Please know these are my own notes, except where noted that I was copying from a handout. My personal opinions and thoughts are not included, just the information given by the doctors and speakers at their presentations. If you have questions on anything here, something you think I may be able to clear up... please feel free to email me! Winna
PCOSupport Oregon - 2001 Northwest Regional Symposium
September 22, 2001Opening speaker: Dr. Phillip Patton, Reproductive Endocrinologist (Portland, Oregon) "PCOS and the Female Reproductive System"
Stein & Leventhal - 1935 - four original criteria: hirsutism, obesity, polycystic ovaries, infertility cystic ovaries: one could have up to 100 cysts filled with androgens hirsutism: certain ethnic groups have no excess hair growth (Asian, American Indian...) 25% of normal ovulatory women have ovarian cysts but not PCOS Hyperandrogenemia - Dr. Patton’s criteria: <8 *ovulatory* cycles per year increased androgen production To diagnose ovulatory irregularities: irregular cycles low serum progesterone (<5 ng/ml produced after ovulation) as little as .3 degree rise in BBT LH kits negative Endometrial biopsy: proliferative (grows without progesterone) To define *ovulatory* cycyle: the growth AND RELEASE of an egg, followed by menstrual cycle +/- 14 days later There is a hirsutism scale doctors use (didn’t get the name of it) Patient scores points 1-4 depending on degree of hair growth (1 being sparse and 4 being coarse, dark, covering a larger area) Score >9 gives diagnosis of hirsutism High androgens: cause acne or hair loss (more acne than hair loss in PCOS women) Biochemical Testing: total testosterone - (this changes amongst doctors... last week it was free testosterone, this week it’s total testosterone... assays are variable)?!?! Dr. Patton’s *must have* tests to rule out other problems: TSH - rules out hypothyroidism Prolactin - rules out hyperprolactonemia 17-hydroxyprogesterone - rules out adult onset adrenal hyperplasia (there is usually a family history of it) but a very important test to have Free Testosterone - PCOS Women have significant risk of NIDD aka Type II Diabetes Obese PCOS Lean PCOS IGT 35-40% 5% NIDD 10% 2% (IGT = Glucose Intolerance) (NIDD=Non-Insulin Dependent Diabetes) We need periodic testing! (to catch diabetes in the earliest stages) Majority of PCOS women have increased insulin to control glucose (hyperinsulinemia aka IR) Glucose Homeostasis - glucose absorption - glucose production - glucose utilization Insulin Resistance: Increased insulin leads to decreased IGF-BP-1 and decreased SHBG which leads to increased IGF1, IGF2 and increased androgens *SHBG - sex hormone binding globulin (insulin decreases it, which results in increased androgen) Decreased SHBG leads to increased Free Estrogen, which results in abnormal bleed which leads to 3 times the risk of ECa (endometrial cancer) Long Term Risks of IR: Hypertension (7 times the risk) Dyslipidemia (lipid profile) Impaired Fibrinolysis Type II Diabetes Endometrial Cancer Cervical Cancer IR - significant cardiovascular risk!! (**Heart Disease is the #1 killer of women**) *Weight loss is key in reducing and reversing IR (even tho it almost always comes back... people can’t seem to sustain the regulated diet) *insulin sensitizers - Metformin has the safest track record so far *chiro-inositol - INSMED - looks encouraging! PCOS women have 1½ -2 times the risk for miscarriage... the cause? not sure - maybe IR (Metformin is Type B medication, presumably safe for pregnancy but we just don’t know yet) *PCOS women have increase risk for Gestational Diabetes *PCOS women have increase risk for Pregnancy Induced Hypertension *PCOS women have increase risk for Low Birth Weight babies Therapy Goals should be: Lower Androgens Lower risk for ECa Lower Insulin Lower lipids Lower weight To control androgens: * Birth Control pills are easiest way but won’t reverse androgen production, just decrease it * Antiandrogens To help lower risk of ECa: * Birth Control pills * Progestins (commonly Provera - brings on bleed but has no effect on androgens) * Ovulation Induction To test Insulin: Lipids Fasting Glucose/Insulin ratio 2 hr Glucose Metabolic Testing: Fasting Glucose/Insulin ratio <4.5 2 hr Glucose <140 normal > 140-199 = IGT > 200 = Type II Annual testing you need if abnormal results or if weight increase (or no weight loss) would be: blood, fasting glucose, lipids (If you lose weight and keep it off, testing doesn’t need to be done as often)~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Session 1 - Strategies for Making a Lifestyle Change Dr. Shannon Braden, Naturopathic Physician
Naturopaths have to go through 4 years of med school just like doctors. Their focus is on diet/lifestyle/herbs/homeopathy. IR can be controlled by diet & lifestyle * weight control * exercise - even if your weight doesn’t go down, exercise 3 x/week will help IR (cortisol and serotonin levels down) * diet - Zone is tailored to PCOS women a tip to remember at meals, the size of your palm should be the amt of protein you have and the size of your fingers should be the amt of carbs non-fat usually means high carb! avoid saturated fats - animal products, margarine, cheese, ice cream avoid deep frying foods - the oil breaks down and becomes carcinogenic avoid hydrogenated oils - never use or buy margarine! Substitute olive oil for butter when possible ideas for protein: lean meats, fowl, fish, chicken, turkey ideas for fats: nuts (except peanuts), seeds, olive oil ideas for carbs: whole grain (avoid processed) enriched means it’s processed then they spray on vitamins (B12) Protein Powder is a great source of protein - have it in the morning (soy or rice milk with some fresh or frozen fruit) Genisoy is one of her favorite brands If you want fruit, have it with protein (in the protein shake is her recommendation) Supplements are good because our diets stink and food isn’t always organic but the supplements have to be absorbed for it to be any good (many over the counter vitamins aren’t!) You can test your supplements by placing a pill in a small cup of vinegar, if the pill isn’t dissolved within 30 minutes, it’s not being absorbed into your system. Vegetables - fresh whenever possible! Frozen is next alternative. Never buy or eat canned (it’s been processed and overcooked, the nutrients are gone) Soy - phytoestrogens (estrogen-like properties but not exactly estrogen) Get only organic soy and non-genetically modified Sugar substitutes are *terrible* Stevia is the exception because it’s from a plant Type II Diabetes is just sustained IR fiber - can lower insulin - -vegetables (dark green leafy), fruit (apples), oat bran, silium seeds, beans - if you use a fiber supplement, always follow it with 8oz water!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Session 2 - Fertility Awareness Method - Rose Fuller
Men are generally fertile all the time There are observable and recurring signs of ovulation Cervical Mucous is produced as a woman’s body prepares for ovulation A woman is fertile several days prior to ovulation, the egg cell lives 12-24 hours or up to 5 days if good cervical mucous is present! Therefore, there could be a 5-7 day window of fertility. (charts showing men’s system, LH and FSH are basically level and steady throughout their month while women’s LH, FSH, estrogen, and progesterone are a roller coaster throughout the month, all up and down at different times...) (chart showing cervical mucous differences - infertile is thick and barrier-like while fertile is thin, ladder-like that guides sperm through) Progesterone: 1. prevents ovulation 2. rise in temperature and stays elevated if pregnant 3. mucous plug (becomes dense) 4. lining (becomes lush) Tissue Exam: wipe with clean dry tissue, front to back - if it *glides* then you look for stickiness, stretchiness, white in color... Things to look for and chart: [letters in brackets is their code for charting] dry [0] sticky [M] (possibly infertile time, doesn’t *glide* but stickiness is less than 1", it could be white or opaque egg-white [EW-M] (most fertile sign!, it’s the most supportive to the sperm, ovulation is to come, stretches 1" or more, color is clear vaginal sensations: dry or itchy [d] secreting moisture [mM] teardrop feeling or feeling of bubbles bursting lubrication [L] slippery/runny/wetness Temperature: men are monophasic - 1 level women are biphasic - 2 levels best before 7:30am +/-45 minutes is okay best if unaffected by other things (no shower, no aerobics, no caffeine) use basal or digital thermometer (digital takes one extra minute) don’t use ear thermometer take temp orally 5-8 minutes A constant in most women: it’s 2 weeks from ovulation till next cycle, the thing that varies is the beginning of your cycle (meaning if your cycle is 24 days long or 48 days long, it’s still usually just 2 weeks from ovulation till the next cycle, it was the length prior to ovulation that was different) They consider cycles 23-39 days typical or normal Ovulation can occur within 3 days *before* or *after* peak day! You could still have mucous in the second half of your cycle but it would be the sticky kind, not the EWCM... or you could be dry Chart of symptoms and possible problems: >98.3 degrees for the first 3 days - could be a sign of endometriosis <97.0 degrees - could be sign of hypothyroid erratic, shallow or short luteal phase - could be sign of infertility, low progesterone, hormone imbalance, risk of miscarriage limited mucous - could be a sign of hormonal imbalances, low progesterone premenstrual bleeding, spotting, tail-end brown bleeding for > 1 day - could be a sign of low progesterone production Their website: www.nwfs.org Handout: Basics of Natural Family Planning 1. Natural Family Planning consists essentially in the knowledge called "natural fertility awareness" together with sexual union during the known fertile time to conceive a child, and complete abstinence during the known fertile time to avoid pregnancy. Method effectiveness is 99% 2. The woman releases all the eggs for a given cycle during one 24 hour period in that cycle, about two weeks before menstruation. Usually only one egg is released (single ovulation), and once it is released, hormones from its former housing work fast to prevent other eggs from being released: within 24 hours no further ovulation is possible. 3. Once released, an egg dies within 24 hours if not fertilized by a sperm. There is no known way to pinpoint the exact moment of ovulation, but there is a way to know that a possible ovulation may be approaching. This is the woman’s observation of the cervical mucus at the vaginal entrance. 4. Sperm need favorable cervical mucus in order to survive in the woman’s body. Sperm viability (ability to fertilize) is dependent on the quality of the cervical mucus. When good fertility mucus is present, sperm can live from 2 to 5 days. 5. Dry days prior to the start of mucus are a sign of relative infertility. The cervical mucus secretion is a sign of fertility, and the change back toward dryness, with a sustained temperature rise is a sign of infertility. 6. Couple fertility depends on ovulation, cervical mucus, and genital contact. Without an egg, conception cannot occur; without satisfactory mucus, sperm cannot get to the egg; without genital contact no sperm is present to fertilize an available egg. 7. Pregnancy can result from mere contact of sexual organs on fertile days -- without penetration or ejaculation, and even though contraceptive devices be employed. 8. Successful Natural Family Planning depends on: a. Thorough instruction with regular follow-up by qualified NFP Providers (reading a book is not sufficient) b. Understanding the significance of the various signs of fertility and infertility (primarily the temperature, cervix, and cervical mucus signs). c. Daily charting (relying on memory does not work). d. Accurate observation (paying attention to the signs). e. Mutual motivation (the safety, reliability, and moral value of natural family planning must be understood and truly chosen by both husband and wife). f. Loving cooperation (natural family planning is much more than a method of birth control - it is a way of life). Northwest Family Services 4805 NE Glisan Portland OR 97213~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Session 3 - "PCOS Teen" - Heather Lubinsky
Girls should not have long-lasting acne in school! Cyclic acne is normal but long-lasting says something is wrong! After 1st year of menses, if cycles are still irregular, something could be wrong (irregular during the first year is probably okay) Remember to the teen girl something like feeling different could be earth-shattering! On-going battle - should the teen go to a Pediatric Endocrinologist or a regular Endocrinologist *Prioritize your symptoms before your doctor’s visit - list 5 things you want to treat (in order) and discuss them with your health care provider~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Session 4 - "Natural Approaches to Treating PCOS" - Dr. Kimberly Windstar
Handout: Covering the basics What is PCOS? Polycystic Ovary syndrome is an endocrine (hormonal) disorder It affects between 5 -10% of all women of childbearing age (includes teens!) regardless of race or nationality Symptoms usually present themselves during puberty but may also begin in the early to mid 20’s Certain symptoms are life long, the others will cease at menopause Primary Characteristics: Clinical Presentation - Hirsutism, anovulation, acne, amenorrhea, oligomenorrhea, menorrhagia (excessive bleeding), normal menses, obesity Causes: Over production of androgens (testosterone) Women usually produce 50% of testosterone in ovaries and 50% in adrenal glands. Pcos patient make most of their testosterone in ovaries Over production of LH from the pituitary gland (direct result of anovulation) and decreased to normal FSH (direct from estrogen dominance) Inability to process insulin effectively = Insulin Resistance or Hyperinsulinemia Effects: Increased insulin leads to - increased ovary production of testosterone (some say it is the opposite - increased Androgen production leads to increased insulin production) obesity (approximately 50%) low blood sugar Type II Diabetes glucose deposited into cells as adipose (fat) High testosterone levels lead to: high levels of LDL which is commonly termed the bad cholesterol decrease your levels of HDL which is the good cholesterol increase your risk of cardiovascular disease and your coronary risk ratio infertility or subfertility due to the hormonal imbalances preventing regular ovulation anovulation with oligomenorrhea (irregular menses), amenorrhea, menorrhagia (decreased ovulation can lead to infrequent menstruation. This irregular shedding of the uterus lining can increase the chances of producing abnormal and cancerous cells and endometrial hyperplasia) Anovulation with an otherwise regular menstrual cycle Obesity: Increases insulin resistance Increased peripheral conversion of testosterone (causes increased estrogen) Increased storage of estrogen Increases testosterone which leads to increased free fatty acids (lypolisis) Both these inhibit liver excretion of insulin and add to hyperinsulin condition Diagnosis: Often missed Many of the symptoms of PCOS are often considered unrelated Women often complain to their Dr about one symptom at a time and the treatment is usually given for that symptom Good history is important There is no single test for PCOS Diagnosis is dependent upon the knowledge and skills of your doctor Physical exam: Androgen symptoms - acne, hair growth (face, umbilicus, chest, abdominal, buttocks, thighs), deepening of voice, increased muscle mass, clitoral hypertrophy, menstrual irregularities, Frontal-temporal balding Hip to waist ratio > 0.8 (apple shape) Gyn exam with bimanual of ovaries Cardiovascular (lipid panel) exam > 30 yr or Hi BP Dexa (bone scan) for those with anovulation of > 6 mo Basal Body Temperature Pelvic ultrasound for endometrial hyperplasia, ovary size and cystic properties Endometrial biopsy (to rule out hyperplasia) Hormone levels: Free Testosterone DHEAS (if high, it’s a sign of adrenal producing testosterone) Androstenedione (high testosterone = ovarian hyperandrogenism, high DHEAS = adrenal hyperandrogenism Estrogen, FSH, LH, prolactin, TSH Levels of LH (luteinizing hormone) or an elevation in the ratio of LH to FSH (follicle stimulating hormone) Lueteal progesterone - on day 21 of cycle should be higher in 2nd half of cycle, if not, *that cycle* was anovulatory OGITT - glucose/insulin ratio of <4.5 fasting (with carb load instead of drinking glucose) Risks: IR, Diabetes, Lipid, Cardiovascular, Endometrial Cancer, Breast Cancer [end of handout] [begin notes from her presentation] weight loss - even a 5% decrease in weight will help significantly weight loss will: decrease free testosterone by 30% decrease insulin improve insulin response by 130% lowfat/low calorie diet - RE: "Eat Right for Your Type" diet - she has not seen one case where it wasn’t successful for an O Type blood!! Diet: protein - lowfat animal protein (chicken, turkey breast, fish, some red meat is okay for O Type blood) decrease simple carbs & sugars (eat low glycemic) fruits & vegetables - 6-9 servings/day low calorie diet leads to 2X increase in SHBG, which ties up androgen and renders them inactive, which leads to a decrease in insulin Supplements: fiber - increases insulin sensitivity and decreases gastric emptying, reduces nutrient absorption which results in decreased insulin secretion Flax Seed - phytoestrogen/adaptogen - improves circulatory hormones and increases SHBG (*ground* NOT the FlaxSeed Oil) Fish Oil - Omega 3 Fatty Acids (*should have Vitamin E in it!) - enhances insulin sensitivity, increases thermogenesis (weight loss), decreases body fat deposition, is an anti-inflammatory, and improves glucose clearance Chromium picolinate - assists in fat and cholesterol metabolism (GTF is okay too) Vitamin C - balances blood sugar, increases insulin sensitivity Soy - isoflavones - genistein & diadzein (sp??) - adaptogenic - bind estrogen receptors - modulates SHBG - inhibits 5-alpha reductase - increases HDL, decreases LDL, VLDL, TG Herbs - - Urtica Dioica - Stinging Nettles - increases SHBG - Serenoa Repens - Saw Palmetto - widely used for BPH and reduces androgens and estrogens - Green Tea - increases SHBG -Tincture - progesterone effect: - caulophyllum (blue cohosh) - dioscorea (wild yam) - fenugreek - smilax *vitex is very controversial Exercise 20-90 minutes/day Lifestyle: ALL of these overload the liver: Alcohol Smoking OTC medications Caffeine [after the session, I asked her opinion of using Natural Progesterone Cream] Natural Progesterone can be great to treat symptoms but if you have hyperplasia or something going on with the endometrial lining, oral progesterone is better (dose is stronger and more accurate)~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Closing Speaker - Dr. Andrew Ahmann, Endocrinologist
Insulin - made in pancreas from the beta cells - helps glucose get into tissues (as energy) - prevents liver from over-producing glucose Insulin Sensitivity - ability of insulin to lower circulating glucose IR = low insulin sensitivity IR is inherited and acquired (environmental) inherited meaning from genetic influences acquired meaning from inactivity, overeating, aging, medications, hyperglycemia, elevated FFA’s (Free Fatty Acids) Studies have shown people with IR who have *normal* beta cells generally don’t develop diabetes, but people with IR who have *abnormal* beta cells generally get diabetes over time. [I asked the doctor after the lecture how one would test if their beta cells were abnormal or not... he said it wasn’t possible, I think he said it’d be too costly] IR is the tip of the iceberg - below the surface can be: central obesity high lipid profile high PAI-1 cardiovascular disease atherosclerosis Type II diabetes hypertension IGT AN There was a 33% increase (in the United States) in adults with diabetes from 1990 to 1999. Diabetes is affecting people younger than ever before.
