Polycystic ovary syndrome (PCOS) is one of the most common gynecological conditions, and also a frequent cause of infertility. In this podcast, Perspectives’ Sharon Eisenhour talks with Talia Maas, MD, an OBGYN in the Einstein Healthcare Network, now part of Jefferson Health, about the symptoms, diagnosis and treatment of PCOS.
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Welcome to Einstein Perspectives, an ongoing podcast series from Einstein Healthcare Network, now part of Jefferson Health. I’m Sharon Eisenhour. And today I’m speaking with Talia Maas, MD, an obstetrician and gynecologist at Einstein Medical Center Philadelphia. Dr. Maas also sees patients at Einstein Healthcare Network offices in Germantown and Mayfair. Dr. Maas will be discussing polycystic ovary syndrome or PCOS, a common condition among women and a frequent cause of infertility. Well, first of all, welcome Dr. Maas.
Dr. Talia Maas:
Hi, thank you so much.
And the question is, what is polycystic ovary syndrome, also known as PCOS?
Well, PCOS is a very, very common syndrome that I frequently see in the office. Its hallmark or its defining factor is anovulation or irregular periods. It is basically defined by someone who does not ovulate regularly. So while many or most women will ovulate monthly, somewhere between 21 and 40 days, women who have PCOS tend to ovulate less frequently. Sometimes that can manifest as having no periods at all. Or sometimes that can manifest as having two or three periods a year. Sometimes that can manifest as also having just very, very long cycles – so patients that have periods that last anywhere from seven to 15 days. Sometimes I see patients that have periods that last for 30 days. So this syndrome, or this disease, tends to just be a catchall for women who have irregular cycles or irregular periods.
So what causes PCOS?
That’s a great question, because honestly we haven’t really nailed down a cause of PCOS. There isn’t one specific thing. But what we do know is that it’s caused by having a fluctuation or irregularity in your hormones. So basically women who have increased testosterone or increased estrogen or hormones that are not typically found in women that cycle regularly. Typically, these hormones are created in the ovaries, and that irregularity will cause you to have irregular cycles.
There is a connection between obesity and PCOS. So women who have a BMI of greater than 30 or 35 can tend to have more PCOS-like symptoms. Sometimes a reduction of just 5% of your body fat can actually decrease your PCOS and actually bring you back into normal, every-28-day cycles.
What are the symptoms of PCOS? How do you know you have it?
I have a lot of patients that come to me and say, oh, I was diagnosed with PCOS when I was 14. Fourteen-year-olds tend to have irregular cycles, and so many, many young girls are diagnosed with PCOS at a very young age. And as they grow up and mature, they tend to regulate their cycles. Some people get put on the pill when they’re very young. When they get off the pill, when they’re in their late teens or early 20s, they tend to then have regular periods. Those patients do not have PCOS.
Patients that have PCOS, the most defining factor, and what really diagnoses PCOS, is having irregular periods or not cycling between 28 and 40 days. Any woman that has irregular periods should be evaluated by an obstetrician and gynecologist to kind of tease out what is going on because oftentimes it is PCOS, but there are other, more concerning diseases that we’d like to rule out to make sure there isn’t anything else going on.
Can PCOS increase the risk of other health problems?
Yes, and I think this is the most important part of PCOS. Women who do have PCOS have increased risk of having something called metabolic syndrome. Metabolic syndrome is defined by having irregularities in control of glucose, which also puts women at risk for things like diabetes and at that point also things like heart disease. They also have trouble regulating things like cholesterol, and that can also increase your risk of heart disease.
Can you say a little bit more about exactly how PCOS is diagnosed?
So the biggest hallmark of diagnosing PCOS, of course, is when you come to your provider and you say, I have an irregular period. That triggers me to think, well, what’s causing these irregular periods? The first thing to do is to keep a bleeding diary. I always tell patients, humans are not perfect and neither are your periods. Some minor irregularities are expected and that’s okay, but we just have to make sure that your irregularities are not actually a symptom of PCOS or another more concerning finding.
The next thing we do is many times we’ll order an ultrasound. On ultrasound, we can see your ovaries and we can see what actually has given PCOS its name, the typical polycystic appearance of the ovaries. In PCOS you get what we call a string of pearls around the ovaries. And these are small follicles or eggs that are not maturely developed because you don’t have enough of the hormone to ovulate appropriately. So you see this characteristic appearance of the ovaries on ultrasound.
Other things we tend to order are things like lab work to make sure hormones such as your thyroid or another hormone called prolactin are normal, because these are other reasons why you can also have irregular cycles. And probably the most important and the most understated and typically forgotten is just a regular physical exam.
There are other findings in PCOS, such as central obesity – or people that carry their weight more in their stomachs. Some women will have increased hair on their face and on their neck. And another finding, which we call acanthosis nigricans, is a darkening of the skin. Typically, this is on the neck, or under the armpits, or underneath the breast.
What would be the treatments for PCOS?
The most important part of PCOS is the concern that if you’re not having regular cycles, you’re not shedding the lining of your uterus. While most women will shed the lining of their uterus monthly, women with PCOS tend to not shed the lining of their uterus or have a regular period every month. So what this can cause down the line are concerns for developing irregularities of the lining of your uterus. And that could eventually lead to things like uterine cancer when the uterine lining grows and grows and grows and grows, but doesn’t ever have the opportunity to leave or shed or to be excreted from the vagina.
So typically we really would like to protect the uterus or protect the lining of the uterus with things like birth control, IUDs, or other progesterone or hormonal medications, to make sure that that lining of the uterus never really, really grows thick so that your body doesn’t have to shed it.
So typically, depending on other risk factors and other medical conditions of the patients, our first line of treatment tends to be birth control pills, just regular run-of-the-mill birth control pills, combined with estrogen. Or, depending on a lot of other medical problems, we’ll veer towards things like progesterone IUDs or progesterone pills. For women who are really bothered by hair growth, we can add another medication called spironolactone and that medication targets the testosterone and really helps with symptoms of hair growth that really bother some women.
We also sometimes use a medication called metformin. This medication is a medication for diabetes, and that kind of hearkens back to what we were talking about earlier, of women with PCOS having increased risk of having issues controlling their glucose or with diabetes. It’s really important for these patients, not only to be followed by a gynecologist, but also to be followed by a primary care physician to make sure things like their glucose and their cholesterol are well managed to mitigate other future issues of things like heart disease.
So can women with PCOS get pregnant and give birth?
Yes. I mean, PCOS is a very common cause of infertility, but also very treatable. In my practice, I’ve helped many women get pregnant. There are medications that help women to get pregnant by help inducing their ovulation. What I mean by that is we have multiple medications that we can prescribe and walk you through the process of taking the short course of medication, using regular ovulation kits to help predict your ovulation, having timed intercourse with your partner and help you achieve your goal of pregnancy. And then we’d hope to care for you and deliver your baby.
But I will say there is a 5 to 7% increased risk of multiples. So we just have to make sure to always tell patients, are you ready for twins? Because sometimes that’s going to happen.
Eisenhour: What symptoms should prompt a visit to your doctor?
The symptoms in PCOS that would prompt a visit to your doctor would be specifically irregular periods. If you feel like your periods are too long, they’re not frequent enough, they’re coming too frequently, I would say any sort of abnormality in your periods. If you see a deviation from your normal periods, for example, you’ve had normal periods all your life, and suddenly you haven’t had a period for three months, that would be a reason to go to your doctor. If your periods are lasting greater than seven days, are heavy, those would be another reason to go to your doctor.
I think it’s very important to keep a bleeding diary. There’s a lot of different apps available on the market, basically that you mark down how heavy your period is and the day that you’re bleeding. And so that when you come to see the doctor, the doctor can really tease out, is there an abnormality with your period? Because sometimes periods have a wide variety of regular. Another thing is if you have increased hair growth or any of that darkening of the skin, or you’re having trouble getting pregnant, that would all be reasons to come and see your doctor.
Our thanks to today’s guest, Dr. Maas, an OBGYN at the Einstein Healthcare Network. To learn more or to schedule an appointment, call 1-800-EINSTEIN or visit the OBGYN section of the Einstein website at einstein.edu. For Einstein perspectives, I’m Sharon Eisenhour.
Learn more about Obstetrics and Gynecology at Einstein.