One of the most common findings when a couple enters a practice with the complaint of difficulty achieving a pregnancy is polycystic ovaries, or PCO. Sometimes the condition is referred to as PCOS or PCOD, adding either syndrome or diseases after PCO. I am not sure we can truly classify the problem as a single entity by declaring it a disease or syndrome. We know of at least 2 causes of the problem.
The majority of women with PCO are insulin resistant. By that, I mean that their cells do not respond adequately to insulin, so they must make extra insulin to keep blood sugar normal. No, that does not mean they are diabetic. However, people who are insulin resistant are at greater risk to become diabetic. They are also at greater risk for heart attack and stroke.
On of the things insulin does very well, even in people who are insulin resistant is to convert the carbohydrate they eat into fat for storage. The more fat they have stored, the worse their insulin resistance; the higher their insulin levels rise in response to a carbohydrate load, and the faster they convert carbohydrate to fat. It’s s vicious circle. We have to break the circle. I strongly recommend my insulin resistant patients drastically cut their carbohydrate consumption to 30 grams a day.
In addition to carbohydrate restriction, I prescribe a medication called Glucophage (metformin). It will decrease carbohydrate absorption from the intestine and increase the response of her cells to insulin. We also know that women with PCO have a lesser risk of miscarriage if they are taking Glucophage, and women who are insulin resistant have a lesser risk of developing gestational diabetes, if they are taking Glucophage.
The side effects of the medication are related to the inhibition of carbohydrate absorption from the intestine. The carbohydrate remaining in the intestine draws water into the intestine and the bacteria in the intestine make gas, when they eat the carbohydrate. The result is diarrhea, cramping and gas. Carbohydrate restriction decreases the symptoms. The other side effect, if patients really follow the protocol, is weight loss. Most of my patients like that side effect.
The other known cause of PCO is a deficiency of an enzyme in the adrenal gland. The enzyme involved is called 21-hydroxylase. It is part of the pathway to create cortisone. There are 2 known molecular variants of the enzyme abnormality. One is relatively mild, and the other more severe. It requires 2 copies of the gene to make the enzyme – one from each parent. If a woman has 2 abnormal copies of the gene, and one is a mild version, she will have a condition which will be clinically described as PCO. Adding a low dose of steroid at bed time will help. If one gene is a severe variant, and her pregnancy inherits that one and a severe abnormal copy from her husband, the child will have a condition called adrenogenetal syndrome. If it is a girl, she will have ambiguous genetalia. Both boys and girls are at risk to be salt wasters and have severe disorders of blood chemistry. Diagnosis is critical. These gene abnormalities are among the most common known, and are present, in at least a carrier state, in at least 5% of some ethnic groups.
Ovulation induction to help achieve a pregnancy for women with PCO can be assisted using treatments such as Glucophage or steroids, if indicated, but alone, neither is usually adequate. There are specific medications available for ovulation induction. The oldest, and to my thinking the worst, is Clomid. Far better is the group of products that are pituitary hormones which cause development of the ovarian follicles which contain eggs. The use of these medications is safest if done by a Reproductive Endocrinologist.
Dr. Jacobs is a Reproductive Endocrinologist, practicing in Carrollton, Texas, a northern suburb of Dallas. He completed his residency training in obstetrics and gynecology at Baylor College of Medicine in Houston, and remained at that institution to become its first fellow once Baylor achieved accreditation for an advanced training program in Reproductive Endocrinology and Infertility. Dr. Jacobs has served on the faculty of several medical schools and was director of Reproductive Endocrinology at TexasTechHealthScienceCenter in Amarillo. Currently, in addition to his clinical activities caring for infertile patients and those with recurrent pregnancy loss, he is Chairman of the IVF committee at BaylorMedicalCenter in Carrollton.
Barry Jacobs, M.D., 4323 M. Josey Lane, Suite #201, Carrollton, TX 75010www.texasfertility.com Phone: 972-394-9590 Fax: 972-394-9597