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Archive for the ‘Irregular Periods’ tag

PCOS: The Unwanted Pearl Necklace

By David Kreiner MD, and Tracey Minella

September 6th, 2012 at 7:49 pm

credit: maggiesmith/freedigitalphotos.net

There’s nothing at all sexy about PCOS, or Polycystic Ovarian Syndrome. In fact, some women who suffer from PCOS are not only fertility-challenged (by tiny ovarian cysts appearing like a string of pearls on an ovarian sonogram), but may be cursed with any number of other annoyances, including facial hair and acne and extra poundage. How lovely.

Dr. Kreiner, of Long Island IVF explains PCOS, its affect on your ability to conceive, and the way it can be managed:

PCOS is the most common hormonal disorder of reproductive age women, occurring in over 7% of women at some point in their lifetime.  It usually develops during the teen years.  Treatment can assist women attempting to conceive, help control the symptoms and prevent long term health problems.

The most common cause of PCOS is glucose intolerance resulting in abnormally high insulin levels.  If a woman does not respond normally to insulin her blood sugar levels rise, triggering the body to produce more insulin.  The insulin stimulates your ovaries to produce male sex hormones called androgens.  Testosterone is a common androgen and is often elevated in women with PCOS.  These androgens block the development and maturation of a woman’s ovarian follicles, preventing ovulation resulting in irregular menses and infertility.  Androgens may also trigger development of acne and extra facial and body hair.  It will increase lipids in the blood.  The elevated blood sugar from insulin resistance can develop into diabetes.

Symptoms may vary but the most common are acne, weight gain, extra hair on the face and body, thinning of hair on the scalp, irregular periods and infertility.

Ovaries develop numerous small follicles that look like cysts hence the name polycystic ovary syndrome.  These cysts themselves are not harmful but in response to fertility treatment can result in a condition known as  Ovarian Hyperstimulation syndrome, or OHSS.

Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the belly and occasionally around the lungs.  A woman with Hyperstimulation syndrome may become dehydrated increasing her risk of developing blood clots.  Becoming pregnant adds to the stimulation and exacerbates the condition leading many specialists to cancel cycles in which a woman is at high risk of developing Hyperstimulation.  They may also prescribe aspirin to prevent clot formation.

These cysts may lead to many eggs maturing in response to fertility treatment also placing patients at a high risk of developing a high order multiple pregnancy.  Due to this unique risk it may be advantageous to avoid aggressive stimulation of the ovaries unless the eggs are removed as part of an in vitro fertilization procedure.

A diagnosis of PCOS may be made by history and physical examination including an ultrasound of the ovaries.  A glucose tolerance test is most useful to determine the presence of glucose intolerance and diabetes.  Hormone assays will also be helpful in making a differential diagnosis.

Treatment starts with regular exercise and a diet including healthy foods with a controlled carbohydrate intake.  This can help lower blood pressure and cholesterol and reduce the risk of diabetes.  It can also help you lose weight if you need to.

Quitting smoking will help reduce androgen levels and reduce the risk for heart disease.  Birth control pills help regulate periods and reduce excess facial hair and acne.  Laser hair removal has also been used successfully to reduce excess hair.

A diabetes medicine called metformin can help control insulin and blood sugar levels.  This can help lower androgen levels, regulate menstrual cycles and improve fertility.  Fertility medications, in particular clomiphene are often needed in addition to metformin to get a woman to ovulate and will assist many women to conceive.

The use of gonadotropin hormone injections without egg removal as performed as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies and therefore one must be extremely cautious in its use.  In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy especially when associated with a single embryo transfer.   Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.

It can be hard to deal with having PCOS.  If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition.  Ask your doctor about support groups and for treatment that can help you with your symptoms.  Remember, PCOS can be annoying, aggravating even depressing but it is fortunately a very treatable disorder.

* * * * * * ** *

Do you suffer from PCOS?

 

 

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When Periods Come and Go

By Dr. Eli Rybak

October 22nd, 2010 at 8:24 am

Recently a patient asked me:

“I don’t get my period regularly – and I am thinking about trying to get pregnant.  Should I be worried about infertility? Is there anything I should do now?"

This is an excellent question – and one that arises frequently in reproductive medicine.

I will address it both with a brief response below, and then with a longer explanation.

The Bottom Line:

Having irregular periods is a common challenge among women of reproductive age.  Thankfully, it is one that can be overcome – via lifestyle modification and/or medication / hormonal therapy.  Occasionally, assisted reproductive technology is warranted – and proves highly successful in inducing ovulation among women with irregular periods.  And, yes – a woman who does not get her period regularly should see her gynecologist even if she is not thinking about pregnancy in the short-term.  If she desires a pregnancy, she should see a reproductive endocrinologist (“fertility specialist”) for a specific diagnosis regarding her irregular periods and for a treatment plan.

The Big Picture:

A normal menstrual cycle should be approximately 25 – 35 days, with ovulation occurring approximately 14 days prior to a woman’s (next) period.  When the hormonal pathways between the brain and ovary are functioning properly, a follicle (usually a single follicle, 1% of the time – 2 follicles, reflecting the 1% incidence of twins in the absence of assisted reproduction) grows during the follicular phase (first-half of the menstrual cycle) and produces increasing amounts of estradiol.  At a certain point, this heightened level of estradiol produces a massive surge of LH (a hormone from the pituitary gland) that triggers ovulation – release of an egg from the grown follicle.  Whether or not the egg is fertilized, the empty follicle – now called a corpus luteum – begins to secrete progesterone, which transforms the uterine lining (thickened already from its exposure to rising estradiol in the first-half of the menstrual cycle) to prepare for a possible pregnancy.  The corpus luteum survives in the absence of pregnancy for 14 days.  During this time (the luteal phase), the pituitary secretes pulses of LH to maintain the corpus luteum, which, in turn, produces progesterone.  By 14 days after ovulation, these LH pulses attenuate, the corpus luteum regresses, progesterone production ceases, and the uterine lining begins to bleed – menses has arrived.  If, however, a fertilized egg (now embryo) implants into the uterine lining and secretes HCG (the “pregnancy hormone” detected in the home urinary pregnancy test or in blood tests) to “rescue” the corpus luteum, then the corpus luteum resumes progesterone production – to support the uterine lining and pregnancy – until about the tenth week of pregnancy, when the placenta takes over this role.

A woman who never has a period should see her physician ASAP.  First, of course, she needs a pregnancy test!  Second, her diagnostic workup will depend upon whether she never had a period in her life (primary amenorrhea) or whether she has had periods in the past, but no longer (secondary amenorrhea).  I mention this, only because some of the conditions that cause irregular periods might, in more severe circumstances, cause amenorrhea – i.e. secondary amenorrhea, or the total cessation of menses.

Back to our scenario, having irregular periods means that a woman is not ovulating regularly.  She is not releasing an egg, nor does her uterine lining experience progesterone from the corpus luteum.  Instead, her uterine lining remains exposed only to estrogen – a dangerous phenomenon if this occurs (i.e. if a woman has no period) for many months at a time.  Why?  Because the uterine lining thickens under estrogen influence, and after a prolonged “unopposed” exposure to estrogen there is the long-term (thus, do NOT panic) increased risk of endometrial cancer.  In the short-term, this “anovulatory” woman will experience irregular bouts of breakthrough bleeding, possibly combined with occasionally ovulatory cycles followed by menses.  The nature of these bleeding episodes may be similar, and the woman will not be able to distinguish whether or not she has ovulated – other than to rely on the rule (not-absolute) that cycles more than 35 days apart are unlikely to be ovulatory.

So, if a woman has irregular periods, she should see her doctor for a work-up.  Irregular periods can result from lifestyle factors.  These might include: stress, eating disorders, or an intensive exercise regimen that affect the brain’s regulation of female reproductive hormones.  Indeed, for normal menses and ovulation to occur, a woman must maintain a body weight within a certain window – thankfully this “window” is lenient.  But should her weight sink too low (anorexia, training for the marathon) or climb too high – and each person has a different threshold – then periods may become irregular.

A physician will also investigate other causes for irregular periods:  Does the patient have excess hair growth or acne suggestive of elevated levels of androgens (“male” hormones)?  Does the patient have galactorrhea (milky secretions from the breasts) occasionally seen with hyperprolactinemia?  Are there symptoms including fatigue or cold intolerance suggestive of hypothyroidism?

Among patients I see, The Polycystic Ovarian Syndrome (PCOS) is the most common cause of irregular periods.  But it is important to remember that PCOS is a diagnosis of exclusion.  Other causes of anovulation / irregular periods must be specifically excluded prior to labeling a person as having “PCOS”.  Specifically, thyroid and prolactin function must be assessed.  Additionally, an appropriate array of blood tests should be ordered to ensure that hyperandrogenism is not caused by an adrenal or ovarian tumor (rare) or by late-onset congenital adrenal hyperplasia (more common in the Hispanic and Ashkenazi Jewish Populations).

Treatment for these endocrine disorders is fairly straightforward.  Hence, I repeat my encouragement to such individuals: Do NOT stress or worry about irregular periods.  Rather, proactively pursue medical intervention.  Prolactin or Thyroid dysfunction may warrant some more tests but, ultimately, the vast majority of such patients can be treated with medication that will treat both the underlying disorder, and promptly restore normal menstrual function.  PCOS patients seeking to conceive will benefit from a variety of ovulation induction agents as needed.  Should imminent fertility not be desired, then a physician could prescribe an oral contraceptive or variation thereof to enable the uterine lining to “experience” both estrogen and progesterone.  This will avoid long-term risks of unopposed estrogen and short-term risks of irregular, breakthrough bleeding episodes. 

Bottom Line: Irregular periods warrant a visit to a gynecologist or reproductive endocrinologist.  If a woman is seeking to conceive, she should not wait 12 months (or less, if she is in her thirties) if she has irregular periods.  The “12-month” rule applies to couples without any known disorders.  Having irregular periods is a disorder, but one that, thankfully, is very amenable to hormonal treatment!

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Irregular Periods? Ask Dr. Eli Rybak

By Dr. Eli Rybak

July 26th, 2010 at 7:59 am

“I don’t get my period regularly – and I am thinking about trying to get pregnant.  Should I be worried about infertility? Is there anything I should do now?"

This is an excellent question – and one that arises frequently in reproductive medicine.

I will address it both with a brief response below, and then with a longer explanation.

The Bottom Line:

Having irregular periods is a common challenge among women of reproductive age.  Thankfully, it is one that can be overcome – via lifestyle modification and/or medication / hormonal therapy.  Occasionally, assisted reproductive technology is warranted – and proves highly successful in inducing ovulation among women with irregular periods.  And, yes – a woman who does not get her period regularly should see her gynecologist even if she is not thinking about pregnancy in the short-term.  If she desires a pregnancy, she should see a reproductive endocrinologist (“fertility specialist”) for a specific diagnosis regarding her irregular periods and for a treatment plan.

The Big Picture:

A normal menstrual cycle should be approximately 25 – 35 days, with ovulation occurring approximately 14 days prior to a woman’s (next) period.  When the hormonal pathways between the brain and ovary are functioning properly, a follicle (usually a single follicle, 1% of the time – 2 follicles, reflecting the 1% incidence of twins in the absence of assisted reproduction) grows during the follicular phase (first-half of the menstrual cycle) and produces increasing amounts of estradiol.  At a certain point, this heightened level of estradiol produces a massive surge of LH (a hormone from the pituitary gland) that triggers ovulation – release of an egg from the grown follicle.  Whether or not the egg is fertilized, the empty follicle – now called a corpus luteum – begins to secrete progesterone, which transforms the uterine lining (thickened already from its exposure to rising estradiol in the first-half of the menstrual cycle) to prepare for a possible pregnancy.  The corpus luteum survives in the absence of pregnancy for 14 days.  During this time (the luteal phase), the pituitary secretes pulses of LH to maintain the corpus luteum, which, in turn, produces progesterone.  By 14 days after ovulation, these LH pulses attenuate, the corpus luteum regresses, progesterone production ceases, and the uterine lining begins to bleed – menses has arrived.  If, however, a fertilized egg (now embryo) implants into the uterine lining and secretes HCG (the “pregnancy hormone” detected in the home urinary pregnancy test or in blood tests) to “rescue” the corpus luteum, then the corpus luteum resumes progesterone production – to support the uterine lining and pregnancy – until about the tenth week of pregnancy, when the placenta takes over this role.

A woman who never has a period should see her physician ASAP.  First, of course, she needs a pregnancy test!  Second, her diagnostic workup will depend upon whether she never had a period in her life (primary amenorrhea) or whether she has had periods in the past, but no longer (secondary amenorrhea).  I mention this, only because some of the conditions that cause irregular periods might, in more severe circumstances, cause amenorrhea – i.e. secondary amenorrhea, or the total cessation of menses.

Back to our scenario, having irregular periods means that a woman is not ovulating regularly.  She is not releasing an egg, nor does her uterine lining experience progesterone from the corpus luteum.  Instead, her uterine lining remains exposed only to estrogen – a dangerous phenomenon if this occurs (i.e. if a woman has no period) for many months at a time.  Why?  Because the uterine lining thickens under estrogen influence, and after a prolonged “unopposed” exposure to estrogen there is the long-term (thus, do NOT panic) increased risk of endometrial cancer.  In the short-term, this “anovulatory” woman will experience irregular bouts of breakthrough bleeding, possibly combined with occasionally ovulatory cycles followed by menses.  The nature of these bleeding episodes may be similar, and the woman will not be able to distinguish whether or not she has ovulated – other than to rely on the rule (not-absolute) that cycles more than 35 days apart are unlikely to be ovulatory.

So, if a woman has irregular periods, she should see her doctor for a work-up.  Irregular periods can result from lifestyle factors.  These might include: stress, eating disorders, or an intensive exercise regimen that affect the brain’s regulation of female reproductive hormones.  Indeed, for normal menses and ovulation to occur, a woman must maintain a body weight within a certain window – thankfully this “window” is lenient.  But should her weight sink too low (anorexia, training for the marathon) or climb too high – and each person has a different threshold – then periods may become irregular.

A physician will also investigate other causes for irregular periods:  Does the patient have excess hair growth or acne suggestive of elevated levels of androgens (“male” hormones)?  Does the patient have galactorrhea (milky secretions from the breasts) occasionally seen with hyperprolactinemia?  Are there symptoms including fatigue or cold intolerance suggestive of hypothyroidism?

Among patients I see, The Polycystic Ovarian Syndrome (PCOS) is the most common cause of irregular periods.  But it is important to remember that PCOS is a diagnosis of exclusion.  Other causes of anovulation / irregular periods must be specifically excluded prior to labeling a person as having “PCOS”.  Specifically, thyroid and prolactin function must be assessed.  Additionally, an appropriate array of blood tests should be ordered to ensure that hyperandrogenism is not caused by an adrenal or ovarian tumor (rare) or by late-onset congenital adrenal hyperplasia (more common in the Hispanic and Ashkenazi Jewish Populations).

Treatment for these endocrine disorders is fairly straightforward.  Hence, I repeat my encouragement to such individuals: Do NOT stress or worry about irregular periods.  Rather, proactively pursue medical intervention.  Prolactin or Thyroid dysfunction may warrant some more tests but, ultimately, the vast majority of such patients can be treated with medication that will treat both the underlying disorder, and promptly restore normal menstrual function.  PCOS patients seeking to conceive will benefit from a variety of ovulation induction agents as needed.  Should imminent fertility not be desired, then a physician could prescribe an oral contraceptive or variation thereof to enable the uterine lining to “experience” both estrogen and progesterone.  This will avoid long-term risks of unopposed estrogen and short-term risks of irregular, breakthrough bleeding episodes. 

Bottom Line: Irregular periods warrant a visit to a gynecologist or reproductive endocrinologist.  If a woman is seeking to conceive, she should not wait 12 months (or less, if she is in her thirties) if she has irregular periods.  The “12-month” rule applies to couples without any known disorders.  Having irregular periods is a disorder, but one that, thankfully, is very amenable to hormonal treatment!

no comments


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