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Melanie Cole (Host):  Welcome. I’m Melanie Cole and today we’re speaking to Dr. Gregory Christman. He’s a J. Wayne Reitz Professor of obstetrics & gynecology and Reproductive Biology and the Director of the Division of Reproductive Endocrinology and Infertility at UF Health Shands Hospital. We’re discussing the required characteristics and criteria to establish a diagnosis of polycystic ovarian syndrome. We’re going to address the various options available to address infertility secondary to poor or absent ovulation in women with PCOS and offering advice to best deal with the nonreproductive impact of PCOS on one’s health.  Dr. Christman, it’s such a pleasure to have you with us. Explain a little bit about polycystic ovarian syndrome. Is it a gynecological or an endocrine disorder?

Gregory Christman, MD (Guest):  Well to answer your question, it’s actually both. Okay. Most people are familiar with it based on what type of doctor they need to see. So, in the medical endocrine world, they embrace it as their disease and gynecology we embrace it as something that we have to help patients with. But in reality, it’s just a concern for the patient that sometimes has different presentations at different times of their lives.

Host:  So, is this pretty common in young girls? Is there a genetic component to it? Tell us a little bit about what we know that causes it and what other providers should be aware of as far as conditions that may mimic PCOS and list associated physiologic causes and alterations with this common condition.

Dr. Christman:   Well polycystic ovarian syndrome is incredibly common. Perhaps 10% of the population has some evidence of it if you look carefully. Fortunately most people it’s much less common to have a severe presentation with this. But in reality, when 10% of the population has something; it’s almost as if you are saying that being left handed is a concern because 10% of people are left handed. Polycystic ovarian syndrome has some characteristics and it’s important to remember that the name is that this is a syndrome.

It's not a disease. There probably are multiple diseases that can fall under this label of having polycystic ovarian syndrome. So, one of the first things we tell patients is it’s not all the same. I need to see what’s causing your PCOS because PCOS is just – is sort of a vague label and really to address the people’s needs, you really need to sort of focus on what exactly is the pathophysiology.

But to keep it simple, there’s a very common definition of polycystic ovarian disorder and what it is, it is stemmed from a meeting that was held in the Netherlands many, many years ago where the doctors who were studying this and taking care of patients decided that they really needed to come up with some criteria. So, the criteria now to be labeled as having polycystic ovarian syndrome is you have to have two of three things. You need to have one, symptoms of irregular menstrual cycles. So people who have regular 28 day cycles like clockwork probably do not have PCOS.

The second thing that you need to have is some evidence that your androgens or testosterone level are higher than what they should. And this could be as simple as someone just telling you geez, I think I have acne more than my friends or I have a little bit excessive hair growth on different parts of my body. And the third criteria is if you have an ultrasound done that you see multiple follicles more than 12 on either the right or the left side to have what we call a polycystic ovarian appearance. Hence the name, polycystic ovarian syndrome.

But there are many people who have normal ultrasounds who – you need two of the three. So, in that regard, it’s a group of symptoms and then the challenge to the doctor is to figure out what is underlying this cause and that’s how you really can sort of decide on the appropriate treatments for whatever the patient needs at the time.

Host:  Well you mentioned ultrasound. Are there other lab tests that are performed? Because the diagnostic criteria are controversial and a little bit and so tell us a little bit about that and why it’s difficult to diagnose.

Dr. Christman:  Okay I wouldn’t really say that the criteria are controversial. But I would have to admit that the definition that’s used in common practice or in the literature or in the newspaper is somewhat vague. The use of ultrasound is optional and there is no really specific lab tests. I think this is important for doctors to remember because sometimes we’re just looking for one test as physicians to document or confirm things. This is not a disease or a condition that where you have an ah ha moment, this laboratory test documents this. This is something you need to talk to the patient and say you have this constellation of symptoms where all these things are going on at once and now, I need to figure out what the cause is. So, ultrasound isn’t required and there’s really no specific lab tests. The reason why you would do lab tests is when you suspect that the person doesn’t have in this common condition because of other things you observe as a physician.

An example would be if someone was incredibly tired which is not part of the syndrome, then maybe they are hypothyroid. If someone has conditions where you think that these androgen symptoms are simply far too excessive; you might want to order an ultrasound or get a testosterone level to sort of narrow things down. But in reality, this is not something that’s a complicated diagnosis to make. It can be made even by the patient themselves by just applying the criteria that I mentioned.

Host:  Well thank you for clearing that up. So, let’s talk about treatment and is treatment different if a woman is trying to get pregnant or done with her reproductive years? Give us some of the options available for treatment.

Dr. Christman:  Well when it comes to treating patients with PCOS basically people generally have one or two things that they would like assistance with. One of the common reasons for presenting to a doctor is that having irregular cycles and a history of not being able to conceive in a reasonable amount of time which for most patients that’s immediately but in medicine we usually feel like someone should have a chance to get pregnant within six months to a year. People present with either subfertility or the other concern people present with is increased acne or facial hair growth. And the treatment for those are exactly the opposite. Because when someone is having one or two menstrual cycles a year and only ovulating perhaps once or twice a year; by definition, it’s going to be harder to get pregnant because most women get thirteen opportunities a year to get pregnant and here, you are getting only one or two cycles or perhaps you are not even ovulating at all. So, the treatment to help women conceive is medicines to help them ovulate. When people have excessive hair growth or acne the opposite is true and usually the ovary is making too much testosterone or androgen, so you normally put them on pills, the most common one is birth control pills to just keep the ovary quiet so that the symptoms of excess testosterone go away.

So, the treatments depend on what the patient wants, and you can’t treat both unfortunately and the technology to help people conceive with medicines has really advanced tremendously in the last seven years and many of these advancements I was fortunate enough to participate as one of the key authors on several trials that the NIH did to help women conceive with this condition.

Host:  Is there an issue with complications if it’s left untreated, if young women have those diagnostic criteria, maybe they’ve self-diagnosed or maybe they’ve seen their OBGYN. Are there any complications you’d like them to be aware of if there is not treatment available?

Dr. Christman:  Well generally, fortunately, the answer is most of the time people live a full and health life with this condition because it’s so common. Like anything that’s going on, sometimes this condition can be associated with an increased incidence of developing diabetes, sometimes people do not ovulate on a regular basis and if this continues for years and years and years without treatment, sometimes that might predispose to precancerous conditions of the endometrium. But I always remind my patients that these consequences are incredibly rare, easy to look out for and even if they are noticed; are generally fairly easy for the doctor to treat and have people keep doing the things that they enjoy with very few reasons to show for a doctor.

So, like most patients, when they ask what do I really need. They really don’t need anything different than other patients other than a physician who is keeping an eye on them and addressing whatever needs they have at the time and if they are doing fine, they are doing fine.

Host:  Are there any effective lifestyle changes in the treatment of PCOS?

Dr. Christman:  There are. Okay. And again, the thing that I mentioned earlier is that there’s different versions of PCOS. One of the things that was very confusing at least when I was in my training many, many years ago; is that you would have wise faculty members pointing at patients and saying see that person has PCOS and another person who has PCOS. And at the time, as a naive medical student or resident, I’m going like well they look completely different. One person seems to have diabetes and concerns controlling their weight and the other person is thin as a rail and has none of these issues. How can they both have the same condition. And that’s because some people with PCOS it’s caused by how the brain communicates to the ovary. And in other people, who have concerns with their weight or increased facial hair growth; sometimes that’s due to a problem where they don’t use insulin efficiently and, in those patients, sometimes lifestyle changes are advantageous. So, certainly patients who have difficulty with weight gain and prediabetes; those patients can have benefit with exercise and weight regiment plan to keep their weight controlled or to lose weight.

So, again, all these treatments have to be individualized. So, if someone comes in and says my patient has PCOS, what do they need? I can never answer that question unless I ask more questions like what else is going on in their lives? What have you seen? What’s their weight? What are they doing? What are the kinds of problems they’ve had? So, it takes a conversation to really take care of patients with PCOS. Specific lab tests or labels aren’t really too helpful. You really have to engage the patient and figure out what exactly is going on and hear their story.

Host:  Well thank you for that answer. Very comprehensive and I’m glad that you made that point about how individual it is. As we wrap up, Dr. Christman, please tell us what other providers can expect after referring a patient to the gynecology team at UF Health Shands Hospital and what you would like them to know about PCOS, diagnosing their patients, helping them with these symptoms and what you can do for them at UF Health Shands Hospital.

Dr. Christman:  Well, one of the big advantages of sending your patients to UF Health Shands Hospital is that one of the concerns I guess in doctors sort of treating this condition is that they made perhaps tings more complicated or more risky than what they should be. One of my great passions in life is – and part of this is from having relatives because sometimes this does run in families with the same condition. When people have difficulty conceiving; at one time I took a big interest like how could we actually make these things work better so that people didn’t need complicated fertility therapies?

So, one of the things that we are very well-known for in the area and I was fortunate enough to be involved in the original NIH trials that pioneered the use of letrozole which is a very simple inexpensive medicine, costs perhaps $4 per dose and yet it really changed how we take care of patients because it’s 40% more effective, no side effects and the biggest complication of fertility therapy in young healthy women is if it works too well and they get twins. And letrozole cut that rate in half.

So, when it turned out that it was more effective, less risky and no side effects; shortly after we did the study which was published in the New England Journal of Medicine; it became the standard of care five years ago. And now there are so many patients who conceive with this very simple, inexpensive treatment who never get to all these advanced stages of treatment. So, my advice out there for someone with PCOS is that if you are just starting your therapy and you have trouble conceiving; you need to start with something very simple because the world has changed a lot in the last five years and these things are now effective or perhaps a decade ago, if people aren’t paying attention; have now made simple things actually effective where perhaps if you are still practicing old time sort of reproductive care; it would seem that people would need very expensive therapies like IVF which we usually find there’s a place for that, but that’s not how you start. The simple things really work really reasonably well.

Host:  Well that’s a great ending. Thank you so much Dr. Christman for coming on and sharing your incredible expertise in this pretty common condition. Thank you so much. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates please follow us on your social channels. I’m Melanie Cole.