Our Bodies, Ourselves (139 page)

The exact cause of PCOS is unclear, although risk increases in women who are overweight. PCOS is more common in certain families. There is evidence for a genetic cause, but the exact gene(s) responsible have yet to be identified.

PCOS results from a combination of several related factors. Many women with PCOS have insulin resistance, in which the body cannot use insulin efficiently. This leads to high blood levels of insulin, called hyperinsulinemia. It is believed that hyperinsulinemia is related to increased androgen levels, as well as to obesity and type 2 diabetes. In turn, obesity can also cause insulin resistance and increase the risk for or worsen PCOS.

Large amounts of androgens can block egg growth and ovulation. Because they are male sex hormones, they can also cause women to develop male secondary sex characteristics such as facial hair or hair thinning at the front of the head.

When a woman has an ovulatory problem, her reproductive system does not produce the necessary amounts of hormones to develop, mature, and release a healthy egg. In this case, the ovaries become enlarged and develop many small follicles. These follicles produce androgens, which further interfere with ovulation. Some researchers believe that the cysts contain eggs that didn't mature and didn't get released during ovulation. Others disagree. Studies have shown that not every woman with PCOS has these numerous follicles. Nor does every woman with these numerous follicles have PCOS. Some women with polycystic ovaries have regular menstrual cycles.

The signs and symptoms of PCOS are related to hormonal imbalance (excess male hormones), lack of ovulation, and insulin resistance and may include:

• Irregular, infrequent, or absent menstrual periods

• Hirsutism—excessive growth of body and facial hair including hair on the chest, stomach, and back

• Acne or oily skin

• Enlarged and/or polycystic ovaries

• Problems with fertility

• Being overweight or obese, especially around the waist (central obesity)

• Male-pattern baldness or thinning hair

• Skin tags—small pieces of skin on the neck or armpits

• Acanthosis nigricans—darkened skin areas on the back of the neck, in the armpits, and under the breasts

In addition, women with PCOS may be at increased risk for developing certain health problems, including:

• Type 2 diabetes

• Elevated cholesterol levels. Triglycerides—fatty acids in the bloodstream—may be higher than normal in some women with PCOS, whereas HDL, the “good cholesterol,” may be lower than normal. This could raise
the risk of heart attacks because arteries and other blood vessels are more likely to be narrowed or clogged over time.

• High blood pressure

• Elevated blood clotting factors

• Missed periods followed by prolonged and heavy bleeding

• Endometrial cancer. Lack of ovulation for an extended period of time may cause excessive thickening of the endometrium (the lining of the uterus). Abnormal cells may build up in the lining of the uterus when it is not shed regularly during a menstrual period. Eventually, some of these abnormal cells may turn cancerous.

• Some studies show a relationship between PCOS and breast cancer.

The symptoms of PCOS may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

In addition to a complete medical history, a physical examination, including a pelvic exam, can be used initially to diagnose PCOS.

A variety of tests can also be used to detect PCOS. Blood tests are used to detect increased levels of androgens and other hormones. Other blood tests can measure blood sugar, cholesterol, and triglyceride levels.

Physicians sometimes use an ultrasound (also called a sonogram)—a diagnostic technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function and to assess blood flow through various vessels. Ultrasound can determine if a woman's ovaries are enlarged and if cysts or follicles are present, and also evaluate the thickness of the endometrium.

Sometimes it can be difficult to diagnose PCOS with certainty because of how it varies, both from woman to woman and even over time in the same woman.

Specific treatment for PCOS will be determined by your clinician based on your age, overall health, and medical history. In addition, your health care provider will take into account the extent of the disorder and expectations for improvement; your tolerance for specific medications, procedures, and therapies; and your preferences. Treatment also depends on whether or not you want to become pregnant.

For women who do not want to become pregnant, treatment is focused on treating the symptoms and preventing long-term consequences of the condition. Treatment may include the following.

Weight reduction:
A healthy diet and increased physical activity allow more efficient use of insulin and decrease blood glucose levels, and also lower risk of heart disease and diabetes. Some women with PCOS who lose weight will start having regular periods.

Oral contraceptives:
Birth control pills may be prescribed to regulate menstrual cycles, decrease androgen levels, control acne, prevent balding or hair thinning, and decrease facial hair.

Cyclic progesterone:
Can be prescribed intermittently to ensure women don't go too long without a period.

Spironolactone:
A less common but often helpful treatment that can minimize excess hair growth. Other procedures such as bleaching, electrolysis, and laser hair removal may also be used to decrease facial hair.

Diabetes medication:
Metformin, a medication used in the treatment of type 2 diabetes, is often used to decrease insulin resistance in PCOS. Some preliminary studies of women with PCOS
who are insulin resistant show that such drugs may also help reduce androgen levels, hair growth, acne, balding, and body weight and may help a woman ovulate more regularly. No long-term studies of this form of treatment are available. Some studies have shown a reduction in the risk of miscarriage in pregnant PCOS patients taking metformin, while others have not. Your clinicians will discuss this with you if you become pregnant.

For women who want to become pregnant, treatment is focused on weight reduction and promoting ovulation and may include the following.

Weight reduction:
A healthy diet and increased physical activity allow more efficient use of insulin and decrease blood glucose levels and may help a woman ovulate more regularly.

Ovulation induction medications such as Clomid:
These medications stimulate the ovary to make one or more follicles (sacs that contain eggs) and release the egg for fertilization. Metformin is sometimes used for this purpose as well.

Surgery:
In cases of infertility where drugs don't work, surgical techniques that make small holes in one or both ovaries may be suggested. This surgery often restores ovulation, though not always permanently. Adhesions—scar tissue that can twist the ovaries or make them cling to other organs—are a potential drawback. Because of these concerns, this procedure is rarely performed today.

CHAPTER 23
Navigating the Health Care System

T
he united States does not ensure access to health care and related services. While the federal health care reform law passed in 2010 will make substantive and important improvements, many of us will struggle to get the health care that we need.

Access alone, however, does not guarantee the care we receive will be medically and culturally appropriate or even effective. In order to increase the quality of care, we need to learn how to navigate the health care system maze. This complex task is somewhat easier when we understand medical insurance and health care options, have access to care providers we trust, and know how to find accurate and up-to-date health information.

This chapter addresses some of the social, political, and economic factors that affect our health and the quality of the care we receive and focuses on what we can do as individuals to get good reproductive and sexual health care. For additional information on the broader factors that affect our health, see
Chapter 26
, “The Politics of Women's Health.”

We regularly make decisions that affect our health: every day we make choices like whether to fasten a seatbelt, use a condom, or have a cigarette. These self-care decisions, including what we eat and how we manage stress, can have profound effects on our well-being and need for medical care.

No matter what choices we make, almost all of us will at some point turn to health care providers for advice, testing, or treatment. Sometimes a team of professionals is needed to manage different aspects of care and coordinate different services and treatment plans.

When it comes to reproductive and sexual health, determining when we need care can sometimes be difficult because most aspects of reproductive health and sexuality are not diseases or disorders. Medical care can sometimes lead to medicalization—meaning that normal body processes such as menstruation, childbirth, and menopause come to be defined as diseases that need close monitoring and medical intervention. Medicalization can chip away at our confidence in our bodies and expose us to risks and costs from unnecessary medical tests and treatments.

On the other hand, there are many times when health care providers are needed to sort out whether a troubling symptom is normal or a sign of a problem. And we rely on the expertise of health care providers when we experience illness, chronic pain, or injury. Underuse of health care in these situations may lead to poor health outcomes or drive up the eventual cost of our care.

Making good health care decisions can be challenging. A good decision involves gathering and evaluating information, weighing what's important to you, finding the resources needed to maximize the quality of care you receive, and dealing with the associated costs. All tests and medical treatments have potential positive and negative effects, and each of us values these potential effects differently.

Benefits of a test or treatment may include:

• Gaining important information about your health

• Avoiding or terminating an unwanted pregnancy

• Achieving a wanted pregnancy

• Getting welcome relief from symptoms

• Improving your ability to function in your job or recreational activities

• Acquiring information that will allow you to make better choices regarding your health and health care

• Increasing your chance of living longer

We must balance the likelihood of these benefits with possible negative effects, which may include:

• The possibility that the test or treatment will be ineffective

• The possibility that the test may give unreliable information that may require more
costly or risky tests to confirm, or lead to unnecessary treatment

• Impact on the ability to conceive and carry a healthy pregnancy or to breastfeed a child in the future

• Impact on sexuality or body image

• Increased chance of health problems in the future, such as cancer risk from radiation or certain hormone treatments

• Impact on family and community support systems

• Financial costs

• Effect on ability to work

• Pain and discomfort

• Emotional effects

For some tests and treatments, especially those that are newer, long-term effects are uncertain. Even when research is available, it is more likely to address physical effects than emotional well-being, effects on family or work, or financial costs. As a result, we must often make health care choices without complete information.

Our choices matter because getting too little, too much, or the wrong health care can have serious negative consequences. In addition, the right care may not be the same for all women. Many of the challenges to getting the right care in a timely manner may not be under your individual control. You may lack the time or money needed to follow up on appointments or treatments; there may be errors in your medical record that lead to delays; or your care providers may not tell you about the full range of options because of financial conflicts of interest or simply because they are too busy. We need to advocate for changes in the system, while recognizing the system's limitations and making the best choices we can with the resources available.

I went to my doctor because I was having an awful, burning pain during sex. She did a test to see if cell changes in my vagina could be leading to dryness. The result came back showing a bacterial infection and cell changes consistent with inflammation, which she said was most likely caused by the infection. She prescribed an antibiotic and I was pain-free within a week. Later, my doctor insisted that we do Pap tests every three months just in case the cell changes were from abnormal cells that “fell off of my cervix.” I had done a lot of research on my symptoms and infection and asked a few friends who had medical backgrounds, and we all agreed that such frequent Paps were overkill, especially since I was low risk (I was monogamous with my partner). I got reminders by phone and even a certified letter from the doctor's office reminding me that I “needed” the Pap tests. I know they were just covering themselves in case I had cervical cancer and sued them. But I know I made the right decision, and I've had normal Paps and no pain for nearly a decade since then
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