Modern Approach to Women with Polycystic Ovary Syndrome

Additional Info

• Audio File:uab/ua162.mp3
• Doctors:Hurd, Bill
• Featured Speaker:Bill Hurd, MD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4128
• Guest Bio:Dr. Hurd has practiced clinical reproductive endocrinology and infertility for over 3 decades at a number of Universities and currently holds the academic ranks of Professor Emeritus of Obstetrics and Gynecology at Duke University School of Medicine, and Adjunct Professor of Obstetrics and Gynecology at the University of Alabama School of Medicine. 
  
  Learn more about Bill Hurd, MD 
  
  Release Date: August 14, 2020
  Expiration Date: August 14, 2023
  
  Disclosure Information:
  
  William W. Hurd, MD, has no financial relationships related to the content of this activity to disclose. Also the planners, Ronan O'Beirne, EdD, MBA, and Katelyn Hiden, have no financial relationships to disclose.
  There is no commercial support for this activity.
• Transcription:UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host):  Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re talking about a modern approach to women with polycystic ovary syndrome. Joining me is Dr. Bill Hurd. He’s a Professor and Reproductive Endocrinologist and Infertility Specialist at UAB Medicine. Dr. Hurd, explain a little bit about polycystic ovary syndrome. Is it a gynecological or an endocrine disorder? Tell us a little bit about it, how common it is, give us a little background on it.
  
  Bill Hurd, MD (Guest):  Yes. Polycystic ovarian syndrome is the most common endocrinologic abnormality in women. It is approximately 10% of all women and so, it’s a common thing that anyone who takes care of women patients is going to see in their practice. It is comprised of two out of three symptoms and or findings and the first of those is irregular menstrual periods. The second of those is increased hair. It could be bad enough to be called hirsutism or it could just be mildly increased hair on the upper lip, chin, chest and lower abdomen. And the final one is polycystic ovary morphology on ultrasound. If the patient has two out of three of those, that is by definition, PCOS as long as there’s not another underlying cause. So, the first thing that we do when we see someone that appears to have PCOS, is look for number one, an underlying cause that mimics PCOS and number two, any of the pathologies that go along with PCOS.
  
  Host:  Well thank you for telling us about the physical findings that would suggest PCOS. And as we’re talking about lab tests and diagnostic criteria; Dr. Hurd, why is this controversial in the medical community?
  
  Dr. Hurd:  I don’t think there is really anything controversial about it. It’s basically a standard thing and it’s got a standard approach to it. I think some people are more concerned about different symptoms that are associated with it. And that’s natural because it depends what the patient came in with that, they want help with. The first thing we do is we do a basic workup on them and looking for other causes, we check standard antigens including testosterone, DHES and 17-hydroxyprogesterone. And we also check just a TSH screen for hypothyroidism. Unless they have obvious signs of congenital adrenal hyperplasia adult onset; we usually don’t test for that. If those are out of the normal range significantly; then we have to worry about tumors of either the ovaries or the adrenal gland. If they are all in the normal range and some are slightly elevated; that goes along with PCOS and as long as they are not hypothyroid. Once we’re sure it doesn’t have an underlying cause, then the next part of the workup is to make sure they don’t have a problem that goes along with PCOS but is associated with it but probably not causal.
  
  The number one, one of those is diabetes which is probably found in about 2% of people with PCOS and an additional 1% a year for as long as the patient has it. people with polycystic ovary syndrome are also prone to have metabolic syndrome which is something that the internal medicine physicians concentrate more on. The things that make that different from PCOS is that the patients are often obese, they have increased lipid abnormalities and they often have hypertension and or diabetes. So, they overlap, approximately half the people with polycystic ovary syndrome have obesity as a problem. But it’s not necessary or sufficient to make the diagnosis of PCOS.
  
  So, those are the kind of tests that we order to make sure that they don’t have other associated things and then we focus on the patient’s concerns to see how we’re going to treat it.
  
  Host:  Well thank you for telling us about the other disorders that could be included in a differential diagnosis of polycystic ovarian syndrome. So, as we’re talking about treatment, Dr. Hurd, how is it treated, speak about pharmacologic treatments and also does treatment differ if a woman is trying to get pregnant or done with her reproductive years?
  
  Dr. Hurd:  Yes. It’s very important to figure out what is bothering the patient, what symptom that’s associated with PCOS that they want to be treated for. And the main ones are irregular periods, hirsutism and infertility. And so the very first question you find out from the patient is are they trying to get pregnant now or are they planning on getting pregnant in the future. If they are not planning to get pregnant right now, then the treatment is mainly focused on helping them have regular menses and decreasing their increased hair. In extreme cases, it can actually have male pattern hair loss which is very distressing to people but that’s not common. More commonly, they have increased hair that they can deal with but is some nuisance on their face and chest and lower abdomen.
  
  The cornerstone of treatment for these people is to decrease free androgens or the androgen effects and that’s done primarily by two medications. The first one is oral contraceptives. The estrogen in oral contraceptives increases sex hormone binding globulin by stimulating the liver and this decreases free testosterone. It also decreases the FSH and LH stimulation of the ovary and so this decreases androgen secretion by the ovaries. The second part of treatment for the more extreme hirsutism cases is to block the androgen receptors directly and the most common drug to use that is spironolactone. It’s a very safe antiandrogen. It has very little risk and very little side effects. The most common side effect we see is if you give it to someone having regular menstrual periods, some of them will become irregular. So, we routinely only use it in people who are on oral contraceptives to keep them regular.
  
  This is also important because it could have negative effects on a developing fetus since it blocks testosterone which is important especially in the development of a male fetus.
  
  Host:  What about lifestyle? Is there any lifestyle changes in the treatment of PCOS? And what would you like other providers to counsel their patients on as they look to some of these treatments?
  
  Dr. Hurd:  The biggest worry to women is that it’s going to make them heavy and hairy. And certainly, more than half of people with PCOS do have problems with being overweight and of course hirsutism is part of the triad. Not only do they have trouble with being overweight, but overweight makes the syndrome worse. Many of these women are insulin resistant and that’s why there are so many diabetics in the group. So, the way to help insulin resistance, there’s two. One is to have them lose weight and the other one is if the patient is either prediabetic or diabetic, then an insulin sensitizer most commonly metformin can help with this.
  
  So, if a woman is overweight, we strongly encourage her to try to lose weight to see if that will help with her insulin resistance. There’s good data to support that insulin directly stimulates theca cells in the ovaries to make more androgens. So, in that group of women, it is not only the effect of PCOS but it’s also a cause of it. Now, it’s not the only cause of PCOS because almost half the women are not overweight, they are slender, and these women aren’t going to turn into heavy women. They have a different cause of their PCOS.
  
  So, if the woman is heavy, the number one thing we say is they need to work on weight reduction which is as everyone knows, a very difficult thing for many women to do. It takes a lot of support. It takes a lot of work on increasing activity, decreasing portion size and decreasing carbohydrate intake. We routinely send our PCOS patients who are overweight to a weight reduction program here at UAB that’s been very effective in helping them.
  
  Host:  Dr. Hurd, is there a role of surgical intervention for treatment of PCOS? Risks and benefits. Speak about that a little bit.
  
  Dr. Hurd:  You know the other group we haven’t talked about yet are people with infertility. It is one of the most common causes of infertility, probably 40% of the women who are having trouble conceiving have PCOS in this population. And so, those people that can’t be treated for their increased hair because those drugs are not good in pregnancy, but the treatment is to get them to ovulate. Most commonly, we can do this with either traditional clomiphene citrate or the commonly used now letrozole which is aromatase inhibitor. So, we try to get them to ovulate. Some of them end up needing in vitro fertilization.
  
  Decades ago, they did a wedge resections on ovaries and more recently, we did ovarian drilling, a laparoscopically cauterizing the ovary and decreasing the androgen output. And this seemed to work okay but it caused adhesions and is not commonly done anymore. So, the answer is yes there are surgical things that can temporarily treat the syndrome, but they are not used commonly because they do cause scar tissue in the pelvis.
  
  Host:  Dr. Hurd, this is such a great topic. And as you said, such a common syndrome that you see. what would you like other providers to know and primary care providers, gynecologists that are seeing adolescents or women in their reproductive years and they’re wondering, the diagnostic criteria. Wrap it all up for us what you would like them to know about referral and diagnosis for PCOS?
  
  Dr. Hurd:  I think most people that have a interest in gynecology and gynecologic problems will want to stay up to date and know the standard diagnostic workup for these patients and the standard treatment. Once it gets to infertility, if they do any kind of infertility, they can certainly use oral medications to induce ovulation and if this doesn’t work send them to an infertility doctor. The only other thing that we haven’t mentioned that’s important is these women are at approximately three plus times as likely to have endometrial cancer in their life related to not ovulating. And so the last thing the gynecologists or primary care doctors should do is allow these women to go months and months without periods. They should be on some sort of contraception that has progesterone in it which is birth control pills, IUDs with progesterone or IUD implants or injections. This protects the endometrium and probably puts them back in the normal risk for endometrial cancer.
  
  So, if they’re not able to follow patients with this kind of thing then they definitely should refer them to either an interested gynecologist or a reproductive endocrinologist.
  
  Host:  Thank you so much Dr. Hurd. Fascinating information. Thank you again for joining us. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.
• Hosts:Melanie Cole, MS