Do you know what the most common cause of female infertility is? Polycystic ovary syndrome, also known as PCOS. It is estimated that 15-20% of women will be diagnosed with PCOS at some point in their lives.1 It is the most common endocrine (hormone) disorder for women of reproductive age.2 Approximately 90-95% of women with anovulation (not ovulating) who attend infertility clinics have PCOS.1 It is a major concern for women. So, what do we know about PCOS and what is the latest research on it?
PCOS was first reported in 1935, but the criteria to diagnose it were not derived until much later. PCOS is diagnosed by exclusion, because many other impairments, such as thyroid dysfunction, can have the same symptoms. There is no single diagnostic test for PCOS, but most experts agree to use the Rotterdam Criteria of 2003 to diagnose PCOS, which are that two of the following three symptoms must be present in order for PCOS to be diagnosed: clinical and/or biochemical hyperandrogenism, polycystic ovaries, and/or chronic anovulation.2 Insulin resistance and hyperinsulinemia are common with women with PCOS, however testing insulin levels is not required for a diagnosis of PCOS.1
Three main symptoms:
Hyperandrogenism is an excess of male hormones, such as testosterone, in the female body. It can be clinical, biochemical, or both.3 Clinical hyperandrogenism presents as acne, hair loss, and/or hirsutism (unwanted male-pattern hair growth). Biochemical hyperandrogenism is an increase in androgens (male sex hormones) in the female body and is assessed through hormone laboratory tests.
In anovulation, the oocyte or egg is not released. This can lead to an unpredictable menstrual cycle. Menses that occurs at less than 21 days or greater than 35 days are indicative of ovulatory dysfunction.3 It’s important to know that anovulation can occur with regular cycles as well.
A polycystic ovary is one that has multiple cysts. Follicles in the ovary are stimulated by hormones to release an egg. However, if the egg is not released, the follicle can continue to grow, and turn into a cyst. Experts agree that a diagnosis of a polycystic ovary is defined as having 12 or more antral follicles that are 2-9 mm in diameter and/or the ovarian volume is greater than 10 mL.3 Not every women with PCOS has polycystic ovaries, which is why screening for hyperandrogenism is important.
PCOS is responsible for a number of symptoms and it adversely affects the endocrine, metabolic, and cardiovascular systems.1 Please check out PCOS Awareness Association for more information on symptoms. For a list of health risks associated with PCOS, please visit UCM’s link.
What’s the latest research on PCOS?
Genetic, metabolic, endocrine, and environmental abnormalities all contribute towards PCOS, making it a multifactorial disorder. However, the latest research suggests PCOS may be caused by an elevated anti-Mullerian hormone (AMH).4 In May 2018, the medical journal Nature Medicine published an article by Tata et al. with new evidence that demonstrates an increase of AMH in utero may affect the development of the female fetus contributing towards their development of symptoms of PCOS later in life. Women with PCOS have higher AMH levels: according to Tata it can be two to three times higher than women without PCOS. It used to be thought that AMH typically decreases during pregnancy, but Tata et al’s research found that women with PCOS continue to have elevated levels of AMH, particularly if they are lean. (For some reason, obese women with PCOS do not have the same elevated AMH levels as lean women during pregnancy. More research is needed to fully understand the difference between the two body types.) With this new discovery, Tata and her team wanted to know if an elevated AMH level could cause PCOS. To do this, they injected higher levels of AMH into pregnant mice and followed the neuroendocrine characteristics of the babies. They found that the female mice babies developed PCOS-like reproductive and neuroendocrine characteristics in adulthood. This is an extremely important finding. In the past, researchers thought PCOS was passed genetically, however they were never able to find the exact gene that caused PCOS. It turns out, a hormone is the culprit.
Tata and her team took the research one step further and found a new way of treating PCOS in mice. They administered the drug cetrorelix, which is a GnRH antagonist drug used in IVF treatment, to the babies and found their neuroendocrine abnormalities were normalized. Does this mean the mice were cured of PCOS? I’m not sure, but it does open the door for new treatment that can potentially restore ovulation and pregnancy for women. The researchers are planning a clinical trial of cetrorelix to women with PCOS soon.5 We’ll need to keep an eye out for their findings.
Treatment:
For now, treatment of PCOS is focused on alleviating symptoms. Here’s a checklist that your doctor might go through.
- Treatment for androgen related symptoms:
- Oral contraceptive pill (OCP) is the first line of treatment
- Hair removal for hirsutism: laser hair removal, waxing, or prescription creams
- Antiandrogen medication, such as spironolactone, if OCP and hair removal don’t work
- There is limited data on appropriate treatment for alopecia
- Treatment for hyperinsulinemia:
- Metformin, which lowers insulin by improving insulin sensitivity and in return can decrease circulating androgen levels
- Treatment for anovulation:
- OCP, such as a cyclic progestin or a low dose combined hormonal contraceptive that contains estrogen and progestin, to help with inhibiting endometrial proliferation – this is the primary recommended treatment
- Weight loss: 5-10% reduction in weight can improve androgen levels and improve menstrual function and possibly fertility.1
- Treatment for infertility:
- Weight loss is the first-line of treatment
- Clomid is the first drug of choice
- Works by causing the release of GnRH by the hypothalamus leading to an increased release of FSH from the pituitary gland
- IVF (In vitro fertilization)
- For more information on fertility, please visit Rachel’s blog
Finally, how can pelvic floor physical therapy help?
Pelvic floor physical therapy can help with the pain that can be associated with PCOS, which can include abdominal pain, pelvic pain, pain with sex, and dysmenorrhea (painful periods). Not every woman with PCOS experiences pain, but some do, and PT can help. Visceral manipulation, which is a manual therapy technique used to help restore normal movement and function of the organs, may help with fertility. Research is limited on visceral manipulation and PCOS; however, if you have had a good experience with it, please leave a comment in the comment section below. To find out what a good pelvic floor PT treatment session is like, please read Stephanie’s blog.
PCOS is a major concern for women; however, treatment is available for the associated symptoms, and the latest research brings hope for a cure.
References:
- Surmins S and Pate K. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clinical Epidemiology. 2014. V.6.
- Goodman N, et al. American association of clinical endocrinologists, american college of endocrinology, and androgen excess and PCOS society disease state clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome – part 1. Endocrine Practice. Nov. 2015. Vol 21 No.11.
- McCartney C. and Marshall J. Polycystic ovary syndrome. N. Engl J Med. July 2016. 375(1): 54-64.
- Tata B, et al. Elevated prenatal anti-Mullerian hormone reprograms the fetus and induces polycystic ovary syndrome in adulthood. Nature Medicine. June 2018. Vol 24, 834-846.
- Klein, A. Cause of polycystic ovary syndrome discovered at last. NewScientist. May 14, 2018. https://www.newscientist.com/article/2168705-cause-of-polycystic-ovary-syndrome-discovered-at-last/
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
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