59. PCOS 103: Targeted Treatment Strategies

In this episode, Dr. Monica Minjeur explores treatment options for PCOS, depending on your health and fertility goals. She shares a real-life patient story, explaining how personalized care goes beyond standard treatments that are often recommended like oral contraceptives or a one-size-fits-all approach. From lifestyle changes to bioidentical hormones and ovulation stimulators, this episode focuses on restoring balance and addressing root causes. Tune in for practical advice on managing PCOS while keeping your reproductive goals in mind! 

Transcript

Monica: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. Today we're going to continue in our series of episodes focused on PCOS. or polycystic ovary syndrome. Since September is National PCOS Awareness Month, I am focused on creating educational content in an area that is otherwise so lacking. PCOS is often not appropriately diagnosed nor treated, and in many clinics the supposed standard of care is prescribing oral contraceptive pills rather than treating the root cause and addressing other lifestyle factors. On today's episode, we're going to talk all about different treatment options for PCOS, depending upon your goals. In my practice, not everyone is treated the same for PCOS, and this is because it's important to take a woman's health and reproductive goals into consideration anytime that you prescribe treatment. For example, if you're trying to get pregnant, the treatment course will be very different than if PCOS symptoms. We also need to take into consideration the different subtype of a woman's PCOS based on their individual lab and clinical findings, as this will also help to guide our treatment course. Now, if you haven't listened to last week's episode yet, make sure to go check out that episode to learn more about the different subtypes of PCOS as that will help the treatment options to make more sense today. And since we are going to be talking about treatment options this week, I do want to include a medical disclaimer that this podcast and especially this episode is not intended to be medical advice. Every woman's situation is different, and you should work with a knowledgeable healthcare professional who understands the nuances of PCOS treatment. In order to get a unique treatment plan tailored for your situation, please do not begin any treatment course, including supplements without the advice of a qualified healthcare professional. So let's get started today with a story about a past client of mine, who we'll call Izzy. Now, Izzy had been to her obstetrician. and got diagnosed for PCOS because she had elevated androgen levels and irregular cycles with anovulation. Now, in this case, I do agree that she got an appropriate evaluation and diagnosis, so we were off to a good start. Izzy's goals when she went to see her obstetrician were to was that she wanted to treat her facial hair as well as get some regular cycles back. At this point in time, she was planning to avoid pregnancy, but she was getting married within the next year and wanted to start a family shortly thereafter. Her OB doctor recommended that she start on a prescription of oral contraceptive pills to regulate her cycles as well as metformin. Now, Izzy came to see me because, first of all, she didn't want to be on the oral contraceptive medications, especially since she was wanting to get pregnant the following year. But she also didn't want to be on metformin. She didn't understand the reasons why this had been prescribed and didn't know that this medication would be a good fit for her or if the side effects were going to outweigh any potential benefits. So as always, we got Izzy started working with one of our charting instructors in order to be able to track her cycles and see what was going on. I also ordered more in depth lab assessment for other evaluations to see if there were other pieces that were playing a root cause in her PCOS diagnosis. And finally, I also ordered an oral glucose tolerance test, which checked her blood sugar levels as well as her insulin levels in response to a higher carbohydrate load, to evaluate for possibility of insulin resistance, which would make it more likely to be needing to be on the metformin medication. So what we found with Izzy's labs is that she actually did not have any problems with her blood sugar or insulin resistance. She did have some additional adrenal insufficiency, so her cortisol levels were abnormal. And she also had some thyroid dysfunction, which can very commonly run hand in hand. Now, what we find is that if we treat the underlying causes, we support the adrenal glands, and we give appropriate thyroid prescription and supplementation, this would help with our progress and whatever we ended up doing with PCOS treatment. You see, Izzy's body had been under some physical stress for quite some time, dealing with the irregular cycles and the subsequent effects of PCOS. And so we really needed to get back to the basics, treat her body, not just to manage the menstrual cycles, but also to get back to better baseline health for the long run. We also ended up prescribing her some cyclical progesterone therapy to help with her ovulation patterns and getting her cycles back on track. And I'll talk more about this in greater detail a little bit later in the episode. The goal with our treatment and why we chose this path instead of just saying, hey, start on birth control pills and metformin, is that these treatments were going to make it such that she didn't have a significant transition period when she wanted to try and achieve pregnancy in the future. We also were able to positively influence her long term health goals while minimizing side effects of unnecessary prescription strength medications and again get to the root cause of her symptoms to help improve her PCOS symptoms. So let's think back to our subtypes and the criteria we talked about last week when we reviewed the diagnostic criteria for PCOS. and really these things are going to help us to target therapy that are pertinent to your individual symptoms. So we then want to think about things like anovulation or irregular cycles. We want to evaluate hyperandrogenism. So those elevated testosterone levels. either clinically, uh, so things like we might see our facial hair growth or the excessive acne or in your actual lab work. We also want to focus on other pieces as far as targeting therapy, including metabolic treatment if necessary, as well as restoring baseline health when it comes to thyroid function, adrenal glands, and prolactin. So let's start with talking about how we manage anovulation or irregular cycles once we have that diagnosis of PCOS. So, one of the most common prescriptions that we will prescribe is a bioidentical progesterone therapy. Initially, we utilize this medication for just 10 days, and if you're having long irregular cycles, we may start this at any point in time. However, the intention is that we want to eventually get to the point of taking that progesterone timed with your cycle, starting 3 days after ovulation, and this will become more apparent as the cycles get more regular and as we're doing that cycle charting. Okay. Now, the idea with this progesterone therapy is twofold. First of all, it helps to trigger your current cycle to have a withdrawal bleed. So, it may not be a full actual menstrual period, it may not be actual ovulatory, but we want to get that next cycle started so that we can start that process over again and break this cycle of, you know, sometimes three or four or five months worth of Anovulation in these prolonged cycles. The second thing that progesterone therapy does is it helps encourage ovulation to happen the next cycle. So when you have a period, within a couple of days after starting your period, your body starts getting ready for that next follicle development to happen. And so that progesterone therapy can really help to trigger that next ovulation to happen a little bit more normally, so that hopefully we don't continue into these long anovulatory cycles. The other thing that we can utilize to help stimulate regular cycles and stimulate ovulation is actual ovulation stimulation medications like letrozole or Clomid. Now something that's really important with this, especially in the case of PCOS, is that we want to monitor the both your lab levels as well as follicular ultrasound so that we're not hyper stimulating the ovaries. We know that women with PCOS oftentimes already have an excessive amount of follicles and so we don't want to over stimulate things. And this is what really sets us apart in the world of restorative reproductive medicine is that we don't just give these mega doses of ovulation stimulation medications. We're really adjusting those medications, sometimes each cycle in order to make sure that we're not over stimulating. Overstimulating things and this makes things really safe longer term, especially for women with PCOS Something else that we can utilize with irregular cycles or anovulation would be HCG injections. Now you can utilize this either in the follicular phase in order to help encourage growth, or in order to help trigger ovulation to happen, or you can use HCG injections during the luteal phase of your cycle. after you've ovulated to help the developing follicle to produce more estrogen and progesterone. Now the dosing is different, the instructions are different, so HCG injections can have a lot of different uses, but we do use them often with PCOS depending upon, again, what your unique needs are, as well as determining what you need each cycle as we're evaluating that follicular ultrasound and your lab work. So let's shift gears a little bit and talk about how we would treat excessive androgens or testosterone. So again, we're talking not only about clinical signs that we see, but also lab signs that we see. And ultimately, we want to correct the underlying imbalance. And this is going to help correct things long term. So it's not just enough to say we're going to give you a medication or a supplement that's just going to treat you. turn off testosterone, because ultimately we don't want to block testosterone completely, and we don't want to block it long term. The idea is correct that underlying imbalance, which oftentimes is from anovulation or from excess estrogen. And so really getting to the root cause of what's causing that imbalance. elevated testosterone in the first place is going to help us long term. Now, there are also many different medication therapies that we can use to help with hyperandrogenism, and this is oftentimes where metformin does come into play. So, metformin, as you may or may not know, is oftentimes used to treat insulin resistance or diabetes. But metformin also can be used to help and reduce testosterone. In fact, we know that in many women, being on metformin treatment will reduce their testosterone levels by 20 to 25%. Now in some cases this can be a good thing, um, but in other cases if your testosterone levels are already on the lower end or if they're normal, we want to be really cautious with metformin because we don't want to crash your testosterone levels too low. Another treatment therapy that we utilize to help with the treatment of excess androgen levels would be steroid therapy. Now, this is typically going to be very low doses of prednisone therapy, and when I mean low doses, we're talking five milligrams, maybe two or three days per week. For comparison's sake, if you go to the doctor and you get put on a steroid medication because you have either a respiratory infection or an upper sinus infection, Usually that dosage is going to be anywhere from 20 to 40 milligrams for five days continuously. So a significantly lower dose of the steroid therapy if we're using it to treat excess androgens. Again, the other important piece here is that we're monitoring the lab levels over time. So we're making sure that we're not crashing those levels too low. We're making sure we're not creating other problems as we go along. And again, the steroid therapy does not need to be a forever medication. but enough to help and bring those levels down while we are balancing the rest of the cycles. Another common treatment plan that many women get recommended to treat their excess androgen levels is Spironolactone. Now this is an aldosterone receptor antagonist and it's a diuretic medication and it does work fairly well to help with getting rid of excess testosterone in the system. However, I would caution this medication is not safe to take with pregnancy. See it's It's not recommended even if you're trying to get pregnant because it can create some longer term issues. So some of the other medication options are a bit more safe. However, the spironolactone does tend to work fairly well, and it does tend to work fairly quickly, especially for treating things like acne. Speaking of acne, we also do see often times that when you have those excess testosterone levels, we can have some significant problems with acne, especially along your chin, perhaps your upper chest, your upper back, and really the focus again here is to treat that acne with acne medications. So sometimes we'll utilize low doses of topical or oral medications. Antibiotics, sometimes we'll utilize certain different cleansers, and really just talking about good skin care routine, rather than just saying, hey, we have to put you on birth control pill to treat this acne, which is hormonal. If you are dealing with problems of scarring from your acne, if you are dealing with excessive facial hair growth, there are many cosmetic procedures that you can have done to deal with that, as far as those consequences of having the high testosterone levels. However, we always recommend that you wait until after your testosterone levels are lower and that they're more balanced, because if you don't, then the problems can come right back again after you've had your cosmetic procedures. So really importantly, making sure that we get those testosterone levels down, correct the underlying issues to keep them down, is going to be the best option. Again, when we're looking at other forms of treatment for PCOS, we will talk a lot about different things for metabolic treatment. Now, as we discussed last week, having a diagnosis of insulin resistance or elevated blood sugars is not a part of the diagnostic criteria for PCOS. However, we do know that many women with PCOS do struggle with their weight, with insulin resistance, and with blood sugars that are elevated. And so this is the most common indication that I will see or recommend that a woman would start on a medication like metformin or a supplement like myoinositol. What we know with these medications is that they specifically work to treat insulin resistance by lowering your threshold as far as what your body is able to absorb. maintain as far as a steady state for blood sugar. It also helps to decrease how much excess glucose your liver will produce even during the times that you're not eating. When we treat insulin resistance, we know that it improves your ovulation function. And so by getting to that root cause of the metabolic disturbance of insulin resistance, We are subsequently treating and managing the PCOS and again as we reviewed in the last couple of weeks on our episodes We talked about that. This is not just for getting those regular cycles back But also looking at your long term health, with balancing your weight, with decreasing your risk for progression onto diabetes and heart disease. The other mainstay of treatment when it comes to treating the metabolic disturbances are going to be dietary modifications. So again, talking about how we balance your carbohydrates, decreasing your overall carbohydrate load, making sure you're getting plenty of good proteins, Plenty of good, healthy fruits, vegetables, and healthy fats throughout your day, and trying to minimize or decrease your carbohydrate load without taking it down to complete zero. We also want to be doing what we can to manage your weight. And oftentimes this is one of the most common complaints I get of women that are struggling with PCOS is that they are just struggling to maintain a healthy weight. And I want to give you some reassurance today that maintaining your weight with PCOS is is incredibly challenging and you are fighting an uphill battle, but it is not impossible, especially if we are treating the underlying metabolic dysfunction or managing any excess testosterone levels. And we're getting you back to having regular ovulatory cycles. We're going to have a much better chance of helping you to maintain a nice healthy weight and get things better in balance. So again, with all of these treatment things, I just want to make sure that I underline that PCOS oftentimes will coexist with a thyroid or adrenal gland dysfunction, as we saw in the case of Izzy. And it creates that increased chronic stress on your body just having PCOS, which can then in turn create thyroid dysfunction, or it may be that thyroid dysfunction came first and then that helped to exacerbate the PCOS. One final note is that women with PCOS do have an increased chance of having endometriosis, which may require possible surgical evaluation. Now I'm going to chat a little bit more about this in our next week's episode where I talk all about PCOS and fertility, but more importantly, we're going to discuss how to increase your chances for a successful pregnancy if you have been diagnosed with PCOS. oh, With PCOS as well as how to get appropriate evaluation for endometriosis that may coexist with that PCOS. Imagine if you had a better way forward to treat your PCOS rather than just being told to start on birth control or other standard medications that may not be the best fit for you. Now you have a more clear path to working with a health care professional in a way that works best for your body to improve your health and promote fertility. If you're ready to work with our elite team of health care professionals, go to our website RadiantClinic. com to schedule a free discovery call with me and learn more about our package based pricing for comprehensive care. We are currently able to see people for in person appointments in the Cedar Rapids, Iowa area or can arrange for a telehealth visit if you live in the state of Iowa. Illinois, or Minnesota. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom.