If you have been trying for a baby but have yet to be successful, you may want to check if you have a condition called Polycystic Ovary Syndrome (PCOS). While this may not sound familiar, it is more common than you think. According to Dr Tan Toh Lick from Department of Obstetrics and Gynaecology at KK Women’s and Children’s Hospital (KKH), PCOS affects one in every 14 women.
What is PCOS?
PCOS or Polycystic Ovary Syndrome is also known as Stein-Leventhal Syndrome. Women with PCOS may exhibit symptoms like:
• irregular or absent periods
• acne, excess facial or body hair
• scalp hair loss
• weight gain, and more
However, being overweight and having the symptoms listed above does not mean that you have PCOS. Your doctor will order a blood test to confirm high levels of male hormones in the blood, and an ultrasound scan to confirm that there are many cysts in the ovaries to confirm.
The causes of PCOS are not known. It may be inherited, or due to environmental factors. As a first step, doctors advise lifestyle changes such as diet and exercise for women who have it.
Take the Signs Seriously
The most obvious sign is that your periods seem to come and go as they please. Claudia Sim, 36, a homemaker with two daughters aged six and three, had menstrual cycles that extended until her periods were almost non-existent. Claudia tried Traditional Chinese Medicine to regulate her cycles but this did not work. As Claudia was in her early 20s then, her gynaecologist advised her to leave it alone until she was trying to conceive.
Why does this happen?
The ovaries, where a woman’s eggs are produced, have tiny fluid-filled sacs called follicles or cysts. As the egg grows, the follicle builds up fluid. When the egg matures, the follicle breaks open, the egg is released, and the egg travels through the fallopian tube to the uterus (womb) for fertilisation. This is the process of ovulation.
“In women with PCOS, the ovary doesn’t make all of the hormones it needs for an egg to fully mature. The follicles may start to grow and build up fluid but ovulation does not occur,” explains Dr Fong Kah Leng of Sincere Medical Specialist Centre for Women.
This lack of ovulation is usually the reason for fertility problems in women with PCOS.
Weight gain could be another sign. Although there are slim women with PCOS, the condition can cause you to put on the kilos. If this has happened and you are obese, this obesity needs to be treated. “Actual weight loss has been shown to restore ovulation in those with metabolic syndrome [http://www.hpb.gov.sg/HOPPortal/dandc-article/590]. In addition, it can help reduce or prevent many of the complications associated with PCOS, including Type 2 diabetes and heart disease,” Dr Fong says.
The Possible Scenarios
Women with PCOS may undergo a procedure called Laparoscopic Ovarian Drilling (LOD), where shallow punctures are made on the ovaries. This helps to decrease testosterone secretion and boost fertility. For some women, however, this is not enough.
During a routine health screening in 2009, Zheng Pei Yee, 28, a sales support specialist, discovered a cyst in her right ovary. After a year, it was still there. Pei Yee saw an obstetrician and was diagnosed with PCOS. She was then prescribed contraceptive pills to balance her hormones.
One day, Pei Yee felt a sharp pain at the location of the cyst. She had to undergo emergency surgery and a bag-like cyst with smaller cysts within it was removed from her ovary. Before surgery, Pei Yee and her parents had been cautioned that her entire reproductive system could be at risk. Thankfully, this was not the case. Pei Yee now monitors her condition through annual pelvis screening, and is engaged to be married.
Another concern for women with PCOS is the risk of developing uterine cancer, particularly if menstruation occurs less than three to four times a year. Uterine cancer (which is also referred to as endometrial cancer) is caused by the build-up of the inside lining of the uterus — due to the lack of periods –- and the thickening of it.
“Such women may be offered a pelvic ultrasound scan to assess the lining of the womb (endometrium) for abnormal growth and/or offered hormonal contraceptives or progesterone to induce regular menstruation,” says KKH’s Dr Tan.
Women with PCOS are also more likely to suffer from depression and mood swings, snoring and daytime drowsiness, shares Dr Tan. He advises women who are affected to consult a health professional to identify and manage these problems.
Dr Fong also warns that women with PCOS who conceive either naturally or through assisted reproduction have a tendency to miscarry. On top of that, successful pregnancies may have increased risk of induced hypertension and gestational diabetes.
Trying for a Baby
While having PCOS may cast a shadow on your fertility, the chances of getting pregnant — with fertility treatments — is very good, says Dr Fong.
First, medicines like Metformin or Clomiphene are used to induce ovulation. Metformin helps manage the weight and menses of women with PCOS — particularly in those complicated with Type 2 diabetes — when lifestyle improvement fails, or when hormonal contraceptives are not appropriate.
Clomifene (Clomiphene or Clomid) is a medication to help stimulate ovulation to enable women to conceive — if there is no other reason why they do not conceive. “If this medication is not effective, then injections of a small dose of gonadotropins may be necessary,” adds Dr Fong.
Laparoscopic Ovarian Drilling (LOD), a treatment to trigger ovulation, may also be used. This surgery is not commonly used. But it can be an option for women who are still not ovulating after losing weight and trying fertility medicines.
The final line of intervention would be In-Vitro Fertilisation (IVF). If there are other conditions such as severe endometriosis, male factor infertility and tubal damage, IVF may be used earlier.
“When trying for my first child, I took Clomid to stimulate ovulation. We were fortunate to get pregnant on the second cycle. When trying for my second child I took Clomid again but was still unsuccessful after six cycles of the medication. I understood from my obgyn that we should not take more than six cycles of Clomid as it could increase our risk for ovarian cancer. Hence, ART (Assisted Reproductive Technology) was needed. We were given the option between IUI and IVF. We chose IVF as it had a higher success rate,” shares Claudia.
During her trying to conceive and pregnancy stages, Claudia also ate healthily and took the hormonal support medication prescribed by her obgyn.
“My first gynae who diagnosed me did not provide much information on my condition other than that it would affect my TTC (Trying To Conceive) chances. Of course this was 10 to 15 years ago,” says Claudia.
She continues, “My current gynae has informed me that if I do not get a period at least four times a year, my risk for uterine cancer increases tremendously. Her suggestion is to take hormone pills every three months to induce a period or take birth control pills to regulate periods if I do not get them naturally.”
Improve Your Lifestyle
In her book Natural Solutions To PCOS, Dr Marilyn Glenville describes how PCOS operates in a vicious cycle: increased insulin (the hormone which regulates the amount of glucose in the blood, the lack of which would cause diabetes) increases testosterone (male hormone which prevents ovaries to function properly and causes extra hair growth) which exacerbates insulin resistance, leading to more weight gain.
It doesn’t mean that if you are overweight, you have PCOS. But if you have PCOS, your weight would be harder to shift. As Dr Glenville confirms, “a woman with PCOS can eat the same amount of calories as a woman without PCOS, but still gain more weight”.
There is hope though. Eating well and living an active lifestyle can help with PCOS management. Ms Nehal Kamdar, a Senior Dietition from the Department of Nutrition and Dietitics of KKH advises, “If you are overweight, losing five to 10 per cent of your current weight may help normalise menstrual cycles and reduce insulin resistance.”
These are the recommended steps to take:
• Limit refined carbohydrates such as white bread, white rice and plain biscuits. Choose whole-grain foods such as wholemeal bread, wholemeal pasta, barley, oats instead. Whole grains take longer to digest and absorb. This helps you feel fuller for a longer time and helps maintain blood glucose level.
• Reduce dairy product intake to bring your level of male hormones under control. When you do consume dairy products, opt for the low-fat or non-fat versions.
• Reduce alcohol intake to improve the function of your liver. Consuming alcohol adds empty calories which lead to weight gain.
• Reduce caffeine intake to rest your adrenal glands who are responsible for releasing hormones.
• Reduce saturated fats and stop all trans-fats intake to avoid possible inflammation.
• Choose lean cuts of meat, remove the skin from poultry and use healthier cooking methods such as steaming, boiling, stir-frying or pan-frying instead of deep-frying.
• Consume foods rich in Omega-3 fats so that your body will be more sensitive to insulin to overcome insulin resistance. Eat fish two to three times a week. Not only will the protein help you feel fuller for a longer time, deep sea fatty fish such as tuna, salmon, herring and sardine contain fats to improve heart health.
• Eat more vegetables, peas, and beans to raise the protein needed to control the male hormones. This will also cover your daily requirement of 25 to 30 g of dietary fibre.
• Avoid sugar and smoking as best as you can and exercise regularly.
By controlling insulin levels, the ovaries will produce less testosterone, allowing you a more healthy balance of hormones. This, in turn, would help to trigger ovulation.
Eggs in blue bowl image: Geri-Jean Blanchard