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PCOS, Pregnancy, and Lactation: Why Ovulation in Your Teens Matters

Published on June 15, 2020

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PCOS and Irregular Periods in Teens

Polycystic Ovarian Syndrome (PCOS) is one of the most common hormonal disorders for women. It is both a metabolic and endocrine disorder, which means it affects insulin production, metabolism, and reproductive hormones. Contrary to its name, it doesn’t necessarily mean you have polycystic ovaries. In fact PCOS has many different faces. PCOS symptoms include irregular periods, difficulty conceiving, hirsutism, acne, and obesity. Research is now uncovering that you may not exhibit any of these symptoms but still have the disorder. This means that PCOS is either commonly misdiagnosed or not diagnosed at all.

The standard treatment for teenagers with irregular periods is hormonal contraception. On the surface it seems to fix the problem. It gives them a regular bleed and often clears up pesky acne. The seemingly regular ‘period’ is deceiving, however. It is not a menstrual cycle. There is no ovulation while on hormonal contraceptives and the bleeding is simply what is called a ‘pill withdrawal’ bleed; meaning if she were not to cease taking the pill every month, she would never bleed.

Hormonal contraceptives trick the body into thinking it has already ovulated by providing a steady stream of synthetic hormones, which override brain and ovarian function giving negative feedback to tell the brain to halt any hormone production. In a healthy and functional cycle, there is a wax and wane for all of the reproductive hormones – kind of like an orchestra. All hormones have a part to play. Estradiol and progesterone, the two dominant ovarian hormones, balance each other out and protect bone and heart health as well as the development of the immune system. Having a period is much more than an accessory, it should be considered the fifth vital sign of health for women. A woman on hormonal contraception is not simply not ovulating and menstruating, she is missing out on the benefits of endogenous hormones while also losing time to get to the root issues of her hormonal disorder.

Though it is worth noting that some irregularity is to be expected during the years of puberty, for other girls’ irregularity can be indicative of a hormonal disorder like PCOS. This is concerning since a teenager with PCOS might spend the next 15 years on the pill and not think twice about it. When she is ready to conceive, she will get off of the pill and is likely to find conception difficult, depending on the severity of the underlying PCOS that led to pills in the first place.

Conceiving With PCOS

Since irregular menstruation (and therefore irregular ovulation) is common with PCOS, this is the most obvious obstacle in conceiving. If a woman is not ovulating, she cannot conceive. But that is not the only obstacle in conceiving with PCOS. Women with PCOS often have altered levels of androgens as well FSH and LH which all affect the cycle. Even if a woman with PCOS conceives, if these hormone levels aren’t addressed at the root, a pregnancy could likely need many interventions – as well as the birth and postpartum.

Without proper support, a woman may turn to IVF which might yield a baby, but is unlikely to solve her underlying hormonal disorder. In many cases, IVF could even worsen her health. In this 2014 study researchers concluded:

“Women with PCOS are at an increased risk of adverse pregnancy and perinatal outcomes, which could not be explained by assisted reproductive technology. These women may need increased surveillance during pregnancy and parturition. Future research would benefit from focusing on glucose control, medical treatment and hormonal status among women with PCOS during pregnancy.”

Postpartum and Lactation with PCOS

We know that the more interventions that are needed in a pregnancy and birth, the more the risk of trauma and stress increases. Birth interventions often delay lactogenesis II, the stage of milk production where colostrum transitions to the white viscous milk that we commonly think of when we imagine breastmilk. This transition usually occurs within 24-48 hours after giving birth, but we often see it delayed as long as 4 or even 5 days after a traumatic birth.

Furthermore, while research is still developing in this area, there is enough data to support the idea that PCOS (and its accompanying insulin resistance) plays a major role in milk supply. This study showed that a particular gene is expressed more prominently when a mother is insulin resistant, than in insulin-sensitive individuals. This gene is intricately tied to milk production.

Milk Supply and Insulin Resistance

Let’s talk about breast milk supply for a minute. The two main things that drive milk supply: 1) prolactin production (think baby or pump suckling on nipple, this corresponds with surge in prolactin) and 2) sufficient glandular tissue. As a lactation counselor, when someone comes to me with “low supply”, the first thing I need to parse out is if this issue is baby sourced or parent sourced. Does mom have an adequate supply, but the baby isn’t able to get it and the body responds in classic supply demand fashion by lowering the supply OR is the mom truly unable to make a full milk supply? Clinically it is usually the first option, but occasionally it is the second.

To make an adequate supply on the mom’s side, she must have sufficient glandular tissue. This means that the breast tissue grew appropriately at the time of puberty as well as during pregnancy (this is the final stage of maturation for breast tissue). And of course, it needs to contain enough milk ducts. We know that insulin has a direct action on the mammary glands during breast development. To develop adequately, breast tissue cells must remain insulin sensitive. In this study on mice, “It was found that both IGF-1 and IGF-2 activate the expression of milk protein β-casein in the presence of prolactin and hydrocortisone. It was found that β-casein expression is accompanied by cyclin D1 co-expression.” This means that fewer receptors = fewer milk ducts. And most importantly, this means that breast development during puberty has implications later on in reproductive life.

Moms with Hypoplasia, or Insufficient Glandular Tissue (IGT), don’t all have the same breasts. Size is not indicative of the quantity of glands. IGT breasts can be big, small, medium, round, flat, high or low – the only thing they all have in common is that the glandular tissue is simply not sufficient to make a full milk supply. The biggest indicator of IGT is if a mom’s breasts do not grow during pregnancy. This is usually a huge red flag. However, with the right support, moms with Hypoplasia can still breastfeed. It often looks like adding in supplementation with either donor milk or formula, and sometimes supplemental nursing systems may be used. Some women with PCOS have lactation troubles, but others do not. Women can have insulin resistance without PCOS, but still have lactation trouble. Women can have PCOS and insulin resistance and have no lactation trouble. While less common and much less understood, women can have lactation trouble (in the form of IGT) without PCOS or insulin resistance.

In the case of a mom with insulin resistance, and especially a missed diagnosis of PCOS, they may have no idea what could possibly be causing their low milk supply. Being labeled “IGT” often feels defeating and devastating. If they struggled to conceive, the mom may feel that their body is simply working against them every step of the way on their journey to motherhood. This increases their risk of postpartum mood disorders and it becomes a bit of a domino effect.

The Importance of Diagnosing PCOS (and other Disorders) Early

So how do we nip this narrative in the bud? It is a simple answer with a not so simple execution. For starters, health care providers need to prioritize regular, functional ovulation for teenagers. Rather than being put on the pill at 15, struggling to conceive at 30, going through IVF, and having difficulty producing milk – this story could be radically changed at its first juncture. This also extends to women in their 20’s and 30’s and even into their early 40’s – a time when cycles should be regular and functional, unless a woman is breastfeeding (in which anovulation is biologically normal). Hormones change throughout reproductive life. A teenager may have PCOS but the symptoms may not become apparent until after their first birth or during a really stressful period in their life. Health care is fluid and should move along with women as they shift and transition through different seasons in life. The importance of getting an annual exam and pap smear are commonly emphasized to women – but little do we emphasize the benefits of getting a hormone panel done periodically to check in. In some cases, a full hormone blood panel isn’t even necessary. You can get enough information from your symptoms and a Fertility Awareness Based Method chart.

Prioritizing Women’s Menstrual Health

If we are prioritizing functional and regular ovulation for women (and therefore balanced hormones), women can mitigate their symptoms and learn to live with PCOS. While there are no hard and fast cures for PCOS currently, there are many ways to manage it. Some of these variables are in a woman’s control (diet and exercise) while others are much more systemic, cultural, and political such as access to nutrient rich food and health care resources. In industrialized nations, cultural priorities do not often support general health and in modern life, we are exposed to more blue light, less sunlight, and we are chronically over-booked causing higher cortisol levels which also affect insulin sensitivity. But this is a conversation best saved for another day.

It should also be noted that a PCOS diagnosis doesn’t necessitate impaired glucose tolerance. Since PCOS operates on a spectrum (which doesn’t even necessarily correspond with symptoms!), there are many variables at play. The most important takeaway here is that insulin resistance does seem to play a role in breast tissue development and teens with PCOS, which is often misdiagnosed, may miss out on crucial breast tissue development.

In any case more information is critically needed. We cannot ignore this too common condition anymore. More knowledge on hormonal disorders and insulin resistance and lactation deserves to be studied. If you find yourself with either a PCOS diagnosis or lactation struggles, it is worth finding the practitioner who is willing to help you dig deeper and get more answers. This process isn’t easy. There are certainly cases that seem unanswerable, but the more we hear about them, the more we can learn about them.

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Maternal Vitamin D: Pregnancy and Beyond

by Susan Rex Ryan

Published on December 16, 2015

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Researching the role of vitamin D in pregnancy for this article, I unexpectedly blew inches of virtual dust from a page of medical correspondence published almost seven decades ago. With keen interest I read “Vitamin-D Requirements in Pregnancy,” published in a 1947 edition of the British Medical Journal. The author Edgar Obermer, MD asserted the necessity for English pregnant women to supplement with robust daily doses of vitamin D.

Perhaps Dr. Obermer was ahead of his time, or today we are behind in understanding the power of vitamin D. I think both are true. Nonetheless, his assertion about relatively high maternal vitamin D doses accentuates vitamin D’s importance during pregnancy. Today pregnant women typically supplement with prenatal vitamins, most of which only contain enough vitamin D to prevent rickets.

Unfortunately, taking prenatal vitamins without supplementing with extra vitamin D provides expectant mothers with a false sense of health for their babies and themselves. In this article, I address vitamin D’s role in pregnancy, recent evidence supporting the positive effect of vitamin D on expectant moms and their babies, and vitamin D supplementation guidelines for pregnant and lactating women and their infants.

A Healthy Pregnancy

Many people may not realize that vitamin D is actually a steroid hormone produced in our body. We manufacture vitamin D when we take a quality vitamin D3 supplement, expose our skin to optimal sunlight, or consume lots of wild-caught fatty fish or vitamin D3-fortified foods.

The female reproductive system comprises billions of cells. Every cell in the female reproductive system contains genetic codes as well as a receptor to receive vitamin D. Cells in the female reproductive system (including the ovaries, fallopian tubes, uterus, placenta, decidua, vagina, and breasts) are replete with vitamin D receptors.

When we have ample amounts of activated vitamin D in our cells, the vitamin D binds with its receptor to regulate genes in our reproductive system. For example, the vitamin D pathway genes affect in utero fetal development. Conversely, when the female reproductive system lacks activated vitamin D, genes essential to a smooth pregnancy and sound fetal health are not expressed.

Mom Needs Nutrients for her Health

Vitamin D is vital to a pregnant women’s health. An expectant mom with adequate vitamin D levels may enjoy a reduced risk of pregnancy complications including preeclampsia, gestational diabetes mellitus, Caesarian section, and preterm birth. However, low vitamin D blood serum levels are common in pregnant women.

The recent findings of a Canadian study published in the December 2014 edition of the journal Current Opinion in Obstetrics and Gynecology once again accentuate the importance of vitamin D to maternal health. Lead researcher Shu-Qin Wei, MD, PhD examined scientific evidence of the role of maternal vitamin D on pregnancy outcomes. Focusing on studies published between January 1, 2013 and July 1, 2014, she concluded: “Recent evidence supports that low maternal vitamin D status is associated with an increased risk of adverse pregnancy outcomes. Interventional studies demonstrate that vitamin D supplementation during pregnancy optimizes maternal and neonatal vitamin D status.”

A Seed for Healthier Babies

Vitamin D is vital to fetal bone and cell development. Medical research suggests some seeds for disease are sown before birth. Low vitamin D during pregnancy may be one of those seeds. Babies born to mothers with a vitamin D deficiency are more likely to develop a number of medical conditions including asthma; autism; soft bones (rickets, craniotabes); brain disorders; cardiovascular malformation; and type 1 diabetes mellitus.

A new study highlights the benefit of vitamin D to fetal skeletal development. Dutch researchers explored the effect of vitamin D supplementation during pregnancy and early infancy on skull formations. The scientists recommended that women in their last trimester and early infants take a daily vitamin D dose of 400 international units ((IU) albeit a small amount). The research team found that non-adherence to their recommendations for vitamin D supplementation by pregnant mums and infants is linked to an increased risk of skull deformities in babies at 2 to 4 months of age. This study was published in a November 2014 issue of the journal Maternal & Child Nutrition.

Labor, Lactation, and Early Infant Life

Vitamin D also plays a beneficial role regarding labor pain, breastfeeding, and early infant health.

Labor. The benefits of maternal vitamin D have recently been extended to decreased labor pain. In October 2014, Andrew W. Geller, MD, a physician anesthesiologist at Cedars-Sinai Medical Center in Los Angeles, presented a study about vitamin D‘s effect on labor pain to the American Society of Anesthesiologists’ annual meeting. Dr. Geller and colleagues measured the vitamin D levels of 93 pregnant women prior to delivery. All of the patients requested an epidural for pain during labor. The research team then measured the doses of pain medication required by each woman during labor. They compared the quantity of pain medicine consumed by women with higher vitamin D levels with those with lower vitamin D status. The patients with lower vitamin D levels used more pain drugs than those women who enjoyed higher vitamin D status. Dr. Geller concluded that “prevention and treatment of low vitamin D levels in pregnant women may have a significant impact on decreasing labor pain in millions of women every year.”

Lactation. Nature intended for newborns to obtain their nutrients, including vitamin D, from breast milk. Breastfeeding provides babies with the vitamins and minerals required for healthy development. That’s why it is imperative that lactating mums supplement daily with adequate vitamin D. Vitamin D supplementation guidelines are discussed in the next section of this article.

Early Life. Vitamin D is important to all stages of life including neonatal. The growth and development of an infant is associated with the vitamin D intake during pregnancy.

Recent research from the University of Southampton in the United Kingdom suggests that young children are likely to develop stronger muscles when their mums enjoyed a higher level of vitamin D during pregnancy.

The connection between vitamin D levels and muscle strength has been well-established by the scientific community. However, the Southampton study, published in the January 2014 issue of the Journal of Clinical Endocrinology and Metabolism, marks the first time that the relationship between maternal vitamin D status during pregnancy and the muscle development and strength in offspring was examined.

Led by Nicholas Harvey, PhD, the researchers measured the vitamin D levels in 678 mothers from the Southampton Women’s Survey in their later stages of pregnancy. Four years after the babies were born, the Southampton team measured their hand-grip strength and muscle mass. The researchers found that the higher the levels of vitamin D in the mother, the higher the grip strength of her child. A secondary finding addressed a lesser connection between maternal vitamin D and the child’s muscle mass. The Southampton study’s outcome suggests more far-reaching health benefits. Dr. Harvey commented,

“These associations between maternal vitamin D and offspring muscle strength may well have consequences for later health; muscle strength peaks in young adulthood before declining in older age and low grip strength in adulthood has been associated with poor health outcomes including diabetes, falls, and fractures. It is likely that the greater muscle strength observed at four years of age in children born to mothers with higher vitamin D levels will track into adulthood, and so potentially help to reduce the burden of illness associated with loss of muscle mass in old age.”

Supplementation Guidelines for Mum and her Newborn

The importance of vitamin D supplementation cannot be overstated for the health of mothers and their infants.

British nutrition expert Sara Patience, author of the new book Easy Weaning, stated, “It’s important for mums to understand that their baby will be born with the same vitamin D status as themselves, therefore, if mum is vitamin D deficient during pregnancy, baby will be too. Women, who are pregnant, or planning to become pregnant, should ensure they are vitamin D sufficient, not only to protect their own health, but also to protect the health of their baby.”

The most effective source of vitamin D3 (cholecalciferol) is an oil-based soft gel or liquid supplement. Vitamin D3 supplements (usually measured in international units) are available over-the-counter in retail and online stores. Beware of vitamin D prescriptions as most contain vitamin D2 (ergocalciferol) that is much less effective than vitamin D3.

How much vitamin D a pregnant woman (or anyone, for that matter) needs continues to be a topic of debate.

First, let’s consider Dr. Obermer’s surprising recommendation in 1947. Remarking that the subject of vitamin D supplementation in pregnancy “is a difficult and complex one,” he concludes, “In a climate like that of England every pregnant woman should be given a supplement of vitamin D in doses of not less than 10,000 i.u. per day in the first 7 months, and 20,000 i.u. during the 8th and 9th months.” (Note: England’s distance from the equator denies its residents from enjoying optimal sun light exposure during the majority of the year.)

Second, a few noted organizations recommend daily intake of vitamin D for pregnant women as follows:

Vitamin D Council: 4,000-6,000 IU (Upper limit: 10,000 IU)
Endocrine Society: 1,500-2,000 IU (Upper limit: 10,000 IU)
Institute of Medicine (IOM): 600 IU (Upper limit: 4,000 IU)

It is interesting (and refreshing) to note that the Vitamin D Council and the Endocrine Society’s “upper limit” recommendations almost mirror those of Dr. Obermer’s. Please note that the IOM’s Food and Nutrition Board’s controversial recommendations, announced four years ago, were largely based on nutritional requirements for bone health. Most vitamin D experts agree that the IOM’s guidelines are woefully low with regard to vitamin D and way too high concerning calcium. Moreover, the intake of magnesium and vitamin K2 (vitamin D co-factors) was not addressed by this IOM panel.

According to the Vitamin D Council, if you are lactating and taking 6,000 IU of vitamin D daily, your breast milk should have enough vitamin D for your baby. If you are taking less than 5,000 IU of vitamin D a day, you should give your baby a daily vitamin D supplement (quality vitamin D3 drops are widely available).

Daily supplementation guidelines for babies include:

Vitamin D Council: 1,000 IU (Upper limit: 2,000 IU)
Endocrine Society: 400-1,000 IU (Upper limit: 2,000 IU)
Institute of Medicine: 400 IU (Upper limit: 1,000-1,500 IU)

Why risk pregnancy and neonatal complications? Vitamin D supplementation is a safe, inexpensive, and effective approach to a smooth pregnancy and birth of a healthy baby.

**This article is a companion post to “Improving Male and Female Fertility with Vitamin D”.

Editor’s Note: Susan Rex Ryan is an award-winning author who is dedicated to vitamin D awareness. Her extensive collection of health articles can be found on Hormones Matter as well as on her blog at smilinsuepubs.com Follow Sue on FB “Susan Rex Ryan” and Twitter @vitD3sue.

This post was published previously in December 2014.

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