Clinical Pearl Wednesday #174

Concept polycystic ovary syndrome, PCOS. Women reproductive system

Typically, women who are diagnosed with PCOS, polycystic ovarian syndrome, often find this diagnosis while they are being evaluated for infertility.  After trying to conceive for months, women often seek out providers with answers and end up hearing the new diagnosis, PCOS.  Typical treatment for PCOS, however, does NOT help women get pregnant since the major treatment is oral contraceptives.   

Prescribing OCPs to these women often brings on terrible sadness and even depression, especially after many months of use, continued infertility and no real hope of pregnancy is seen on the horizon. 

However, there is another option that offers women and families MUCH better hope.  Identifying the root cause of the reproductive hormone imbalance is rarely the goal of mainstream providers, but it is crucial to help these women achieve pregnancy.  (plus, it is an AMAZING feeling to be able to announce to one of these women, “you’re pregnant!”)

In almost all cases, insulin resistance and inflammation are the root causes; sometimes, there are accompanying nutrient deficits, like iron, vitamin D, or protein.  Getting all the right lab tests is essential to your workup, so you’ll be able to address all the issues you can find.  Tests I recommend for infertility/hormone workup:

Complete blood count (CBC)
Comprehensive metabolic profile (CMP) (chemistry panel)
Hemoglobin A1c
Fasting insulin level
Homocysteine
C-reactive protein
Thyroid stimulating hormone (TSH)
TPO & thyroglobulin antibodies
Free T4
Free T3
Reverse T3
Estradiol
Testosterone
DHEA-S
Progesterone
Iron & ferritin panel
Anti-mullerian hormone
B12 & folate
Vit D 

Diagnosis codes I most often use:  Fatigue, Myalgia, and Z86.39.

Once you have all these levels, you can begin to optimize each of them; iron and ferritin are the highest priority if either one of them are lower than 60.  Fasting insulin is ideally 6mcU/mL or less; if insulin is 7 or higher, it is acting as a “bully” – it will push all other hormones out of balance in short order.  

Teaching patients to reduce their insulin levels will provide the best chance for normal ovulation and egg fertilization.  To reduce insulin, reduce carb intake  – the lower, the better.  Prescribing metformin or berberine can also improve insulin levels, resulting in pregnancy. 

Another hormone imbalance that often occurs as a result of elevated insulin levels is hypothyroidism; ideal Free T3 level is about 3.4 – 3.8 ng/dL or higher.  A FT3 that is less than 3.4 is very likely to influence reproductive hormones adversely.  Prescribing liothyronine, even if on a temporary basis like 6 -12 mos, can help improve reproductive hormone balance, improving chances of ovulation and fertilization.  

For more help with these lab tests, levels, and low-carb diet info, see our nutrition course.

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