Polycystic ovary syndrome PCOS: A discussion with Dr. Fiona McCulloch

By Liz Meszaros, MDLinx
Published July 5, 2016

Key Takeaways

Polycystic ovary syndrome is one of the most common endocrine and reproductive disorders in the United States, with a prevalence ranging between 4% to 12%. Women with PCOS are at elevated risk for other chronic disorders, including diabetes and cardiovascular disease, and therefore, early detection is critical to minimize these risks.

Fiona McCulloch, BSc, RAc, ND, is a board certified naturopathic doctor who has been in practice in Toronto, Canada, for over 16 years. She is the founder and owner of White Lotus Integrative Medicine in Toronto, which is a clinic focused on women’s health and fertility issues.

The editors of MDLinx recently spoke with Dr. McCulloch about some of the different manifestations of PCOS and some of the steps clinicians can take in cementing a diagnosis of PCOS.

MDLinx:What is the current prevalence of PCOS, and why has it garnered so much recent attention?

Dr. McCulloch: PCOS is the most common hormonal condition in women. It’s estimated that around 7 million women in the United States have PCOS, and about 50% of them don’t know that they have it.

PCOS is an ancient disorder, and has appeared in all of the ancient medical writings throughout medical history. It is genetic, but is coming to the forefront of medicine today, and there are a few reasons for this. First is our increased awareness of PCOS. We are able to identify PCOS more easily in patients due to better testing, more sensitive ultrasound equipment, and patients actually recognizing the symptoms in themselves from research. Some of the other factors that may be playing a role might be environmental influences on PCOS, including environmental chemicals such as bisphenol A (BPA); and dietary factors that tend to aggravate PCOS, as obesity and insulin resistance aggravates the condition.

MDLinx:What are the primary signs of PCOS, and what should clinicians be alert for in their patients?

Dr. McCulloch: The most common symptom would probably be a long time between periods or missed periods, any kind of irregular period, but especially those that are far apart. Women with PCOS often experience  delayed ovulation or even anovulation, resulting in a delay of the onset of menses which typically occurs two weeks after ovulation. In PCOS, the follicles within the ovary secrete excess testosterone which actually slows the development of the follicles – these stalled follicles can be visualized on ultrasound – and these are the “cysts” the condition is named for .

Some of the other symptoms you will see relate to the effects of androgen excess including hirsutism or androgenetic alopecia, which in females, presents with preservation of front hairline and there is hair loss directly behind that area; acne, particularly adult acne or acne that persists despite intervention, often hormonal, cystic acne, inflammatory, and often on the jawline; and abdominal adiposity, signs of insulin resistance, or markers of pre-diabetes.

MDLinx:What kinds of diagnostic tests are available for clinicians if they do suspect PCOS in a patient?

Dr. McCulloch: PCOS affects many different aspects of women’s health, and the tests can include metabolic testing, including those we typically run to detect insulin resistance as well as hormonal testing. Although testing for diabetes may be only mildly positive or negative, markers of insulin resistance may be positive, including elevated fasting insulin, or a high homeostatic model assessment insulin resistance (HOMA-IR), which is a calculation involving the ratio of insulin to basal (fasting) glucose. If elevated, this is a sign of insulin resistance.

Another marker that I use quite often is a glucose insulin challenge test, similar to the glucose tolerance test, except insulin is also measured. You’ll often see exaggerated or prolonged insulin responses in women with PCOS.

You will often see, as well, high triglycerides, or elevations in GGT due to fatty liver disease. One of the newer serum markers for PCOS is adiponectin, a protein secreted from the fatty tissue which is a protective marker that is often low in women with PCOS . Low adiponectin levels have been found even in children who later present with PCOS. So it can be one of the early detectors we can use looking at the younger patient population.

Going into some of the reproductive hormonal markers, you will often see an elevated ratio of luteinizing hormone to follicle-stimulating hormone (LH:FSH) on day 3 of the menstrual cycle in women who have regular menstrual cycles, and elevated LH levels can be found across the cycle in women who have irregular menses. Serum androgen markers can be elevated, including testosterone (either free or total), DHEA-S (indicating that androgens are coming, at least in part, from the adrenal gland), and androstenedione.

It is always important to consider that androgens naturally decline during a woman’s lifespan. A testosterone or DHEA-S level that would be considered to be high for a 20-year-old woman would be very different than what would be high for a 40-year-old woman, and most lab reference ranges do not typically reflect this.

On ultrasound (US), you may see the multiple, small follicles that are classic to PCOS. It’s important to consider that these follicles are not required for a diagnosis. According to the Rotterdam consensus, only two of the three criteria for PCOS are required for its diagnosis which are delayed ovulation, either clinical or biochemical signs of androgen excess, or the presence of multiple small follicles on ultrasound .

A newer marker is anti-Müllerian hormone (AMH), which is a biochemical marker that has been correlated to the ultrasound criteria. It is typically a marker of ovarian reserve, but women with PCOS have exaggerated levels because in addition to having a greater number of follicles each follicle also produces more AMH.

MDLinx:How do the manifestations of PCOS change throughout a lifetime, in the teen-aged years, compared to the reproductive years, compared to the post-menopausal years?

Dr. McCulloch: In children with PCOS, there are markers of fatty tissue dysfunction that we can detect. Recently, it’s been found that this fatty tissue dysfunction and inflammation coming from the fatty tissue may be at the center of PCOS, and is one of the central aggravating factors that causes insulin resistance. That starts off quite young in children.

As teen-agers go through puberty, the typical and natural process is first that the adrenal glands will activate and secrete cortisol and androgens (adrenarche). The function of this is to produce insulin resistance to help with fat gain so that a woman can reproduce. At that time, androgens become predominant and all girls initially have higher LH than FSH during this first stage of puberty, which in addition to the adrenal secretion causes androgens to be secreted from the ovary as well. This is actually a normal thing. Typically as ovulation occurs, estrogen and progesterone become the dominant hormones and menstrual cycles tend to regulate through the teen years.

In PCOS, the androgen dominant stage persists adolescents often do not begin ovulating and menstruating regularly and can even experience permanent effects on breast development due to lack of exposure to sufficient estrogen during this period. The woman with PCOS then retains that insulin resistance and the androgen excess throughout her life.

During the teen years, it can be difficult to identify PCOS because at first it looks like normal puberty. That is why a lot of clinicians are very hesitant to actually diagnose this in teen-aged girls. Research has found consistently that many teen girls have a polycystic appearance to their ovaries on ultrasound, likely due to the natural androgen excess and this does not necessarily correlate to them having PCOS later on.

Adolescents with PCOS can also experience persistent acne and may start to accumulate weight around their middle.

As women go through their reproductive years, they may discover they have PCOS if they have trouble conceiving. Some symptoms will get worse with age, such as hirsutism and insulin resistance. But as the androgens decrease in the blood with age some of the symptoms like acne can actually improve and the irregularity of the menstrual cycles can resolve as women get older. They also tend to go through menopause around 2 years later, on average and their peak of fertility is later as well..

With menopause, naturally we no longer see the effects of PCOS on the menstrual cycle, but the metabolic symptoms of insulin resistance and inflammation continue to increase with age. A lot of these women will start to develop more abdominal adiposity, or start showing markers of pre-diabetes, and cardiovascular disease. Interestingly, the androgens are still higher than average for women with PCOS even after menopause which has been correlated to protection against osteoporosis and improved maintenance of muscle mass in aging.

MDLinx:What is most important for clinicians to remember in managing patients with PCOS?

Dr. McCulloch: It is always important to screen for PCOS in all female patients because it’s a common condition that carries a lot of risk for chronic disease. We’ve all learned to think of it as a condition of reproductive-age women, but it is lifelong. And it’s one of the major risk factors for diabetes and cardiovascular disease in women.

A preventative approach including nutritional and lifestyle interventions starting as early as possible, as well as screenings for metabolic and cardiovascular disease throughout the lifespan can help protect women with PCOS from many of its serious health risks.

In her new ground-breaking book,  8 Steps to Reverse Your PCOS, (September 2016 http://drfionand.com/about/), Dr. McCulloch, addresses PCOS. Dr. McCulloch has PCOS herself, and is passionate about health education for other women who do. She is on the medical advisory committee of the PCOS Awareness Association, and the Naturopathic Doctor advisor to IVF.ca, Canada’s premier online fertility community.

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