In honor of American Diabetes Month, we asked Dr. Estil Strawn, Reproductive Endocrinologist at Froedtert and Medical College of Wisconsin Reproductive Medicine Center, to explain the relationship between PCOS, insulin resistance, and diabetes. He shares his thoughts below.
The term polycystic ovarian syndrome, or PCOS, is something that many of our patients come into our clinic with knowledge about. Patients commonly arrive in our clinic with a battery of previously performed laboratory tests only to declare, “all of my tests were normal, so what is my diagnosis?” Sometimes, the diagnosis is PCOS, which is really a diagnosis of exclusion.
PCOS diagnosis
It is up to a doctor to exclude other possible causes of PCOS symptoms, including irregular menstrual periods, excessive facial and body hair growth, with or without acne. These other possible causes include:
- Adrenal gland disorders
- Thyroid gland disorders
- Pituitary gland disorders
- Taking medications that are causing the symptoms
If the lab tests are normal or negative for these disorders, then the most likely diagnosis is PCOS. I like to tell all of our patients that PCOS is really just a fancy medical way of saying that the woman does not ovulate on a regular basis and typically will have very irregular menstrual periods.
PCOS and ultrasound
Some patients will comment that a doctor noted “polycystic ovaries” on a pelvic ultrasound either performed for another reason (e.g. pelvic pain) or upon their request. While the presence of greater than 10 small ovarian cysts on an ovary can be one of the criteria for making the diagnosis of PCOS, it cannot be the only criteria. In other words, a woman with consistently regular menstrual cycles occurring between 25-35 days each month, without any history of excessive facial or body hair, and the incidental finding of “polycystic appearing ovaries” on ultrasound should not be informed that she has PCOS. It should also be noted that a significant number of regularly menstruating women with no history of infertility can have ultrasound findings consistent with PCOS. This brings into question the validity of using ultrasound as the primary tool to make the PCOS diagnosis.
PCOS and diabetes
One of the primary goals of the health care provider, after first ensuring that the most likely diagnosis is PCOS, is to evaluate the general health of the patient. Part of this screening process is to determine if the patient is diabetic or pre-diabetic, often termed carbohydrate or glucose intolerant. Up to 40% of women with PCOS demonstrate some degree of carbohydrate intolerance. While many patients have read or heard about the term” insulin resistance” they need to be aware that establishing an accurate diagnosis of insulin resistance is very difficult and probably not nearly as important as establishing whether or not they are carbohydrate intolerant or not. It is generally agreed upon that all patients with PCOS have some degree of insulin resistance as part of their diagnosis, so confirmation of the diagnosis of insulin resistance via fasting glucose to serum insulin comparisons are not essential. However, patients with the diagnosis of carbohydrate intolerance need to be aware that they are on the cusp of having diabetes and the many associated medical problems associated with diabetes, including heart disease and hypertension.
PCOS and obesity
It is important that obese women with PCOS do the following two things to help achieve weight loss:
- Exercise regularly. Try walking briskly for one hour per day as a starter.
- Maintain a complete and truthful dietary diary for 2 to 4 weeks. Meet with a dietician or nutritional specialist to review possible changes in meal portions or food groups. Make any necessary healthy changes.
Ultimately, our patients need a balanced diet without emphasizing the ever-expanding list of low carbohydrate, high protein, nonfat, or other trendy diet recommendations so often noted on the internet, magazines and infomercials.
PCOS and infertility
Oftentimes patients will get very angry with me and state that they know that they are overweight and they just want to have a baby. They will frequently state that they know people who are much heavier who have had no difficulties having children. Unfortunately, for our patients who are overweight and carry the diagnosis of PCOS, the pathway to having a baby can be much more difficult than for the woman who is overweight but does not carry the diagnosis of PCOS. There is an ever growing body of evidence that shows that overweight women with PCOS will require higher doses of medication to treat their infertility, that they become resistant to some of the less expensive medical treatments and require much more expensive therapy such as IVF. They are at greater risks for miscarriages and birth defects for their children and they are at greater risks for developing serious complications in pregnancy including diabetes and high blood pressure.
PCOS fertility treatments
Here at Froedtert and Medical College of Wisconsin Reproductive Medicine Center we offer a wide variety of treatment options for our patients with PCOS, including:
- Weight loss clinics
- Medical therapy to induce regular menstruation
- In vitro fertilization (IVF)
Ultimately, we are responsible for trying to optimize the health of the mother and the health of her baby.
Estil Y. Strawn, Jr. M.D. is doubly board certified in Reproductive Endocrinology and Infertility and Obstetrics and Gynecology. He is the medical director of the Froedtert and Medical College of Wisconsin Reproductive Medicine Center. Dr. Strawn is also full professor with tenure at the Medical College of Wisconsin where he serves as the director of the division of Reproductive Endocrinology and Infertility in the department of Obstetrics and Gynecology.
Dr. Strawn has been helping patients overcome their fertility problems for 19 years, and has directed a center that is the largest provider of fertility services in the state of Wisconsin. This center provides some of the most advanced types of technologies in the country including pre implantation genetic diagnosis (PGD), egg freezing, egg and embryo donation, gestational carriers, as well as robotic surgery for uterine fibroids and reversal of fallopian tube sterilization.
