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PCOS with Elevated Androgens...How to Proceed?

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 5-10% of women of reproductive age.

PCOS is characterized by irregular menstrual cycles, scanty or absent menses, multiple small cysts on the ovaries (polycystic ovaries), hirsutism, and infertility. Many women also have insulin resistance, acne and weight gain. A diagnosis of PCOS can be made when two or more of the following criteria are met: reduced or no ovulation; clinical and/or biochemical signs of excessive secretion of androgens; and/or polycystic ovaries.

PCOS poses significant risks to a woman's health. The hormonal and menstrual irregularities that define PCOS put women at risk for infertility. The continuous endometrial stimulation resulting from unopposed estrogen also increases the risk of endometrial hyperplasia and may increase the risk for endometrial cancer. Although not a part of the diagnostic criteria, it has now been well established that hyperinsulinemia and metabolic syndrome are also frequently associated with PCOS. As a result of these factors, women with PCOS have an increased risk for Type 2 diabetes and cardiovascular morbidity.

Salivary hormone testing should be part of any PCOS diagnostic workup as it will give you information about ovulation and androgen levels. When saliva samples are collected during the luteal surge (days 19-21 of a 28 day cycle), you can determined whether or not your patient is ovulating by looking at progesterone levels. (Below range progesterone = anovulation.) Also, elevations in testosterone and/or DHEA are consistent with PCOS

So you have been diagnosed with PCOS. How do you proceed? If your androgen levels are elevated, the best course of action is to explore howyou metabolizes glucose and insulin. A fasting glucose and insulin test can give you some information, but a 2 hour insulin glucose tolerance test (IGTT) is more sensitive. According to Leon Speroff MD, author of the textbook Clinical Gynecologic Endocrinology and Infertility, "all anovulatory women who are hyperandrogenic should be assessed for glucose tolerance and insulin resistance with measurement of 2-hour glucose and insulin levels after a 75g glucose load."1

Insulin resistance/hyperinsulinemia is present when:

Fasting glucose is elevated (>99 mg/dL)

Fasting insulin is elevated (>20 µIU/mL)

2 hr. insulin (on IGTT) is elevated (>27 µIU/mL)

Insulin resistance/hyperinsulinemia is suggested by:

Fasting insulin >10 µIU/mL

Reduced fasting glucose/insulin ratio <4.5

Insulin level at 2 hours is 5x or greater than the fasting insulin level

Insulin resistance plays a predominant role in many cases of PCOS. When this is true for you, focusing treatment on the insulin resistance will be the key to bringing down androgen levels. The favorite allopathic treatment for PCOS is Metformin which suppresses glucose production in the liver, and enhances glucose uptake and utilization in muscle and fat cells. Metformin has been shown to give a 13% improvement in insulin sensitivity. Interestingly, higher Vitamin D status has been correlated with 60% improvement in insulin sensitivity. (Clinical trial using 1332 IU/day vit D for 30 days in 10 women with type II diabetes improved 21 %)2

Consult with your health practitioner before starting any program.

  

References:
1. Speroff, Leon, MD and Fritz, Marc A. MD. Clinical Gynecologic Endocrinology7 and Infertility. 7th ed. Lippincott Williams & Wilkins. 2005. (p.491)
2. Alternative Therapies Sept/Oct 2004 vol. 10, no 5



 

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The Canary Club is an educational advisory group with a team of medical advisors headed by Richard Shames, M.D.