PCOS

by Jacqueline N. Brian, LDH, MS, and Diedre N. Heine, BS, CCRA

Did you, or do you, have any of the following problems:
• Adult acne?
• No menstrual periods, or less than eight per year?
• Fertility problems?
• Excess facial or body hair?
• Balding or thinning hair?
• Dark or discolored patches on your neck, arms, or skin folds?
• Excess weight, sudden weight gain, or difficulty maintaining weight?

These are some of the symptoms of polycystic ovarian syndrome (PCOS) listed on the PCOS Association's Web site. Anyone with these symptoms may want to consult a physician about PCOS or other endocrine-related disorders.

PCOS, also known as Stein-Leventhal Syndrome, is the most common endocrine disorder in women of childbearing age, and is the leading cause of infertility in women. It usually develops shortly after puberty and causes an accumulation of undeveloped follicles in the ovaries, which become cysts.

PCOS was identified about 75 years ago, yet many general practitioners and gynecologists are not familiar with it. The cause has not been identified, but PCOS affects one in 10 women, most of whom do not even know they have it. Because it is so pervasive, PCOS has become a major women's health issue. It is treatable with medication, but not curable. Only in the last few years has there been more emphasis on research, and studies are focusing on insulin resistance. This disorder can lead to diabetes and is a potential long-term health risk for hypertension, elevated cholesterol, and heart disease.

Textbooks and documents describe the normal ovarian function as releasing hormones and producing eggs. Estrogen and progesterone are released by the ovaries and are responsible for making the uterus a hospitable environment for embryo implantation and development. The pituitary gland also plays a vital role in ovarian function.

The ovary needs follicle-stimulating hormone (FSH), which signals it to grow a follicle (maturing egg). This occurs at the beginning of the menstrual cycle. The pituitary gland also secretes luteinizing hormone (LH), which causes cells around the follicle to secrete androgens (male sex hormones that occur naturally in women in small amounts). The largest follicle then bursts and releases an egg.

This cycle is quite different for women who suffer from PCOS. For them, ovulation and follicle growth often don't occur, usually because of disrupted levels of either LH or FSH. LH can cause the disruption when it is present in excess, while FSH causes a problem when there is an insufficient quantity.

Extra LH leads to the overproduction of androgens by the ovaries. This can cause excess facial and body hair (hirsutism), acne, weight gain, and multiple cysts on the ovaries which become enlarged. There may be increased blood pressure and thinning of the scalp hair (alopecia). Blood sugar levels can increase and often cause weight gain.

Too little FSH can result in the overproduction of androgens, but it can also yield excess estrogen. These hormone imbalances often lead to follicles that fail to mature, which results in the polycystic ovaries, which are seen in women with PCOS. Infertility often follows because the follicles fail to mature or there is an absence of menses. Bathing the body in excess estrogen and androgens can lead to problems beyond infertility. For example, overexposure to estrogen can lead to endometrial thickening, which can cause cancer.

Research has expanded in the last five to seven years because patients have drawn attention to the impact the syndrome has on their lives. The symptoms are no longer considered just cosmetic, but a real threat to fertility and general well-being for many women.

Treatment consists of:

• An insulin sensitizer, such as metformin (Glucophage®),
• Oral contraceptives to regulate menstrual periods, which decreases risk of endometrial thickening,
• Spironolactone (Aldactone®), which is a diuretic used for hirsutism,
• Drugs such as clomiphene citrate that address infertility. Clomiphene citrate works on the pituitary gland to stimulate the release of ova via increased FSH secretion.

Diagnosis

Because polycystic ovaries are not exclusive to PCOS, additional testing — usually blood tests to check hormone levels — is needed to confirm the diagnosis. It is important to rule out Cushing's syndrome, congenital adrenal hyperplasia, and thyroid problems. The following tests will often be performed:

• 17-hydroxyprgesterone level
• TSH levels
• Androstenedione level
• DHEAS level
• Total and free testosterone levels
• Serum FH and LSH levels
• Fasting insulin and glucose
• 2-hour oral glucose tolerance test
• Fasting lipid and lipoprotein levels

A medical and family history will also be taken and can provide clues to diagnosis. A sister or mother with PCOS, a first-degree relative with Type 2 diabetes, or a history of irregular menstrual periods can be strong indications of PCOS.

Treatment options

The first treatment option that is often recommended is weight loss via diet and exercise. Weight loss will often improve the hormone imbalances, but can be very difficult for women with PCOS due to the effects of insulin resistance, and the carbohydrate cravings that are common with increased insulin levels.

Women with PCOS are often able to lose weight by reducing their intake of carbohydrates. Of the carbohydrates they do consume, they are encouraged to eat whole wheat, brown rice, and beans in lieu of cereals, breads, and pastas.

In the past, Demulin 1/35® was often used as the oral contraceptive of choice for women with PCOS. Recently, a new oral contraceptive has gained popularity: Yasmin®. The Web site for Yasmin® (www.yasmin-us.com) says it differs from other birth control pills in that it contains a different type of progestin, which may affect the excess sodium and water in the patient's body while maintaining, and in some cases, increasing, potassium.

Side effects

The side effect most women complain about with PCOS is hirsutism. Treatment for this includes plucking, shaving, waxing, electrolysis, and depilatory creams, along with a topical option and oral medications. Vaniqa® (eflornithine) has been approved by the FDA for treatment of hirsutism. Reports state that it is well tolerated but often takes six months before patients see results. The oral treatment options for hirsutism include oral contraceptives, spironolactone, flutamide, and finasteride.

Another side effect is acne, and several over-the-counter treatments are available.

Skin tags are also common in women with PCOS, and these can be removed surgically. Acanthosis nigricans, which causes darkening and thickening of the skin, especially in the neck, groin and underarms, is more rare. Treatment is usually via Retin-A®, alpha hydroxy acid, or salicylic acid.

Some women with PCOS experience thinning hair (androgenic alopecia) or male-pattern baldness. This can be helped with anti-androgen treatment or Rogaine® (minoxidil). Extreme cases can be treated with hair extensions or surgical implants.

Oral health care providers should provide encouragement and positive reinforcement for patients on these medications. Many patients lack self-esteem due to their weight gain, so making them comfortable in the dental environment is important. For anxious patients, a stress reduction protocol is appropriate.

Patients who have already developed Type 2 diabetes should be questioned about self-monitoring their blood glucose levels. Since patients on metformin may have drug interactions with aspirin, sulfonamides, and barbiturates, it's important to encourage:

• Adequate hydration
• Adherence to a prescribed diet
• Avoidance of excessive alcohol usage
• Monitoring of weight care
• Smoking cessation

Patients may occasionally experience an unpleasant or metallic taste, which resolves during therapy. Those patients who have developed diabetes may have a longer healing time and be more susceptible to infection.

Since the healing response may be compromised, frequent recalls are necessary.

Patients on spironolactone will need to have:

• Vital signs monitored because of cardiovascular side effects
• Salivary flow assessed because of possible xerostomia and the ramifications for caries, periodontal disease, and candidiasis
• Blood pressure monitored because of the increased risk of elevation.

A semi supine position is best for patients because of the GI effects of metformin and abdominal discomfort of clomiphene. Because patients with PCOS are at risk for diabetes, protocol for potential periodontal disease should be implemented.

Providing total patient care gives us an opportunity to discuss dental and medical health history and potential risk factors with each patient. As valuable resource professionals, dental hygienists can alert patients about the signs and symptoms of PCOS and suggest they consult their physician. Our knowledge about this syndrome and its potential risks will allow us to design our dental hygiene appointments to better fit the needs of the patient.

Jacqueline N. Brian, LDH, MS, is a professor of dental hygiene at Indiana University-Purdue University in Fort Wayne, Ind. Diedre N. Heine, BS, CCRA, is a clinical research manager for Pharmacia Corp. in Kalamazoo, Mich.