|
 The
most common problem causing no ovulation, in reproductive age women is commonly
referred to as polycystic ovary syndrome (PCOS) or polycystic ovarian disease
(PCOD). The term, "polycystic ovaries" (PCO) was coined in the 1930's by the
first to describe the problem, Stein and Levinthal. The patients they described
were obese, had male pattern hair growth and irregular menstrual periods, were
infertile and had large ovaries with multiple tiny cystic structures
immediately under the surface. Not all women with (PCO) exhibit all the
physical findings in the group reported by Stein and Levinthal. For
generations, there was little or no understanding of what causes PCO, and
treatment attacked the physical findings, by cutting out part of the ovary.
Truly, some women did ovulate, for a time, after the assault on their ovaries.
Lacking any other approach to managing the problem, wedge resection of ovaries
was the standard therapy, until we began to unravel the abnormal physiology
that causes the disease. In truth, what historically has been dubbed PCO is a
collection of problems caused by more than one underlying aberration of
metabolism. PCO is a medical problem best treated by medical management.
Unfortunately, there are some OB-GYN's who still attack the ovary with a
surgical approach.
By far the most common cause of PCO is insulin resistance (IR). The cells of
people who are insulin resistant do not respond well to insulin, so they must
make extra insulin to maintain normal blood sugar. They are not necessarily
diabetic but they are at increased risk of developing non-insulin dependent
diabetes (type II). They are, also, at increased risk for heart attack and
stroke, even if they do not become diabetic. Managing insulin resistance is a
major health issue, in addition to being impairment to a woman's fertility.
Different practices have different slightly different protocols to manage IR. My
protocol addresses one of the functions of insulin. One of the things that
insulin does, exceedingly well, is convert carbohydrate into fat, for storage.
The more fat stored, the worse the IR, and the higher the insulin levels go in
response to a carbohydrate load. Higher insulin levels accelerate the
conversion of carbohydrate to fat. It is a vicious circle. To break the circle,
we must severely decrease the carbohydrate intake. I recommend my patients with
IR limit their carbohydrate intake to 30 grams a day.
As an adjunct to carbohydrate restriction, I prescribe Glucophage (metformin). I
recommend the brand product, because a few of my patients have had adverse side
effects while taking generic products. Glucophage helps make the cells more
sensitive to insulin, so insulin levels do not rise as much to keep blood sugar
normal. Secondly, Glucophage decreases absorption of carbohydrate from the
intestine. This is both the good news and the bad news. The good news is that
it decreases absorption of carbohydrate from the intestine, so blood sugar does
not go as high, and insulin levels do not go as high. The bad news is that it
decreases absorption of carbohydrate from the intestine, so carbohydrate stays
there, and draws water in with it. The bacteria in the intestine love to eat
the carbohydrate, and make gas, in the process. Too much carbohydrate in the
diet causes diarrhea, cramping and gas. Carbohydrate restriction helps minimize
these undesirable side effects. The protocol I recommend has, what for most of
my patients, a desirable side effect - weight loss.
Over the past few years, several investigators have reported the benefits of
Glucophage, related to reproduction. In women with IR, and PCO, Glucophage may
increase the probability of ovulation, and may improve the probability of
pregnancy. Glucophage has, also, been shown to decrease the risk of miscarriage
in women with PCO, and decrease the risk of gestational diabetes in women with
IR.
An adrenal disorder produces a condition, which was previously lumped in with
PCO, because of its similar physical appearance. In some people, there is an
abnormal enzyme in the pathway to make cortisol. There are two different
aberrations of the enzyme. The more severe is usually diagnosed in the newborn.
The less severe, in women, causes them to have all of the physical
manifestations described by Stein and Levinthal. Measuring the intermediate
product in the pathway for cortisol, on which the defective enzyme works, makes
diagnosis. If the intermediate product is elevated, the enzyme is defective.
Treatment is to give small doses of a synthetic form of cortisol at bedtime. Be
aware, there are potential risks and side effects to the treatment.
Even with the treatments described above, it is usually necessary to induce
ovulation with medications, if pregnancy is the goal. The most commonly used
and least effective ovarian stimulation is with Clomid (clomiphene citrate).
Far more effective is to use a product, which is the pituitary hormone,
follicle stimulating hormone (FSH).
|
Recurrent Pregnancy Loss
Ovulation Disorder
Endometriosis
Tubal Disease
Cervical Factor
Immunological Factor
Unexplained Infertility
Gene Abnormalities
Polycystic Ovary Syndrome
Endometrium
|
