Ovary Disease article in the New York Times
(46) http://www.ebmonline.org/cgi/content/full/229/5/369
MINIREVIEW, Screening for and Treatment of Polycystic Ovary Syndrome in Teenagers.
Experimental Biology and Medicine 229:369-377 (2004) Darren J. Salmi et al.
(47) http://www.drgalen.com/pcos.html
Dr. Galen, Reproductive Science Centerª of the San Francisco Bay Area, POLYCYSTIC OVARY SYNDROME (PCOS) Treatment of PCOS: In cases where ovulation is irregular or absent, medication can be used. The most common agent is clomiphene citrate (Clomid, Serophene), which is generally taken daily from days 3-7 of a cycle. Ovarian follicle development is usually monitored with a combination of home urinary LH testing, and office ultrasound examination. An intrauterine insemination is frequently advised because of clomiphene's adverse effect on a womanÕs cervical mucous quality. Additional endometrial support may be promoted with the use of progesterone or HCG injections. There is a mildly increased rate of multiple pregnancy with clomiphene (6-7%) but there is no increased risk of birth defects. The majority of womn who conceive on clomiphene will do so in the first 4 cycles. If clomiphene fails to successfully induce ovulation and/or pregnancy, then a group of injectable hormone preparations, known as gonadotropins, may be employed.
(48) http://www.clinmedres.org/cgi/content/full/2/1/13
Clinical Medicine & Research Volume 2, Number 1 : 13 -27, 2004, Polycystic Ovarian Syndrome: Diagnosis and Management Michael T. Sheehan, MD. Marshfield Clinic. Excellent review of conventional diagnosis and treatment for PCOS.
(49) http://www.inciid.org/printpage.php?cat=pcos&id=505
Understanding and managing Polycystic Ovarian Syndrome (PCOS) by Sam Thatcher, M.D., Ph.D. director of the Center for Applied Reproductive Science in Johnson City, TN,. Conventional Approach.
(50) http://www.perspectivespress.com/0-944934-25-0.html
PCOS: The Hidden Epidemic. a Book by Sam Thatcher MD PhD, Conventional Approach to PCOS.
(51) http://www.emedicine.com/ped/topic2155.htm
Polycystic Ovarian Syndrome Last Updated: September 15, 2006, on E-Medicine.
(52) http://www.endotext.org/female/female6/female6.htm
ENDOTEXT.COM, HYPERANDROGENISM, HIRSUTISM AND POLYCYSTIC OVARY SYNDROMEChapter 6 - Randall B. Barnes, M.D., Adrienne B. Neithardt, M.D. and Suleena K. Kalra, M.D.November 19, 2003 on Endotext.com
(53) http://jcem.endojournals.org/cgi/content/full/89/2/453
EXTENSIVE PERSONAL EXPERIENCE Androgen Excess in Women: Experience with Over 1000 Consecutive Patients R. AZZIZ, L. A. SANCHEZ, E. S. KNOCHENHAUER, C. MORAN, J. LAZENBY, K. C. STEPHENS,K. TAYLOR, AND L. R. BOOTS The Journal of Clinical Endocrinology & Metabolism 89(2):453–462. All patients with menstrual or ovulatory dysfunction received BCPs' (OCs) when possible. Patients with unwanted hair growth and evidence of excess facial or body terminal hair growth received spironolactone (SPA) (200 mg ; 100 mg/d) in combination with the OC, to minimize the risks of teratogenicity. SPA was rarely used alone, except in the occasional hirsute patient who had previously undergone a hysterectomy or tubal ligation. Other treatment regimens were occasionally used, including glucocorticoids, insulin sensitizers, GnRH analogs, flutamide, finasteride, and other estrogen-progestin combinations, alone or in combination; the majority of these were used as part of clinical trials (24–26).
(54) http://www.joplink.net/prev/200201/ref/01-02.html
Stein IF, Leventhal ML. Amenorrhoea associated with bilateral polycystic ovaries. Am J Obstet Gynecol 1935;29:181–91.
The Environment, Endocrine Disruptor Chemicals and PCOS
(55) http://www.ourstolenfuture.org/Consensus/2005/2005-1030vallombrosa.htm
Vallombrosa Consensus Statement on Environmental contaminants and human fertility compromise.
October 2005.
(56) http://www.ourstolenfuture.org/index.htm
Our Stolen Future, endocrine disruptors in the environment
(57) http://www.ovarian-cysts-pcos.com/news13-pcos-pesticides.html#sec1
Pesticides and PCOS
(58) http://humupd.oxfordjournals.org/cgi/reprint/7/3/323.pdf
Endocrine Disruptors as environmental cause of PCOSThe impact of Endocrine Disruptors on the Female Reproductive System, Stamati and pitsos et al.
Testosterone for Women
(59) http://www.asrm.org/Literature/Menopausal_Medicine/menomedsummer01.pdf
Testosterone Treatment: Psychological and Physical Effects in Postmenopausal Women.
Susan R. Davis, M.B.B.S., F.R.A.C.P., Ph.D. Menopausal Volume 9, Number 2, Summer 2001
Diet for PCOS
(61) http://pcos.is/files/pcosbook1.pdf
A complete online book on Diet and Nutrition for PCOS by Nancy Dunn
(62) http://www.topfitonline.com/chartglycemic.htm
Glycemic Index Chart - handy and useful.
Questionnaire for PCOS
(63) http://www.cfp.ca/cgi/content/full/53/6/1041/T50531041
Table 5 Clinical tool for diagnosis of polycystic ovary syndrome
Can Fam Physician Vol. 53, No. 6, June 2007, pp.1041 - 1047 , Polycystic ovary syndrome. Validated questionnaire for use in diagnosis, Sue D. Pedersen, et al.
(64) http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1949220
Can Fam Physician. 2007 June; 53(6): 1041–1047. Polycystic ovary syndrome. Validated questionnaire for use in diagnosis, Sue D. Pedersen, et al.
(65)http://www.acamnet.org/site/c.ltJWJ4MPIwE/b.2242497/k.2C78/Integrative_Medicine_
Physicians/apps/kb/cs/contactsearch.asp
ACAM doctor's directory
(66) http://www.worldhealth.net/pages/directory
A4M doctor's directory
(67) http://jeffreydach.com/2008/02/27/a-commonly-missed-cause-of-infertility-nonclassical-cah-by-jeffrey-dach-md.aspx A Commonly Missed Cause of Infertility, NonClassical CAH by Jeffrey Dach MD
Non Classical Adrenal Hyperplasia CAH 21-OH Deficiency
(68) http://jcem.endojournals.org/cgi/content-nw/full/91/11/4205/F8
FIG. 8. Non-classical CAH 21 Hydroxylase Deficiency Chart of Disease frequencies in different ethnic groups.
(69) http://jcem.endojournals.org/cgi/content/full/91/11/4205
The Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 11 4205-4214
EXTENSIVE CLINICAL EXPERIENCE, Nonclassical 21-Hydroxylase Deficiency
Maria I. New Department of Pediatrics, Mount Sinai School of Medicine, New York, New York 10029
(70) http://www.mcg.edu/pediatrics/pedsendo/21.pdf
Consensus Statement on Treatment of 21-Hydroxylase Deficiency. JCEM 87(9):4048-4053, 2002.
(71) http://www.questdiagnostics.com/hcp/intguide/EndoMetab/Gen_Misc/TG_CAH/TG_CAH_Fig1.pdf
Chart showing pathways of steroid synthsis Quest LAbs.
(72)http://jcem.endojournals.org/cgi/content/full/91/11/4205/F5
FIG. 5. Nomogram relating baseline to ACTH-stimulated serum concentrations of 17-OHP. The scales are logarithmic. A regression line for all data points is shown.
(73)
http://www.questdiagnostics.com/hcp/intguide/jsp/showintguidepage.jsp?fn=EndoMetab/Gen_Misc/TG_CAH/TG_CAH.htm
Congenital Adrenal Hyperplasia Testing Algorithm Guide Quest LAbs
(74) http://www.questdiagnostics.com/hcp/intguide/EndoMetab/EndoManual_AtoZ_PDFs/CAH_Common.pdf
21 Hydroxylase Deficiency Common Mutations, Quest LAbs
(75) http://www.esoterix.com/files/ss_cah.pdf
DNA TESTING FOR 21-HYDROXYLASE DEFICIENCY, Esoterix introduces a new DNA test to identify deficiency in the 21-hydroxylase gene, the most common cause of congenital adrenal hyperplasia (CAH). CAHDetx evaluates the CYP21 gene, detecting mutations and gene deletion/conversions that account for approximately 90% to 95% of all CAH cases.
(76) http://jcem.endojournals.org/cgi/content-nw/full/91/11/4205/T1
TABLE 1. Common gene mutations of the 21-hydroxylase gene CYP21A2 (75 )
(77) http://www.amazon.com/review/R2IPB7XGMO20NE/ref=cm_cr_rdp_perm
Safe Use of Cortisol is a Unique Medical Classic, December 7, 2007 By Jeffrey Dach MD
(78)
http://jeffreydach.com/2008/02/27/a-commonly-missed-cause-of-infertility-nonclassical-cah-by-jeffrey-dach-md.aspx
A Commonly Missed Cause of Infertility, NonClassical CAH by Jeffrey Dach MD
(C) 2008 All Rights Reserved Jeffrey Dach MD Disclaimer
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Disclaimer: The reader is advised to discuss the comments on these pages with his/her personal physicians and to only act upon the advice of his/her personal physicia. Also note that concerning an answer which appears as an electronically posted question, I am NOT creating a physician -- patient relationship. Although identities will remain confidential as much as possible, as I can not control the media, I can not take responsibility for any breaches of confidentiality that may occur. Finally, permission is granted to copy or reproduce this article on the internet, provided that appropriate credit and a link to the original article is provided.
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Jeffrey Dach MD www.drdach.com disclaimer |
I just read the comment you made on my blog.
So, regarding PCOS; I'm still new at collecting information about it, but I've gathered that there's 2 schools of thought regarding therapy (besides diet and exercise), some say that it is gynecological, while others believe it is entirely metabolic.
So, you say that Progesterone treatment is the best way to treat PCOS?
What are your thoughts about Metformin and Insulin Resistance treatments?
My Doctor, as I wrote in my Blog, is not for either. She says that the only conclusive and best way is to continue what I've been doing, with diet and exercise, and I have seen some difference.
Not with my Unwanted Facial Hair so much, I still have to shave every day, and also, occasionally, I have unbelievably weird first days of my menses. The last one almost had me fainting in the shower with light-headedness. But, overall, I feel a lot better, I exercise almost every single day. (rarely, I miss)
I supplement with some sensible supplements, and I eat according to the GI diet. (though, with my hectic schedule, I'm taking the lazy route and replacing 2 meals)
Overall, I feel great, but, would like to see a reversal altogether. What do you think is the best way for me to approach this? (not that I can convince my Doctor of it, but I'd like to know nonetheless)
Rebecca
________________________________________________________________
Dear Rebecca,
Both John R Lee MD and Jerilynn Prior MD treat PCOS with cyclic progesterone therapy, either with the topical cream or the oral capsule. See the links in the article above for details.
Progesterone
Cyclic Progesterone is the single most important treatment for PCOS. In many cases, the cyclic progesteroine helps to restore normal ovulation and normal cycles, and the elevated testosterone, facial hair and acne resolve once normal cycles are restored. It takes about 6 months, though. The whole point of my article is to alert the reader to the importance of cyclic progesterone therapy for PCOS. Most doctors are unaware of it because it is a natural substance, and not a patented drug. Being natural, it cannot be patented. Progesterone is FDA approved, and has been available and in wide use for 60 years. BCP's inhibit ovulation and aggravate the underlying condition.
Metformin
Metformin (glucophage) is useful for pre-diabetes, insulin resistance (high glucose/insulin ratio) and elevated blood sugar. Metformin improves insulin sensitivity.
Benefits of Metformin go beyond treatment of diabetes, and studies suggest Metformin is a valuable drug treatment for PCOS even in the absence of insulin resistant diabetes or obesity. Many patients with PCOS on Metformin see improvement in symptoms of acne, facial hair and resumption of ovulation with regular cycles.
Spironlactone
Spironlactone (Aldactone) is also used to reduce testosterone levels which improves the acne and facial hair.
If you need to find a knowledgeable physician who can prescribe progesterone, try the ACAM and A4M doctor's directories.
warmest regards,
Jeffrey Dach MD
www.drdach.com disclaimer
Reply to this
Thank you so much for leaving a comment on my blog.
Think that, as you advised Rebecca, I would be printing out your article and showing it to my doctor the next time I visit.
I have not heard of cylic progesterone therapy at all, but to be honest, I haven't done research on PCOS to say that I've exhausted a lot of avenues.
So progesterone requires prescription? It isn't something one can just purchase over the counter? what about other natural sources, I mean aside from pharmaceutical?
Vera
______________________________________________________________________
Dear Vera,
Progesterone cream is available over the counter without a prescription, as well as from a prescription written by a physician.
As mentioned above, I would recommend working closely with a knowledgeable physician for the best results.
warmest regards,
Jeffrey Dach MD
www.drdach.com
disclaimer
Reply to this
Hi Dr. Dach,
I first wanted to thank you for your information on PCOS. I am 23 years old and was just diagnosed with PCOS. My gynecologist told me my only option was BC pills but with all the research I have done, I have found that's not true. I got a prescription for sprinolactone.
I want to try the progesterone cream (I have read that it is better than the oral because the skin absorbs it slower. Can you tell me the name of a progesterone cream that I can buy over the counter? I talked to the pharmacist and she wasn't sure.
My doctor told me to just buy it over the counter.
Thanks for your help and information!
Meredith
______________________________________________________________________
Dear Meridith,
I am very disappointed in your doctor. It is very "bad form" for your doctor to send you away with instructions to just "buy it over the counter". Your doctor should provide you with a prescription from a reputable compounding pharmacy, with detailed instructions, and then monitor your condition serially with follow up office visits. This disappointing behavior by your doctor is merely another indication that our medical system is broken.
Although it is possible to buy progesterone over the counter without a prescription and self administer, I do not recommend doing so. Instead, I recommend that anyone contemplating using topical progesterone should do so under the care of a knowledgable physican. Use these links for the ACAM and A4M Doctor's Directory to find a knowledgable physician in your area.
More information is available on Over the Counter Topical Creams that contain Progesterone at these links:
http://www.johnleemd.com/index.html
John R Lee MD
http://www.hormonewell.com/index.htm
C W Randolph MD
As always, make sure to discuss all medications, including OTC progesterone with a knowledgable personal physician.
Jeffrey Dach MD www.drdach.com disclaimer
Reply to this
I'm confused! You & Dr. Lee & Dr Prior recommend Cyclic Natural Progesterone therapy not BC pills, but you have also stated that Spironolactone can be used. I was under the assumption that in order to take spiro, you had to be on a bc pill to prevent irregular bleeding. Is that correct?
LC
__________________________________________________________________________
Dear LC,
Spironlactone is an aldosterone antagonist diuretic which by coincidence also has anti-testosterone activity, and therefore useful as treatment for elevated testosterone in PCOS.
An adverse side effect of the spironlactone drug in the pregnant female is a possible adverse hormonal effect on the developing male fetus which needs testosterone for normal development into a male child.
Therefore, in order to avoid possible adverse effects on a male fetus, it is standard practice to use some sort of birth control for young females given spironlactone. That is where BCP's come in which are in fact quite effective at birth control and preventing pregnancy. However, any form of birth control may serve quite well.
Many females with infertility caused by PCOS would like to be able to conceive and carry a pregnancy. Infertility is the major issue in such cases, and spironlactone would not be a good choice, since it would be contra-indicated.
warmest regards,
Jeffrey Dach MD www.drdach.com disclaimer
Reply to this
I an 28 years old and have just been diagnosed with PCOS. I have always had irregular periods and weight issues with I have sort of maintained. My blood work should normal sugar and insulin levels but high androgens and testostorone.
I have been put on metformin but I am wondering if i should try the progesterone therapy and then try to conceive 6-8months later??? I also thought spironlactone but then I want to have a baby so??????
Cee
__________________________________________________________________________
Reply to this
I'm confused about something.
(I haven't been officially diagnosed yet, but its strongly suspected that i have pros)I am 24 yrs old and am a type 1 diabetic (to complicate things)
When I was about 19, I went on Diane 35 because I had bad acne and some pretty upsetting hirsutim on my lower abdomen. Diane completely took this away.
I am not sure if I am insulin resistant on top of being type 1 - as i do not thus far take a huge amount of insulin. (i am type 1 for sure as is my dad 2 uncles n 3 yr old cousin)
Now this is where my confusion is...i have always and continue thus far anyway knock on wood to have what i think are timely normal periods..i am also thin (at the moment) gained a bit of weight before going on Diane which i lost while on the pill. Though when i do gain it is always my abdomen.
If pcos is caused by not ovulating and I am...what is causing my symptoms? As a side note: the more insulin i take even a difference of 2 units of long acting insulin the worse symptoms get ie-hirsutism, oily skin and now MY HAIR IS FALLING OUT.
I'm 5'4 and 119-120 pounds. Any help with figuring out this mess would be greatly appreciated I scared im gonna go bald! (my hald sis has pcos she is very thin but needed metformin to get pregnant)
Could i be "mildly insulin resistent"? and could i have a brain to ovary signinally prob as opposed to cysts?
I'm so confused:S
_________________________________________________________
Diane is an oral contraceptive with anti-androgen activity. Here is more info:
Cyproterone acetate (Androcur, Cyprostat,Cyproteron, Procur, Cyprone, Cyprohexal, Ciproterona, Cyproteronum,Neoproxil, Siterone) is an antiandrogen, i.e. it suppresses the actions of testosterone (and its metabolite dihydrotestosterone) on tissues. It acts by blocking androgen receptors which prevents androgens from binding to them and suppresses luteinizing hormone (which in turn reduces testosterone levels). Its main indications are prostate cancer, benign prostatic hyperplasia, priapism, hypersexuality and other conditions in which androgen action maintains the disease process. Due to its anti-androgen effect, it can also be used to treat hirsutism, and is a common component in hormone therapy for male-to-female transgender people.
Oral contraceptives produce regular bleeding cycles with NO ovulation. That is how they prevent pregnancy. There is no ovulation on BCP's.
Many women are confused by this and think the regular cycles on birth control pills indicates normal ovulation. This is incorrect, and couldn't be farther from the truth.
PCOS is caused by lack of ovulation, so oral contraceptivces that prevent ovulation merely aggravate the underlying condition and make it worse.
BCP's are a cosmetic fix that superficially seems to help PCOS, all the while the underlying problem, lack of ovulation, is made worse.
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Hi,
I've been diagnosed with PCOS and am taking 200 mg of Prometrium once a day for 14 days (beginning on day 14 of my cycle) to regulate my periods.
Unfortunately, I begin my period on the 9th day of taking Prometrium. Do I need to increase my Prometrium dosage or decrease it? I'm 31 years old and weigh 115 lbs.
Thank you
Shad
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Dear Shad,
Please call your doctor who prescribed the Prometrium and ask for instructions from them.
Prescribing physicians commonly give the following instructions:
1) Take the progesterone from days 14 to 28 of cycle.
2) If Bleeding period starts early, before the end of cycle, then that becomes a new day one. Starting from the new day One, take 14 days off, and take progesterone on day 14 to day 28 of new cycle.
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Dear Dr. Dach,
My 15 1/2 year old daughter was diagnosed with PCOS by her endocrinologist 2 months ago. She has had Type I diabetes since the age of 3. She has had great blood sugar control up to about 12y.o. when puberty hit. Blood sugars ran higher and higher needing more and more insulin over the last 3 years. And despite this her A1C kept creeping up until it was a 9.0! Over that period of time, she put on a good 40 pounds and she has only had 2 short menstrual cycles over a 9 months apart in her lifetime.
Over the last year she has been exercising like crazy (on the school crew team) and eating only 1200-1500 calories of good whole grain/whole wheat carbs, fruits, veggies etc... Despite all this she didn't lose a pound and her BMI is still 32%!
She has also had uncontrollable acne.
Tests showed an elevated LH level compared to FSH ( LH - 11, FSH - 6). They told us all other hormone levels were normal ( including free testosterone) and the ultrasound of her ovaries was normal.
She went on the YAZ birth control pill 2 months ago to start her periods. She got a normal 4-5 day period a month ago.
I have been reading a lot about PCOS and found articles linking type I diabetes in adolescent girls and young women to PCOS due to the large amounts of insulin needed for good blood sugar control.
It never made sense to me to use the birth control pill for PCOS and reading this website helps me understand that better.
I have 2 questions:
1. I read that in girls with PCOS they may not ovulate because of the lack of LH surge signals to the ovaries. If this is the case in my daughter, how would progesterone help this? I understand that progesterone is needed to tell the lining of the uterus to shed once the attached egg isn't fertilized but, if there is no egg...how can monthly natural progesterone help her? In other words, in PCOS is the problem that no egg is being released? or that it is but the uterus is never shedding and bleeding? How does one tell for each patient?
2. What are your thoughts about "metformin"? I hate to put my daughter on long-term drugs but, from what I read, I think metformin might help decrease the amount of insulin she needs and this in turn may help with PCOS symptoms. Do you know of any long term effects of metformin?
Susan
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Dear Susan,
BCPs - Stopping Ovulation
"She went on the YAZ birth control pill 2 months ago to start her periods. She got a normal 4-5 day period a month ago."
One common misconception is that birth control pills produce normal periods. The cycles and bleeding periods are regular on BCP's, however, there is no ovulation. Birth control pills are a form of chemical castration, which prevent ovulation. The bleeding periods are artificially induced and do not indicate ovulation.
Since the primary defect is lack of ovulation, and absense of the progesterone in the second half of the cycle, it would be logical to supplement with progesterone for the second half of the cycle. Progesterone does not directly induce ovulation. However, it sends a cyclic signal to the brain centers to try to re-start cyclic hormone rhythms, and in many cases ovulation starts on its own with cyclic progesterone stimulation of brain centers.
Metformin is a Valuable Drug for PCOS patients
Metformin (glucophage) is a well known diabetes drug used for decades to control blood sugar in diabetics. Initially, Metformin was used to control blood sugar in PCOS patients with insulin resistant diabetes amd obesity. However, after years of clinical use, it was discovered that Metformin has many benefits for PCOS patients even when there is normal blood sugar, normal insulin and no obesity. In other words, patients with PCOS may benefit from Metformin even though they have no underlying of insulin resistant diabetes or obesity. In these patients with normal blood sugar, the Metformin may reduce the acne and facial hair (hirsutism), lower testosterone levels, and cause resumption of ovulation with regular cycles, all good outcomes from treatment.
See references below:
Metformin improves polycystic ovary syndrome symptoms irrespective of pre-treatment insulin resistance
European Journal of Endocrinology, Vol 157, Issue 5, 669-676, 2007
Susanne Tan, et al.
Long-term effect of metformin on metabolic parameters in the polycystic ovary syndrome
Diab Vasc Dis Res 2009; 6; 110 Kai I. Cheang, Jessica M. Huszar, Al M. Best, Susmeeta Sharma, Paulina A. Essah and John E. Nestler
Evidence-Based and Potential Benefits of Metformin in the Polycystic Ovary Syndrome: A Comprehensive Review
Endocrine Reviews 30 (1): 1-50 2009 Stefano Palomba, Angela Falbo, Fulvio Zullo and Francesco Orio, Jr.
Metformin is an insulin sensitizer widely used for the treatment of patients affected by type 2 diabetes mellitus. Because many women with polycystic ovary syndrome (PCOS) are insulin resistant, metformin was introduced in clinical practice to treat these patients also. Moreover, metformin’s effect has other targets beside its insulin-sensitizing action.
Menstrual cyclicity after metformin therapy in polycystic ovary syndrome.
Obstet Gynecol. 1997 Sep;90(3):392-5. Velázquez E, Acosta A, Mendoza SG. Department of Medicine, Medical Faculty of University of The Andes, Mérida, Venezuela.
OBJECTIVE: To assess the effect of insulin-lowering treatment on menstrual cyclicity in polycystic ovary syndrome (PCOS).
METHODS: Forty oligoamenorrheic women with PCOS were recruited in a prospective clinical study to receive metformin for a minimum period of 6 months. Twenty-two women completed the study. Serum LH, FSH, free testosterone, and glucose and insulin response to oral glucose load were measured both before and after 8 weeks of metformin treatment. Menstrual cyclicity and serum progesterone levels at the midluteal phase were assessed at the 30th week of metformin treatment.
RESULTS: Twenty-one of 22 women had restoration of menstrual cyclicity (95.7%). Four of these women (19%) became pregnant within the 6th and 7th months of treatment. All four of the pregnant women delivered, and the infants were healthy. Thirteen of 15 women who had regular menses demonstrated a serum progesterone level within the ovulatory range (3.1-28 ng/mL). Fasting (P < .001) and the integrated insulin response to the glucose load decreased (P < .001) after 8 weeks of metformin treatment. This was accompanied by significant decreases in serum LH (P < .001) and free testosterone (P < .001) levels and LH/FSH ratio (P < .001). There was a small but significant reduction in body mass index after 8 weeks of metformin treatment (P < .001).
CONCLUSION: A 6-month course of metformin may improve menstrual cyclicity and fertility in women with the PCOS. Insulin-sensitizing agents provide a rational approach to the treatment of the metabolic and endocrine abnormalities in PCOS women.
Jeffrey Dach MD
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Thank you for your speedy response. I would like to take my daughter to a doctor who specializes in endocrine disorders, including obviously PCOS, who can then guide us with a treatment plan to include trying natural progesterone cream. Her present endocrinologist who she has been going to for her type I diabetes is not familiar with such a treatment approach. Can you recommend anyone in our area? We live in Fairfield County, Connecticut.
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