Dr. Amy Nett: I don’t even love the diagnosis of polycystic ovarian syndrome. PCOS here is polycystic ovarian syndrome. It’s kind of a catch-all diagnosis that I think gets thrown around a lot. I use a combination of the DUTCH profile, so I actually look at the complete hormone profile, and what I’m looking for there is a higher production of androgens with relatively low estrogens, and then I’m also looking at the blood panel. I’m looking for any markers of insulin resistance, so I’m going to be looking at fasting blood sugar, hemoglobin A1c, and I also look at triglycerides as an indicator of metabolic dysfunction. Between the combination of the hormone profile, seeing more androgens than estrogens, and then seeing markers of metabolic dysfunction, namely markers of insulin resistance—like high triglycerides, high hemoglobin A1c, and high fasting blood sugar—that’s enough for me to sort of go down the “PCOS pathway,” and that’s mostly going to be supporting metabolic function with things like, maybe, inositol. Inositol will both help with the insulin sensitivity, and it may also help with a decrease in the androgens and a shift to estrogens, so I’ll use something like inositol, vitex, or chaste tree if we need to bring up progesterones, and I might use something like Metabolic Synergy and GlucoSupreme if it looks like there are some insulin resistance issues.
I don’t love to definitely call someone PCOS just because I see that term a little bit too frequently and kind of being thrown around when we just don’t know what else to label something when there is irregular menses and some hormonal imbalances. Classically you want to see a very characteristic finding on ultrasound, which is actually pretty rare to see. It’s surprisingly difficult to see polycystic ovaries on ultrasound because most normal ovaries have cysts, and I think it’s really difficult to differentiate what are normal cysts on the ovaries versus what are truly PCOS. There’s a characteristic appearance of them, but it’s rare to actually see them, so I don’t even necessarily suggest that people get an ultrasound for PCOS. It might clinch the diagnosis, but again, does it really change how you’re going to manage that hormone imbalance and the metabolic dysfunction? Probably not.
Oh, what do I call it then? I call it hormonal imbalance and metabolic dysfunction. I use descriptive terms. If I need to throw in an ICD-10, I think it’s fair to call it PCOS, but I just think it’s a difficult diagnosis to really make. And if I do give a patient a diagnosis of PCOS, I’ll kind of explain that. I’ll say, “I don’t really like this diagnosis, but it’s sort of describing what we’re seeing here in terms of the metabolic dysfunction and the hormonal imbalance.” But, too, a lot of women will then go read about PCOS, and it’s not the most flattering syndrome to have. It’s hirsutism and male characteristics and this sort of thing, and people don’t always want to have that diagnosis either. If it’s truly PCOS, I think it’s hard to say definitively, so I’m just more descriptive. I would say there’s a hormonal imbalance with higher androgens, lower estrogens, and there’s some metabolic dysfunction. We could look at these and basically consider it within this sort of catch-all term of PCOS. And because I do sometimes recommend that they maybe read a little bit more about it, especially if I don’t have patients who are really coming from a strong ancestral health background, there’s one book I like. I think it’s called The Ultimate Guide to PCOS, and then another one of my PCOS patients bought a book called Period Repair Manual, which is actually a pretty good, I think, overview because it is a really complex syndrome, so it can be helpful from that sense if you have patients who want to learn more about it, read more about it, giving them that framework to work in.
I think PCOS is such a huge spectrum, and when you look at your patients, the physical appearance, I’ve heard of “thin PCOS” because you have women who have these lab characteristics but they’re not overweight, they don’t have hirsutism, they don’t have acne, and they don’t have the physical characteristics I would expect in PCOS. It’s a huge spectrum, so that’s why I’m reluctant to just throw a label on it. Hopefully that answers that, Laura.