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Dx PCOS and Dx Polycystic Ovarian Disease Treatments:

Polycystic Ovarian Disease
Standard Therapy..................Surgical Therapy.......................... Alternative Therapy...................Future Therapy

The N.H.S. Choices
"Polycystic ovary syndrome (PCOS) is a common condition that affects how a woman’s ovaries work. PCOS affects millions of women in the UK.

The three main features of the condition are [Rotterdam Criteria]:
*hyperandrogenism (having high levels of "male hormones" called androgens in your body)
*chronic anovulation (your ovaries do not regularly release eggs (ovulate)
*polycystic ovaries (cysts that develop in your ovaries (polycystic ovaries)

You will usually be diagnosed with PCOS if you have at all three of these features.

What are polycystic ovaries?
Polycystic ovaries contain a large number of harmless cysts up to 8mm in size. The cysts are under-developed sacs in which eggs develop. Often in PCOS, these sacs are unable to release an egg, meaning ovulation doesn't take place.

It's estimated that about 1 in every 5 women in the UK has polycystic ovaries, but more than half of these have no symptoms.

Signs and symptoms:
Symptoms of PCOS usually become apparent during your late teens or early twenties. They can include:
*irregular periods or no periods at all difficulty getting pregnant (because of irregular ovulation or failure to ovulate)
*excessive hair growth (hirsutism) - usually on the face, chest, back or buttocks
*weight gain
*thinning hair and hair loss from the head
*oily skin or acne

Polycystic ovary syndrome is associated with an increased risk of problems in later life, such as type 2 diabetes and high cholesterol levels.

Why it happens:
The exact cause of PCOS is unknown, but it often runs in families. The condition is associated with abnormal hormone levels in the body, including having high levels of insulin.

Treating polycystic ovary syndrome:
*There's no cure for PCOS, but the symptoms can be treated.
*If you have PCOS and are overweight, losing weight and eating a healthy diet can help reduce some symptoms.
*Medications are also available to treat symptoms such as excessive hair growth, irregular periods and fertility problems.

There has been a shift to adding an aromatase inhibitor as it may be slightly more effective than clomiphene in inducing ovulation and pregnancy. The Cochrane Database thought the results were statistically not overwhelming but the ACOG committee opinion in #663 stated " For women with polycystic ovary syndrome and a body mass index greater than 30, letrozole should be considered as first-line therapy for ovulation induction because of the increased live birth rate compared with clomiphene citrate.">

If fertility medications are ineffective, a simple surgical procedure called laparoscopic ovarian drilling (LOD) may be recommended. This involves using heat or a laser to destroy the tissue in the ovaries that's producing androgens such as testosterone.

With treatment, most women with PCOS are able to get pregnant."

Medications Used in Treatment:
1. Biguanides: Glucophage®/metformin
2. Glitazones: Actos®/pioglitazone, Avandia®/rosiglitazone
3. Estrogen antagonists: Serophene®/ Clomid®/clomiphene
4. Laparoscopic Surgery/ ovarian drilling (out-patient)- see information below
5. Aromatase Inhibitors: Letrozole.
6. D-chiro-inositol You-tube Video: over-the-counter supplement

Suggested Links
*Medscape on Hirsuitism
*Medscape on Risk Factors
*PCO Foundation

*Menstrual cycles and high HOMA (insulin levels) were regulated at 15 weeks in 51% of PCOS women on d-chiro-inositol daily. This makes this nutrient supplement a first choice in young PCOS women not trying to immediately conceive.

*[Editor] There is now evidence that the xeno-estrogens (environmental toxins)may be linked as causing of polycystic ovary syndrome.

*[Editor] A member of our team brought my attention to the link between endocrine abnormalities, low progesterone in particular, and gastro-intestinal disruption from glutens and lactose products.

Polycystic Ovarian Disease (PCOS) women frequently suffer with hyperstimulation in infertility treatment with gonadotropins. Although ovarian drilling was popular in the 1980's-1990's, it still may have a role in the infertile PCOS patient. The Cochrane review showed that ovarian drilling reduced dramatically the rate of multiple pregnancies. Another Cochrane Review showed that letrozole 1)compares favorably to clomiphene with the live birth rate being higher for letrozole and 2)compares favorably with laparoscopic ovarian drilling-- both reduce the rate of ovarian hyperstimulation with infertility treatment.

Laparoscopic Ovarian Drilling
When the Editor drilled ovaries back in the mid-1980's, we knew that the local effect of testosterone caused the surface thickening. "According to Jerilyn Prior, M.D., insulin stimulates androgen receptors on the outside of the ovary, causing the typical PCOS symptoms of excess hair (on the face, arms, legs), thin hair (on the head), and acne."

Abu Hashim in Arch Gyecol Obstet 2013 stated "Laparoscopic Ovarian drilling, whether unliateral or bilateral is a beneficial second-line treatment in infertile women with clomiphene citrate (CC)-resistant PCOS. It is as effective as gonadotrophin treatment but without the risk of multiple pregnancy or ovarian hyper-stimulation and does not require intensive monitoring."

*[Editor] The most recent research found the over-the-counter supplement, 600mg of D-chiro-inositol taken daily, reduced circulating insulin, decreased serum androgens, and ameliorates some of the abnormlities (including blood pressure and hypertriglyceridemia) of syndrome-X.

*[Editor] Jeffrey Dach, M.D. states "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)."

*[Editor] The newest research identifies that PCOS is linked to exposure to Bisphenol-A (BPA). Dr. Gersh linked neonatal exposure to BPA to the increasing PCOS epidemic affecting 10-20% of all women.

He future showed that in experimental animals, neonatal exposure to PCOS changed the genetic makeup-- causing genetic mutations in the Estrogen receptors.
*1. Reduces the number of oocytes(eggs in ovaries)
*2. Lowers successful number of births
*3. Changes gene expression-- differences only apparent after estrogen exposure
*4. Reduces the function of the Estrogen Receptor Beta
*5. Negatively affects mitochondrial function
*6. Alters hypothalamic pituitary-gonadal axis. Increases testosterone
*7. Lowers progesterone
*8. Alters GnRH (growth hormone) secretion
*9. Increases glucocorticoids (cortisol- raises blood sugar and insulin)
*10, heightens response to stress, elevated levels of anxiety.

*[Editor] Interestingly, Dr. Jerilyn 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.”

*[Editor]  Other Treatable Causes of Anovulation
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.

"Laboratory 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 Insulin-GTT). 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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