We're at the end of September, which is PCOS awareness month, so you might have been hearing more buzz lately about this common hormonal imbalance. We’ll start off with a refresher: polycystic ovary syndrome, or PCOS, is a common imbalance in a woman’s reproductive hormone levels. It’s now estimated that 1 in 10 women have PCOS, though each person’s experience of the syndrome can be different. Some common symptoms include weight gain, hirsutism (hair growth on parts of the body like the face or chin), as well as hair loss, acne, irregular or missed menstrual periods, and infertility.
We’ll focus our attention on that last symptom–infertility–because although PCOS can cause some to struggle with conceiving, it’s also the most treatable cause of female infertility. By managing their PCOS symptoms, many women with PCOS go on to have healthy pregnancies, and deliver healthy babies.
We sat down with Dr. Kurt Martinuzzi, an assistant professor at Emory University in the Ob/Gyn department who specialized in PCOS, multiple gestations, recurrent pregnancy loss and resident education. And we had the opportunity to hear from a new mother who sought treatment to induce ovulation, and recently gave birth to a healthy baby girl.
Modern Fertility: Thanks for being with us, Dr. Martinuzzi. Let’s start at the beginning: How would you diagnose someone with PCOS?
Dr. Martinuzzi: In 2003 experts met in Rotterdam, a city in the Netherlands to agree on criteria to diagnose polycystic ovary syndrome. They decided that healthcare providers should look for three different things:
Signs of extra male hormones, irregular release of eggs, and more than 12 cysts (fluid-filled sacs around developing eggs) seen on an ultrasound. To diagnose PCOS, you need to have at least two out of the three criteria
MF: And how does having PCOS affect fertility?
Dr. Martinuzzi: So, an irregular release of eggs means that some women with PCOS don’t release eggs every month. In order to get pregnant you need 3 things: 1) the release of an egg, 2) at least one open tube, and 3) sperm to fertilize the egg. Most women with PCOS will take longer to get pregnant because they might only release an egg every couple months or perhaps not at all.
MF: Is there anything a woman can do to increase her chances of conceiving?
Dr. Martinuzzi: In the United States, many women with PCOS weigh more than recommended. Instead of using a pound cutoff, we use a formula that looks at height and weight. It allows us to calculate what’s called body mass index, or BMI. The formula uses height in centimeters and weight in kilograms, so I'd suggest just googling "BMI calculator". Plug in your height in inches and weight in pounds and you'll quickly get a result.
If your BMI is over 25-29.9, you are overweight.
If your BMI is over 30, you are obese.
Women who are overweight and don't ovulate regularly can increase their chance of conception by decreasing their weight by even 5%.
Healthy diet and increased exercise will help with weight loss. There is no type of diet that is proven to work best, but smaller studies and clinical experience suggest a diet lower in sugar and simple carbohydrates might work best. Once a woman's BMI is below 30, there are safe medications that can be prescribed to help her release eggs more regularly. Letrozole is the medication that’s most widely used at this time. Clomiphene citrate (Clomid) is another medication that can improve fertility.
MF: Once pregnant, can PCOS complicate a pregnancy?
Dr. Martinuzzi: Women with PCOS are at increased risk for developing diabetes during pregnancy. Many obstetricians will screen people with PCOS for diabetes when they become pregnant and also later in pregnancy (between 24 and 28 weeks). If diagnosed with what’s called gestational diabetes, most patients can maintain good blood sugar levels with diet and exercise. Perhaps 15 percent (or 1 out of 7) women with PCOS will need to take insulin shots during the last part of their pregnancy.
MF: What do you tend to recommend to pregnant patients who have PCOS?
Dr. Martinuzzi: In addition to screening for gestational diabetes I also encourage PCOS to gain only the recommended amount of weight during pregnancy:
If their BMI is in the normal range (between 18.5-24.9), the goal is between 25 and 35 lbs. If their BMI is elevated (between 25-29.6), the goal is between 15 and 25 lbs.
And finally, If their BMI is in the obese range (>30.0), the goal is between 11 and 20 lbs.
I also recommend 30 minutes of brisk exercise 5 days a week for all of my pregnant patients.
MF: Thanks, Dr. Martinuzzi. One last question: How might PCOS affect delivery? Are there special considerations or requirements for someone delivering who has PCOS?
Dr. Martinuzzi: Most women with PCOS will have uncomplicated vaginal deliveries.
There are a few considerations: If any patients desire an unmedicated birth, I often encourage them to look into hiring a doula for support – tt would be great if every laboring woman could have a doula.
If a woman gains the recommended amount of weight and exercises 5 days a week, she's more likely to have a quicker, easier labor. Women who gain extra weight and don't exercise may have larger babies, longer labors and a bit higher rate of C-section.
General Ob/Gyns can help these women take steps to become pregnant. Because PCOS can lead to lifelong increased health risks (like type 2 diabetes, endometrial cancer, high blood pressure and heart disease), it’s important for people with the syndrome to build relationships with doctors who are experienced and well-versed in PCOS.
Now that we’ve got the clinical facts, let’s hear from someone who recently navigated conception and delivery, managing her PCOS symptoms and delivering a healthy baby girl.
Modern Fertility: Hi Emilia, thanks so much for being willing to share. Did you know you had PCOS when you were first trying to conceive?
Emilia: No, it was about 13 years between when I was first diagnosed with PCOS and when we decided to try to start a family. I was actually really worried about trying to get pregnant, since the research I had done 13 years ago is pretty different from how things are today. I remember reading a bunch of online posts from women who were taking medications to induce ovulation and were complaining of some bad side effects.
MF: Can you tell us a bit about your journey to conceive?
Emilia: Sure. I started by going off the hormonal birth control that I was taking to keep my PCOS symptoms at bay. My health care provider told me that some people ovulate regularly after going off hormonal birth control, so I thought it was worth a try.
Since that didn’t happen for me, I ended up seeing my doctor and then taking medication to trigger a withdrawal bleed, and then another medication to trigger ovulation halfway through my menstrual cycle. I got pregnant in my third cycle, so for me it actually ended up happening pretty quickly. I wish I’d had more current information, and not the outdated googling from when I was first diagnosed. Then I probably wouldn’t have been as worried! I also wish I had a more clear idea of the various parts of the process and their outcomes.
MF: Finally, how about your symptoms during pregnancy and now, as a new mom?
Emilia: It’s so interesting because PCOS is a hormonal imbalance, and the hormone profile of the same woman when pregnant and not is completely different. I actually loved being pregnant–I felt more like myself, more in control of my emotions, and more in balance.
One of the hallmarks of PCOS is increased weight gain, and I had to experiment to find what worked for me–I ended up cutting out carbs, since they weren’t feeling right for my body. Interestingly enough, when I was pregnant, I was able to eat carbs again and feel fine. And now that I’m breastfeeding, I still feel fine when I eat them. I’ve learned that it’s a total balancing act–my body's needs were different before, during, and after my pregnancy.