PCOS Management Needs a Makeover

January 25, 2023

PCOS Management Needs a Makeover

PCOS affects up to 12% of reproductive aged females in the United States and up to 20% worldwide. That’s 5 million Americans and over 100 million people worldwide. It's a heterogeneous disorder that is characterized by menstrual irregularities and signs or symptoms of elevated androgen (masculine) hormones and that the majority (approximately 70%) have metabolic disorders, most commonly insulin resistance. People with PCOS have a higher risk of serious diseases like cardiovascular disease and endometrial cancer. People with PCOS seek care for various symptoms and often find themselves being first treated for PCOS according to their most bothersome symptom. By the time I see a patient with PCOS for the first time, they have often seen multiple doctors and specialists before they have come to see me, but more often than not the care is fragmented.

Dermatologists treat their acne and hirsutism, other OBGYNs who treat the irregular menses and menorrhagia, Endocrinologists who treat their insulin resistance, Reproductive Endocrinologists who treat their infertility. Reproductive Endocrinologists are the most knowledgeable about PCOS, but in my experience many do not want to unless in the setting of infertility and they are not accessible to all patients. Psychiatrists who treat their anxiety and obesity, medicine specialists who treat their obesity. Sometimes they are in the care of non-physician professionals. Nutritionists offer excellent nutrition advice but sometimes fail to appreciate some of the real medical risks of PCOS that need to be addressed. Health coaches can offer some great advice, motivation and community but again, not the personalized approach that some people with PCOS need. The supplement industry promotes itself often as a healthy, natural, safer alternative. Supplements may be part of the treatment but the industry as a whole is under regulated.

For me, treating women with PCOS is very rewarding, but in speaking with my OBGYN peers I realize for many it is a frustrating condition to treat. It should be within the scope of generalist OBGYNs or Family Physicians to treat PCOS but we don't always have the tools or the time to do a good job. Our patients bear the brunt of our frustration and they themselves are frustrated as they often bounce around to different specialists, receiving conflicting advice, having their symptoms managed but their underlying condition never treated. They are often given the unhelpful advice of “just lose weight.” My approach to patients with PCOS is not difficult but it is time consuming. As with everything in medicine, it starts with a good history and a proper diagnosis. The history should assess the patient's goals: do they want contraception or do they desire pregnancy? What symptoms are most bothersome to them? What treatments did they try in the past and why did they discontinue them? What supplements are they taking? A diet history is essential.

Physicians can learn tools to complete a nutrition assessment or at very least a screening questionnaire. A screening questionnaire can at least identify some immediate needs, and referral to a trusted Dietitian-nutritionist specializing in women’s health should be made. Emphasis should be made on improving insulin resistance, reducing chronic inflammation and improving gut health.

Education is key. Most of my time with my PCOS patients is spent listening and educating. I use telemedicine as a way to have more frequent engagement with my patients. The OBGYN who is treating PCOS should have a network of referrals at the ready of specialists who are knowledgeable and interested in treating PCOS so that their management plans can be in sync. For example, I am comfortable managing the nutrition portion, prescribing medication for insulin resistance, menstrual disorders or depression/anxiety, but less confident with dermatology and so I have some great referrals from dermatologists who I know are interested in treating PCOS related skin disorders. Multidisciplinary PCOS Centers of Excellence are only just becoming a thing. They bring all the specialists but these are limited. Telemedicine is a great way to bring specialists together to provide comprehensive care and education in an efficient and effective way that is accessible. Social networking is a way for patients to find community but also a way for healthcare professionals to find innovative ways to work together. If you are a person with PCOS who is interested in a more comprehensive approach to PCOS management then sign up here. If you are a physician who would like to learn how to incorporate nutrition counseling into your practice, please contact me.