Discussing PCOS: Misconceptions, management, and encouragment

Lori Homa, MD:

Hi, I'm Lori Homa. I am the medical director of Allegheny Health Network Center for Reproductive Medicine.

Contemporary OB/GYN:

And thank you for speaking with me today. We'll be talking about PCOS, and to get started, could you just give a brief overview of the condition as well as some common and uncommon symptoms?

Lori Homa, MD:

Sure, PCOS is a very common condition. It affects up to 10% of women, and some of the things that women experience in order to get the diagnosis would be irregular periods, and that is one of the most common symptoms. And then the secondary things that they might experience would be elevated androgens, and what that means is kind of testosterone level, or the clinical experience of that would be acne or irregular hair growth, something we term as in the medical field as hirsutism, but hair growth on the chin or chest or back with extra hair growth. So, those are some of the signs of PCOS, but you don't in the clinical sign that we're looking for also is polycystic ovaries on ultrasound. So, a patient at home might just experience irregular periods and that's it, and have PCOS be the diagnosis, or they might experience just the acne or irregular hair growth. And then lastly, they could experience both of those things. So, out of the 3 things, the irregular periods, the excess androgens, and the ultrasound appearance of polycystic ovaries, you only need 2 out of those 3 to get the diagnosis. So, any 2 out of those 3 gets your diagnosis. So, you may just have irregular periods, not the excess hair growth, or you might have excess hair growth and not the irregular periods. But often they do go hand in hand, for people who have excess hair grows having irregular periods. But a lot of times people have irregular periods and have excess hair growth. So, it's a big mixed bag, people do think that they have to have a specific symptom of one of those things, and you don't have to have all of them. So, another thing that is a common misconception is that you have to be overweight or obese to have the diagnosis, and that is not true. So, if you're either underweight or normal weight, you can still have PCOS. And it is just as common in those populations as it is in the overweight population. So, you don't have to be overweight, but you can be and that can exacerbate some other conditions that are associated with PCOS, but you don't have to be.

Contemporary OB/GYN:

Thank you, and how can providers help men and help patients manage PCOS symptoms?

Lori Homa, MD:

I think the first thing to decide is what is the patient's goals? So, are they trying to get pregnant or are they not? And that's a really important distinction, because if they're not trying to get pregnant, we need to protect the endometrium. And to do that that can be any sort of hormonal replacement such as a birth control pill or a patch or NuvaRing. Or it can be a Mirena IUD within the uterus to protect the endometrium from overgrowth and then the increased risk of endometrial cancer down the line. So, protecting the endometrium is most important for a patient who does not want to get pregnant at that time. For a patient who does want to conceive, the treatment would be different. The treatment in that course would be to induce ovulation, and to do that the best medication for that is letrozole. And that's a pill that you take once a day for 5 days starting on the third day of their period, and if they don't get periods at all, then you'll have to induce one with progesterone to bring on a period and then start the letrozole. And once they're on the letrozole and ovulating they can keep cycling each month on the letrozole. So, it's a big distinction on are they trying to get pregnant or not. And I think that that middle ground of doing nothing, of not been on either medication and not deciding well, I'm kind of open to it, but I don't want to commit either way, is a tough place for being in PCOS, because with this condition, it's better to treat one way or the other. Whether it is to protect the endometrium or to induce ovulation, the middle ground of not doing anything does lead to that increased risk of endometrial cancer over time, and that is something that we'd like to avoid.

Contemporary OB/GYN:

And are there any other current management protocols for PCOS you want to talk about?

Lori Homa, MD:

Those are the main ones. Now Metformin is often discussed if they have insulin resistance, then Metformin can be important, but for a patient who wants to get pregnant Metformin isn't the most important route. The most important medication in that instance is the letrozole. And there are studies that show that letrozole alone is better than Metformin and is equal to Metformin plus letrozole. So, you don't really need to add Metformin and you just can just do the letrozole.

Contemporary OB/GYN:

And how can physicians better advocate for their patients with PCOS?

Lori Homa, MD:

Oh, sure. So, when a patient comes in with irregular periods, I think it's important to and they want to conceive it is better to get someone on letrozole right away and not have them have to make a yearlong attempt at conceiving before declaring them having an issue with infertility and then referring them for management with an infertility specialist. So, I would say to start letrozole right away, and then refer if they're not getting pregnant with the letrozole, or they're not responding to the letrozole. So, just refer right away don't have to wait a year. If their periods are irregular, go ahead and start the letrozole and get them to an infertility specialist without waiting that year. Also, I would just encourage practitioners to then encourage their patients to not let the whole situation go over time of just being in limbo of not being on either medication to either protect their endometrium, or to induce ovulation because many patients are afraid in a sense or concerned that a birth control pill or another hormonal medication will be worse for them, but it's actually protective for them and it is in their best interest not in a harmful way.