polycystic ovaries

Why is PCOS so Common?

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Lara Briden ND

We are in the middle of an alarming trend. More and more women are being diagnosed with polycystic ovarian syndrome (PCOS), an endocrine disorder that causes irregular periods, acne, hair loss, and hirsutism.

The disorder is not new, but it is increasing at a dizzying rate. Two decades ago, PCOS was infrequent amongst my patients. Today, I see it all the time. Polycystic ovaries are estimated to now affect close to one in five women, with an even higher incidence in teenagers. What is going on?

Insulin Resistance

A big part of the problem is insulin resistance which is is the hallmark condition of our modern age, affecting 1 in 4 adults. Insulin resistance is the result of too much sugar (concentrated fructose) in our diet, as well as smoking, obesity, trans fat, stress, and environmental toxins. Untreated, insulin resistance can lead to diabetes and cardiovascular disease.

Insulin resistance is estimated to affect between 50-70% of PCOS-sufferers [1], and is generally understood to be a major contributing cause of the condition [2]. Excess insulin causes polycystic ovaries because it impairs ovulation and stimulates the ovaries to make testosterone instead of estrogen.

We have an epidemic of insulin resistance, so it makes sense that we also have an epidemic of PCOS. Except that not all PCOS sufferers have insulin resistance, so what else is going on?

Misdiagnosis by Ultrasound

Proper diagnosis of PCOS requires clinical evidence such as irregular periods, combined with a blood test that shows high androgens. There may or may not also be the ultrasound finding of polycystic ovaries, but that finding alone cannot be used to diagnose PCOS. Why? Because polycystic ovaries occur in up to 25% of normal women, and also in many women on on the birth control pill [3].

Would a family doctor or OB/GYN really attach the label of PCOS to a normal woman solely based on one ultrasound finding? Sadly, the answer is Yes in many cases, and that can lead to a lot of unnecessary confusion and heartache. I almost never accept a diagnosis of PCOS at face value. Instead, I order extra blood tests form my patients to confirm that they do have high androgens.

Fortunately, there are calls to rename the condition, and to re-educate doctors about the relevance of the polycystic finding.  According to Dr. Robert A. Rizza from the Mayo Clinic:

“[The name PCOS]..focuses on a criteria—namely the polycystic ovarian morphology—that is neither necessary nor sufficient to diagnose the syndrome. It is time to assign a name that reflects the complex metabolic, hypothalamic, pituitary, ovarian, and adrenal interactions that characterize PCOS.” [4]

Post-Pill Syndrome

There is one more reason for the increasing incidence of PCOS: The Birth Control Pill. In my clinic, I speak to so many women who simply cannot get their periods going again after stopping the Pill. Some of them did not have regular periods before taking the Pill, so, in their case, stopping the Pill has merely unmasked a preexisting problem. Then there are the women who did have regular periods before the Pill, but now they’re gone. For these women, the Pill seems to be a clear cause of PCOS and hypothalamic amenorrhea.

We don’t yet know exactly how the Pill causes PCOS because that research has not yet been done. We do know that the Pill causes insulin resistance, which in turn, causes PCOS [5]. We also know that the Pill suppresses the pituitary-ovarian communication, which of course it’s designed to do, but that suppression is supposed to be temporary. It’s supposed to be temporary, but some women experience an ongoing elevation of the pituitary hormone LH (even in the absence of other PCOS markers such as insulin and androgens). Without treatment, post-Pill LH elevation can persist for months or even years after stopping the Pill.

What to do about PCOS

If you or your patient has been diagnosed with PCOS, then first find out if it was diagnosed by ultrasound alone. If it was, then the PCOS diagnosis is not certain.  Ask for further blood testing to see if there are high androgens, and most importantly: If there is insulin resistance.

When it can be determined that insulin resistance is the cause of PCOS, the best treatment is to eliminate concentrated sugar (desserts) from the diet, and also to supplement nutrients (such as magnesium) that improve insulin sensitivity.

When insulin resistance is not the cause of PCOS, things get a little more complicated. Non-insulin-resistant PCOS is often the result of the Pill (as discussed above), but it can also be the result of other underlying health issues such as chronic inflammation. I explore the natural treatment of PCOS in my new book Period Repair Manual.

References

  1. Ibricevic D et al. Frequency of prediabetes in women with polycystic ovary syndrome. Med Arch. 2013;67(4):282-5. PMID: 24520755
  2. Dunaif A et al. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev. 1997 Dec;18(6):774-800. PMID: 9408743
  3. Clayton R et al. How common are polycystic ovaries in normal women and what is their significance for the fertility of the population? Clin. Endocrinol. 1992 37 (2): 127. PMID 1395063.
  4. http://www.highbeam.com/doc/1G1-323971757.html
  5. Diamani-Kandarakis E et al. A modern medical quandary: polycystic ovary syndrome, insulin resistance, and oral contraceptive pill. J Clin Endocrinol Metab. 2003 May; 88(5): 1927-32. PMID: 12727935

 

 

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PCOS, Pregnancy, Metformin and Vitamin B12 Deficiency

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pcos, metformin, anencephaly

PCOS or polycystic ovarian syndrome is one of the most common hormone disorders in women. It is marked by a triad of symptoms that include: cardiovascular, metabolic and steroid hormone disturbances. Type II diabetes is common in PCOS and Metformin is the drug of choice to treat PCOS – related Type II diabetes.

In recent years, clinicians and researchers have begun to observe vitamin B12 deficiency in Metformin users. First thought to be a short term problem, researchers are now finding that with long term metformin use not only does the B12 deficiency persist, but it grows. Left alone long enough, vitamin B12 deficiency leads to a host of conditions, many that  Metformin was supposed to prevent, including:

For women, especially of reproductive age, B12 deficiency can be particularly troubling, if not downright dangerous. Vitamin B12 deficiency during pregnancy leads to an increased incidence of neural tube defects and anencephaly (the neural tube fails to close during gestation – anencephaly pictured above) . Once thought to be solely related to folate or folic acid deficiency (vitamin B9), researchers are now finding that B12 has a role in neural tube defects as well. Many women on Metformin are coming into pregnancy vitamin B12 deficient.

This is where it gets tricky. Metformin is used in women with PCOS to reduce insulin sensitivity. Metformin also tends to regulate ovulation for PCOS women and was believed to help women get pregnant (though the data here are mixed here as well). Without regular ovulation, conceiving is near impossible and so the fact that Metformin might have helped with ovulation had been seen as a breakthrough for previously infertile PCOS women. Reproductive endocrinologist embraced this new found fertility tool and as one might expect, the requisite studies (read marketing documents) flooded the esteemed peer-reviewed journals to proclaim the benefits of this new wonder drug. No wait, Metformin is not a drug, it’s a new vitamin – Vitamin M.

We now have a drug that is given liberally to women who become pregnant and then continued across the pregnancy. The drug crosses the placental barrier and there are no studies to indicate either its safety or harm to the fetus. The drug causes significant vitamin B12 deficiency, which alone poses great risk to fetal development (neural tube defects) but who knows what vitamin B12 deficiency plus the endocrine disrupting effects Metformin will have on the developing fetal insulin or cardiovascular systems. Are we looking at more transgenerational effects?  Metformin does not prevent maternal gestational diabetes (as was widely speculated) and increases pre-eclampsia, pulmonary embolism and other nasty pregnancy complications.  And yet, the major patient organizations advocate for its use across pregnancy.

Have we learned nothing from thalidomide and DES?  Apparently, not.

 

Photo credit: Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities

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