Ashley: When did you first become interested in working with PCOS patients?
Dr. Thatcher: My PhD research in the mid nineteen seventies involved the relationship between the ovary, follicle metabolism, and egg quality. While this was not directly associated with PCOS, it served as the foundation for a lifelong interest in ovarian function and dysfunction. Throughout the first part of my medical career, I had a very standard textbook understanding and approach to treatment of PCOS. In East Tennessee, PCOS is the leading cause of infertility and hence, a relatively large portion of my practice. My patients have taught me what PCOS is and with open ears and eyes, I began to understand how common, how varied, how difficult PCOS is and how its tentacles can reach into all aspects of the PCOS patient’s being. To be able to wrap seemingly diverse medical problems, often even unvoiced concerns into a single disorder, to make a diagnosis others have missed, and to be able to offer effective treatment options that can prevent disease and improve quality of life is the true reward for practicing medicine
Ashley: Why are so many women with PCOS undiagnosed or misdiagnosed?
Dr. Thatcher: It is true that many with PCOS are underdiagnosed or misdiagnosed. One problem has been lack of a codified set of rules for diagnosis. A second problem is that PCOS is not a “one size fits all” diagnosis. Rather than a disease with a codified list of symptoms and physical findings, PCOS is a spectrum of diverse, often seemingly unrelated, health issues. That is to say, there are a variety of subtypes, referred to as phenotypes of PCOS, and different patient populations based on the patients’ specific concerns. The PCOS patient population in a dermatologist’s office in evaluation for excessive hair growth may be very different from the infertile PCOS patient seen in a fertility clinic desiring pregnancy. An individual seeing her primary care physician for high cholesterol may be very different from one seeing a psychologist for body image issues. Not only does PCOS cross all the medical professions, but no one specialty specifically addresses all concerns of the PCOS patient.
Unfortunately considerable prejudice is exhibited against some with PCOS that is not limited to medical practice. It has been stated that the obese individual may receive only half the time allotted in a physician’s visit. Obese women are too often credited with having lack of will power when there is an underlying metabolic disturbance contributing to their inability to lose weight. Too often the advice is to “go home and lose 50 pounds”, or “if your had any self control you wouldn’t be so fat” – inexcusable, but true. Often added to these comments are the prejudice of skin issues such as acne and unwanted hair growth, or hair loss.
In partial defense of physicians, too often, too little time is allowed by the “system” to allow addressing the multiple issues of PCOS. In a 15 minute office visit, to perform a focus interview, exam and discuss therapy is a tall order. Especially, the emotional and educational aspects are regrettably discounted.
Finally, too often there is an incomplete understanding of the disorder. There are no courses in PCOS taught in medical schools. Even experts cannot agree on treatment strategies. Awareness and understanding are increasing, thankfully. Many physicians are open to new ideas and information. Beware of those who are not. A rewarding relationship can be forged with patients who want to partner in health maintenance and disease prevention.
Ashley: Why is a diagnosis of PCOS so important?
Dr. Thatcher: The diagnosis of PCOS is important because when one component of the disorder is found others should be sought. A patient seen for ovulatory difficulty is many times not thinking about an increased risk of gestational diabetes, or what effects the metabolic consequences associated with PCOS can have on long-term quality of life.
An equally important and related reason for diagnosis can be peace of mind. Knowing something is wrong, but not having a diagnosis, causes free-floating anxiety. Diagnosis can be paramount to relief and form a foundation on which to construct the framework of therapy. Not that the PCOS diagnosis is a good thing, but better the enemy you know than the one you don’t. In the final analysis and with so may subtypes of PCOS, so much is yet to be known and over diagnosis of PCOS is probably better than its under diagnosis.
A sinister caveat to the PCOS diagnosis is emerging. Because of the potential link of PCOS with increased risk of diabetes and possibly cardiovascular disease, third party payers (insurance companies) are considering PCOS to be a significant risk factor, much like smoking. Some are denying coverage or increasing premiums if the PCOS diagnosis has been made. This link is hardly absolute and many with PCOS may have no increased risk. The policy of discrimination can even go further. I have heard of job discrimination based solely on the diagnosis, not the individual.
Ashley: What are the steps that can be taken to effectively manage PCOS?
Dr. Thatcher: Management of PCOS starts with recognition of all that PCOS can be. While a proactive approach and self-education is vital, it is equally important to find health professionals with an understanding of PCOS with whom to partner. While specific centers dedicated to the evaluation of PCOS are emerging, these are presently few and far between. It is best to have one physician that has both an interest and understanding of PCOS to conduct the initial and what should be comprehensive evaluation. The evaluation should include comprehensive medical history, blood work and pelvic ultrasound. The importance of a complete family history cannot be overstated. It is very likely that other health care professionals such as a nutritionist, individuals involved with skin care and possibly a mental health professional also be team members. Depending on specific resources available, several specialists are sometimes needed to sort the intricacies and specific therapies.
While some may disagree, pelvic ultrasound can solidify the PCOS diagnosis, evaluate the endometrium for dysfunctional overgrowth, and exclude pelvic pathology. Unfortunately, the polycystic ovaries are more often seen than formally reported. The ultrasound diagnosis of PCOS is made when there are 10 or more follicular cysts less than 10 mm and /or an increase in ovarian volume over 10 ml.
Bare in mind, PCOS is not a unified disease. PCOS is not presently curable, nor is it likely to be in the near future. The aim is symptom relief and disease prevention, which is largely within our grasp.
Ashley: Should management of PCOS symptoms change at different stages of life?
Dr. Thatcher: PCOS, or at least a predisposition to PCOS, is genetic and inherited. This means that PCOS is present at birth and its effects persist well after menopause. While the treatment of individual symptoms may remain the same regardless of the stage of life, overall individual needs vary. For the teenager, more emphasis may be placed on cycle regulation, nutrition, and control of skin manifestations of excess male hormones (acne). During the twenties and thirties, reproduction and fertility can be the greatest area of concern. While in the peri-menopause and later, metabolic consequences such as diabetes and cardiovascular disease that can accompany PCOS become increasing prevalent. Some forms of cancer, specifically uterine and colon, may be increased in association with PCOS.
Ashley: Is there a general consensus on the most effective treatment for PCOS, and if so, what is it?
Dr. Thatcher: Since there is no consensus about what PCOS is, there is certainly no consensus about the most effective therapy. One type, or grouping, of PCOS may have more disturbances in the hypothalamic-pituitary--ovarian axis leading to infertility and menstrual cycle disturbance, but have little of the PCOS metabolic consequences. Another group may have had no problem with fertility, but be at significantly higher risk for cardiovascular disease and diabetes.
It is now emerging that with such a high coincidence of insulin resistance with PCOS. This should be evaluated in all PCOS patients. Insulin sensitizers such as metformin can have a significant improvement in many of the symptoms that plague the PCOS patient. In other groups, it may be reasonable to use the new generation of oral contraceptives to reduce hirsutism and improve menstrual cycle control.
All agree that for all of us, lifestyle improvement, smoking cessation, optimizing nutrition, and regular exercise can have a profound impact on quality of life and disease prevention. This goes double, triple, and quadruple for with those with PCOS. The problem remains that this is a very difficult prescription to fill and at present there are not good substitutes.
For those with skin problems, an approach using physical hair removal methods such as laser, medications to reduction androgen production or action (metformin, oral contraceptives, anti-androgens), and possibly topical medications can be very effective. A regimen with multiple strategies is much more effective than any single intervention.
A large armamentarium of strategies is available for those with PCOS attempting a pregnancy. Therapy must be individualized and some with PCOS may be quite tough, while others relatively easy. Metformin can be useful in promoting pregnancy and potentially decreasing pregnancy loss. The good news is that the vast majority of those with PCOS can be successfully pregnant.
Ashley: How can women with PCOS be more proactive about their health?
Dr. Thatcher: Learn all you can. The Internet and patient advocacy groups such as Project PCOS are invaluable. Beware of quick fixes, or unsupported boasting, and anecdotal reports. Some general rules about PCOS are emerging, but each individual with PCOS is unique.
I consider it to be particularly important to know whether or not insulin resistance is present and good (HDL), bad (LDL) cholesterol, and triglyceride levels (lipid profile). Often this will mean a glucose tolerance test (GTT) with insulin levels to properly diagnose insulin resistance. Stimulated insulin levels rise before stimulated glucose levels and both stimulated glucose and insulin levels rise before fasting or random determination. The GTT is especially important in thinner and younger patients where the dynamic testing can uncover latent tendencies, not just present problems. With the lipid profile one can gain insight in terms of cardiovascular risk. If testing suggests both lipid abnormalities and insulin resistance, the patient may be sitting on a time bomb that requires quite aggressive intervention.
As stated above, no medical intervention that is more powerful than lifestyle alteration. The reported charts of ideal weight are probably unrealistic, but good nutrition and regular exercise are within the reach of virtually all.
Ashley: What are the risks of ignoring PCOS management?
Dr. Thatcher: Ignoring the diagnosis is OK, but ignoring the signs, symptoms and potential long term consequences of PCOS can lead to undue suffering and potentially dangerous medical consequences.
A difference of opinion exists as to whether a woman needs to have periods every month. While need for monthly bleeding is questionable, it is clear that long periods of no bleeding may increase the risk of overgrowth of the uterine lining, endometrial hyperplasia, and even cancer, although this is rare in younger individuals.
No physician will ever suggest ignoring lipid abnormalities or altered glucose tolerance. These can lead to diabetes and cardiovascular risk and either premature death or significant decrease in quality of life. In my career, I have watched medical practice move from treatment of the morbid complications of disease, to disease control and now disease prevention. Early and sustained intervention is the key.
Ashley: Are there any new treatments or research regarding treatments for PCOS?
Dr. Thatcher: A recent literature search yielded over 5500 medical publications on PCOS with over 2000 in the last five years. This surge in interest has been due to increased awareness of the scope of PCOS, its association with insulin resistance and infertility treatments. The insulin sensitizer revolution and use of metformin has been a boon to PCOS therapy and was the last and possibly most important advance in therapy. I see no major breakthrough on the horizon, but the continual chipping away at the meaning of PCOS is becoming better appreciated. It is unlikely that there will be a cure found in the near future, perhaps even a cause, but our therapeutic options should continue to expand.
Predicting the future is precarious at best, but I would like a couple of gazes. Obesity is a worldwide epidemic increasing at an astounding rate and ironically, along with starvation, may be our most important health issue today. Obesity has interrelated genetic, environmental, and behavioral origins and often is resistant to our present therapeutic interventions. An effective anti-obesity medication could be worth billions of dollars to the pharmaceutical industry. This prize is too great to ignore and effective weight loss drugs are in our future, but when?
For those with PCOS interested in fertility, the good news is that we are quite effective in our treatments with a success rate that should approach about 90% if couples are willing to utilize all options, especially IVF. A problem is that the development of a follicle/egg takes place over 3 menstrual cycles. Most therapy is aimed at only the last two weeks of follicle development allowing the developing follicle /egg to be under a more hostile PCOS environment for most of its development. As little as 5-10% of weight loss can improve menstrual functional and ovulation. Use of metformin can reduce the toxic effects of high levels of insulin, allowing the ovary to function more effectively. Aromatase inhibitors (letrozole, anastrozole) have fewer side effects and less adverse effects on the uterine lining and cervical mucus. Their use is not specifically approved for infertility therapy and whether they are more effective than clomiphene in PCOS is still unproven. It is increasingly apparent that PCOS is related to increased rates of pregnancy loss. An important cause of miscarriage related to ovarian dysfunction is egg quality. A timelier ovulation can potentially improve egg quality and decrease pregnancy loss. Hopefully we will have more information in the near future about whether metformin can help with pregnancy outcome.
As PCOS awareness increases, the emotional burden of PCOS is beginning to be appreciated. It seems that those with PCOS are at significantly high risk of mood disorders, including anxiety and depression. Recognition is the first step in therapeutic intervention.
Ashley: What is the best advice you can give to a woman with PCOS?
Dr. Thatcher: My best advice to give a woman dealing with PCOS is to “know herself.” No physician can ever understand you as well your capacity to understand yourself. This can sometimes be hard work and it may involve hard choices, but the rewards of your efforts can be translated into a longer, better, more productive, and if desired, reproductive, life. Arm yourself with information, ask questions, weigh answers, make changes, involve others Every life is an experiment in process.
You can also view Dr. Thatcher's Biography.
