[music plays] [no dialogue] >>Lori Banks: On today's edition of Being Well, our guest is OBGYN Mildred Nelson from Effingham.

Our discussion will be about an issue called polycystic ovarian syndrome.

PCOS is a condition that affects many women, who may only discover they have it when they're trying to get pregnant.

However, early diagnosis can help with long term side effects such as diabetes and hypertension.

We'll learn more about the symptoms and the treatment options available.

Stay tuned, Being Well starts right now.

[music plays] Production of Being Well is made possible in part by: Sarah Bush Lincoln Health System, supporting healthy lifestyles.

Eating a heart healthy diet, staying active, managing stress, and regular checkups are ways of reducing your health risks.

Proper health is important to all at Sarah Bush Lincoln Health System.

Information available at sarahbush.org.

Dr. Ruben Boyajian, located at 904 Medical Park Drive in Effingham, specializing in breast care, surgical oncology, as well as general and laparoscopic surgery.

More information online, or at 347-2255.

>>Singing Voices: Rediscover Paris.

>>Lori Banks: Our patient care and investments in medical technology show our ongoing commitment to the communities of East Central Illinois.

Paris Community Hospital Family Medical Center.

HSHS St. Anthony'’’s Memorial Hospital, delivering health care close to home.

From advanced surgical techniques and testing, to convenient care for your family.

HSHS St. Anthony?s makes a difference each and every day.

St. Anthony'’’s.

Where you come first.

[no dialogue] Thanks for joining us for today's edition of Being Well.

I'm Lori Banks.

And Dr. Mildred Nelson has returned to the show today to talk to us about something called polycystic ovarian syndrome.

Welcome back.

>>Dr.

Mildred Nelson: Thank you, Lori.

>>Lori Banks: So, talk to us about what this is.

I had never heard of it before until you brought it up.

>>Dr.

Mildred Nelson: It's a biochemical disorder.

It's a genetic disorder, so you're born with this tendency.

And it can tend to run in families.

And it does not really manifest itself until puberty.

And what you will notice is that you'll have markedly irregular periods.

You may have issues with acne, you may have issues with excessive hair growth.

So, you might have a beard and you have to share, you get a little hair on your boobs, you get hair where-- >>Lori Banks: Hair where you really don't want it.

>>Dr.

Mildred Nelson: Right, hair on your abdomen.

You have weight management issues.

It's harder for you to lose weight, and you tend to be, most PCOS patients tend to be a little overweight.

As you get older, when you want to have children you have difficulty getting pregnant.

And then later on in your life you have a significantly increased risk of developing diabetes, hypertension, so chronic medical conditions.

>>Lori Banks: Where does the name "polycystic" come from?

>>Dr.

Mildred Nelson: So, the sort of root cause of this problem is that circulating in your body are higher levels of what we call androgens, which are male hormones, and insulin levels.

So, the amount of insulin, for example, if I have PCOS that circulates in my body to maintain a normal blood sugar is higher than, for example, yours.

And that insulin acts on the ovary to increase androgen production and make many sort of larger little cysts in the ovaries.

We describe a rosary bead appearance to the ovary, meaning that the perimeter of the ovary will just have like little cysts.

You know, we have millions of cysts on our ovaries, but they're generally too small to really see.

So, these are bigger and they have fluid in them.

And the fluid stimulated by that insulin is androgens, which then express themselves.

And they then inhibit the normal ovulatory process.

So, when my brain sends out a signal, it's time to ovulate this month, those cysts prevent that ovulatory process from occurring.

And no one sort of ovulatory cyst develops.

>>Lori Banks: So, why do they call it a syndrome and not disease?

Is there any reasoning behind that?

>>Dr.

Mildred Nelson: Hmm, good question.

No, so it's a disorder that you're born with, so it's not something you acquire.

So, when I think of a disease, you know, you've got the flu, you've got a cold, yeah.

>>Lori Banks: Is it something that is genetic?

If your mom had it, might you have it?

>>Dr.

Mildred Nelson: Yes, there is a strong genetic tendency towards it.

>>Lori Banks: How is it even discovered in the first place?

>>Dr.

Mildred Nelson: So, it's an interesting story.

So, it was initially understood by infertility specialists, which we call reproductive endocrinologists.

So, you grew up, and who cares if you only have one period a year.

Why would that bother you, right?

And you know, yeah, you had hair on your chin, but you did electrolysis or you waxed your chin, or whatever.

But then you wanted to have kids, and you couldn't have kids.

So, patients were referred to the infertility specialists, who in studying the process of why these patients didn't get pregnant came to understand the endocrine or hormonal abnormalities in these patients that contributed to their infertility.

And then led, you know, obviously to the development of medications to help them get pregnant.

>>Lori Banks: So, really general practitioners didn't even know about it or didn't-- >>Dr.

Mildred Nelson: No, it was that focus, you know, where your primary care physician would become aware of an issue is you'd present with high blood pressure or you'd present with diabetes in middle age.

And all that stuff of irregular periods was sort of irrelevant, right?

The issue was your hypertension or your diabetes, or your weight management or whatever.

>>Lori Banks: So, how common is it?

I mean, are you treating patients with this?

>>Dr.

Mildred Nelson: I see patients all the time.

And I will say I think early diagnosis can be very helpful.

Because, you don't want to be that person at 50 who has hypertension or diabetes.

And it would be nice to know ahead of time what you can do to help enhance your fertility.

And so, yeah.

>>Lori Banks: So, early diagnosis.

When, like some of your patients, some of your younger ones, like what age are they coming in to see you?

20-somethings or even younger?

>>Dr.

Mildred Nelson: Even late adolescent, you know, late teens, 20s, primarily in their 20s.

>>Lori Banks: So, if someone is watching this and maybe, you know, mom's watching it and her daughter has some of those symptoms, what should she do?

>>Dr.

Mildred Nelson: So, I think if, you know, the average age that somebody goes through puberty or starts having menstrual cycles, you know, 12 to 14, and initially a lot of young women don't have regular periods.

But after a year or two, if you don't have regular periods I think being evaluated is helpful.

And because, for example, if you take somebody who has irregular periods and you put them on birth control pills, which are hormones to suppress this process, you retard the progression of the process.

So, untreated over time it gets worse.

It doesn't get better, or it doesn't like exist and that's all it is.

It progressively gets worse.

And people who go through life, let's say, you know, starting at 14 you have one period a year, basically double their risk of getting uterine cancer in their 50s.

So, you can reverse that tendency.

>>Lori Banks: We're going to talk in just a minute about some of those serious long term side effects that you've mentioned.

How do you go about treating it?

You talked about birth control pills.

But if someone comes in fairly young, is birth control pills, is that the first course of action?

>>Dr.

Mildred Nelson: So, first I would want to make the diagnosis.

So, to make the diagnosis, you know, besides just the history the patient has, their personal history and their family history, would be, the next step would be physical examination.

So, do you have hair issues, do you have weight management issues, do you have acne issues.

And then I do a series of blood tests and an ultrasound.

So, the blood tests are to measure your fasting insulin level.

So, if we think about a menstrual cycle, when the menstrual cycle starts your hormones should be at a certain level.

And then as life goes on and we ovulate, or the month goes on and we ovulate, those hormone levels fluctuate.

But in the beginning they should be low.

So, if you came in to see me and you had at day three, so in the third day in your cycle, fasting insulin level greater than or equal to nine, I would be concerned for polycystic ovarian syndrome.

And then I would measure your testosterone levels, your androgen levels, the brain hormone called FSH that's supposed to stimulate ovulation.

There are some other much rarer endocrine metabolism disorders that can also kind of mask themselves as being polycystic ovarian syndrome.

So, there are some less common hormone levels that we sometimes measure to evaluate for those things.

And then I would order an ultrasound.

>>Lori Banks: To see if those cysts are-- >>Dr.

Mildred Nelson: Right, and you're looking for numerous cysts in the ovaries.

And then if I make that diagnosis, the first line of therapy in a young woman would be birth control pills.

>>Lori Banks: So, what's the reaction to maybe a mom saying, "Well I'm going to put your 14 or 15-year-old on birth control pills."

Do you get some adverse reaction to that?

>>Dr.

Mildred Nelson: So, I think you have to, you know, we call them birth control pills.

They're medication.

Happen to provide birth control, but they're medication to suppress the progression of a problem and enhance your ability or your child's ability to be able to have children in the future.

So, I see it as something that's beneficial.

There's another drug that we often use for treatment of polycystic ovarian syndrome.

It's called metformin.

Metformin is a common drug used by middle-aged people who have diabetes.

It's an insulin sensitizing drug, and it decreases your body's circulating insulin levels.

So, you could approach it with starting patients on metformin.

And it is a drug that we would give you if you were in a situation that you wanted to start having a family.

That would be my initial treatment for you.

So, and then, you know, so you could treat the physiologic manifestations of the polycystic ovarian syndrome.

So, young kids are, young adults are very concerned about, you know, being too hairy, shaving.

That's a really big deal, right?

And so, there have been, some people believe that a combination of birth control pills and a medication called spironolactone will decrease new hair growth.

It doesn't work very well, so I'm not a big fan of it.

The second thing you can do is, you know, electrolysis, waxing, you know, all of that sort of thing.

Threading, blah blah blah, shaving.

But the advent of lasers for hair removal, you know, is really becoming more cost effective and more effective long term.

And I personally think that if somebody has a significant problem with hirsutism, which is the medical term for hair growth, seeing a medical esthetician for laser therapy is the most effective.

>>Lori Banks: Because going on the birth control pills is not going to do anything for the hair growth.

>>Dr.

Mildred Nelson: It's not going to make it go away.

It may suppress when combine with spironolactone new hair growth, but it's not going, it'll suppress to some extent, but not 100%.

>>Lori Banks: What about, you know, weight gain is one of the side effects.

Does being on the birth control pill do anything for the weight gain?

>>Dr.

Mildred Nelson: So, studies of looking at birth control pills in terms of do you gain weight...

This is how I pitch these to the patient.

Taking birth control pills is like when you first get pregnant, right?

You've got a lot of hormones circulating and your appetite increases.

So, initially when you start birth control pills you're a little bit hungrier.

But the studies that look at long term birth control use do not show an impact on weight.

So, I tell patients be aware that in the first month or so that when you're on it, you're going to be hungrier, and then just don't eat more.

[laughing] Because that side effect will go away.

That's called tolerance.

>>Lori Banks: So, what about, so maybe someone who doesn't want to have kids right away, they go on the birth control pill.

After they get married, they decide I want to have kids, they go off their birth control pill.

What do you do then for the polycystic?

>>Dr.

Mildred Nelson: Well, so I would put them on metformin.

That would be my initial therapy.

And that might be sufficient for them.

>>Lori Banks: Can you ever do something as radical as just, if you remove the ovaries it gets rid of the problem, or not?

>>Dr.

Mildred Nelson: So, why would I remove the ovaries?

>>Lori Banks: Yeah, if the syndrome is happening, occurring in the ovaries, if you remove someone's ovaries, does that get rid of the polycystic ovarian syndrome?

>>Dr.

Mildred Nelson: So, I think it's more than just your ovaries.

You have elevated circulating insulin levels.

>>Lori Banks: Okay, so it just occurs in there, but they're not really the problem.

Your ovaries are not-- >>Dr.

Mildred Nelson: No, I think they're...

So, it's the effect of the hyperinsulinemia, right, elevated insulin on the ovaries that creates a process that's like going around and around, and getting worse, and worse and worse over time.

>>Lori Banks: So, there really is no, there's no surgical option because it's not a surgical problem.

>>Dr.

Mildred Nelson: Nobody would recommend oophorectomy for polycystic ovarian syndrome as a treatment.

>>Lori Banks: Alright, so once you have it, you're always going to have it and it's something that's just treated with medication?

>>Dr.

Mildred Nelson: It is something that you are born with that is genetic.

>>Lori Banks: Alright, what about when someone hits menopause?

Does it, because your hormones change as you get to menopause, does it kind of go away at that point?

>>Dr.

Mildred Nelson: So, the focus of PCOS has all been on young people and the physiologic manifestations of hirsutism or hairiness, and irregular periods and inability to conceive.

You're asking an interesting question.

I think these are questions that we-- >>Lori Banks: That are still being researched.

>>Dr.

Mildred Nelson: Researching and looking into.

I'm not sure I could answer that.

>>Lori Banks: Alright, well we'll have you back in 20 years to see if things have changed.

Now there are serious long term side effects.

You've kind of talked about them: diabetes, high blood pressure.

You know, just that whole metabolic syndrome can kind of happen to you.

So, let's, for being undiagnosed or untreated, let's get into side effects that could happen that will affect people later in life.

>>Dr.

Mildred Nelson: So, I see this a lot.

And so, when you get pregnant you have gestational diabetes, or when you get pregnant you have an increased risk of miscarriage with PCOS.

Or when you get pregnant you have an increased risk of preeclampsia or toxemia in pregnancy.

After your pregnancy you may continue to have diabetes.

You may develop hypertension, and then you have all the risks that go along with that.

And your metabolism is different and you have trouble with weight management.

And then you develop all the sequelae of adult, you know, chronic medical disorders from hypertension, diabetes and obesity.

>>Lori Banks: And the older we get, we're kind of at risk for getting those.

So, if you have hypertension, diabetes, you're also going to have heart disease.

So, it's just a big-- >>Dr.

Mildred Nelson: It's a cascading problem.

>>Lori Banks: So, if you treat it early, can you-- >>Dr.

Mildred Nelson: Well, so there is a really good question.

[laughing] I don't know if I can...

So, obviously there, so if you control your weight you decrease your risk of diabetes, you decrease your risk of hypertension.

You can't change this predisposing factor.

But if, so the question I guess would be, you know, if I take insulin sensitizing agent metformin from the age of 16 on, will I have a lower incidence of diabetes, hypertension and the sequelae of those medical diseases later on?

I don't know that we have done that study yet.

>>Lori Banks; So again, another, you know, it's something-- >>Dr.

Mildred Nelson: It's a great question, you know.

If I take chronic medication to suppress the progression of my genetic disorder, will it manifest itself in a healthier, later on, in a healthier life later on.

>>Lori Banks: Talk about your patients that come in with it.

Are they having good results after they've taken the... You've put them on birth control.

Are most people, you know, well you probably don't, you can't get rid of the syndrome, but are you seeing good results with those patients that come in early and get the diagnosis, in terms of their symptoms and you know, things like that?

>>Dr.

Mildred Nelson: So, most people enter the medical community after they've seen some, they've had some symptoms.

So, in terms of the hair growth, I mean they're going to have to go have some treatment for that.

You know, if we could capture all these people in adolescence, I could potentially say yes to that question.

I think there still is a major focus for this disease on "I want to control it so I can have a child."

I'm not seeing patients coming in saying, "I want to see you to make this diagnosis so I don't get diabetes 30 years from now."

>>Lori Banks: It's more, they're thinking more the short term.

>>Dr.

Mildred Nelson: Yeah, they're young people.

And the world of adult medicine isn't saying, oh I'm really focusing on could you have this syndrome and, you know, you need to get early intervention so you don't develop hypertension or diabetes.

And those ongoing studies I think, you know, that's research for the future.

>>Lori Banks: That's right.

So, let's talk about what someone should do to prepare for a doctor's visit.

What kind of information, so if they think they have this, they want to come see you or their general practitioner, what sort of information should they as the patient come in with so they can get the most, so the doctor can get the most out of the visit?

>>Dr.

Mildred Nelson: So, I think family history is important.

So, talk to your mom and your grandma, and you know, cousins.

Family history of infertility, family history of high blood pressure, family history of diabetes, is everybody in your family overweight, would be very helpful.

And then your personal health history.

So, when did you start having periods, how often do you have periods.

Have you ever tried to get pregnant, did you have difficulty getting pregnant.

Have you struggled with hirsutism or hairiness.

You know, what have your personal struggles been.

There's another thing that sometimes people get, which is called acanthosis nigricans, which is if you raise your armpit you'll be like excessively brown under your armpits.

>>Lori Banks: Skin darkening.

>>Dr.

Mildred Nelson: Right, so you know, you wouldn't want to go outside in a bikini and, you know, do that, and then when you sit in the sun it gets darker.

So, that's another issue that they may present with.

Do you shave.

A lot of these people shave.

And there's a lot of shame in this.

So, not a lot of people want to come in and just volunteer it.

Okay, so I would say of all the PCOS patients that I see, maybe 10% would come in and say, "Could you please tell me why am I shaving?"

It's more I get to know them and I chat with them, and at the end of the conversation I'm like, "So, what do you do for your hair on your chin?"

You know, and some people can get like, you know, I mean literally hair all over and male balding, I mean all kinds of manifestations.

>>Lori Banks: Yeah, it's not something women, a lot of women want to admit to.

>>Dr.

Mildred Nelson: No, and they're embarrassed.

>>Lori Banks: You know, and then you're, you know, maybe gaining weight that you don't want to.

So, you're right about it being something that you don't really want to advertise.

But there's treatment out there that can help from different sources.

Is there anything else we need to know about PCOS before we wrap up?

>>Dr.

Mildred Nelson: I would just say one thing.

There have been some interesting developments in assisting fertility.

So, initially the primary medication to help somebody with irregular periods to ovulate is called Clomid or clomiphene citrate.

But in the last five to 10 years, there is a drug called letrozole, which now is becoming the drug of choice for ovulation induction in PCOS patients, which has been shown to be far more effective than Clomid.

So, a lot of PCOS patients think they're never going to be able to have a kid, they're going to have to spend a lot of money doing IVF, yadda yadda yadda.

I think PCOS patients can get pregnant with a little assistance much more readily than they could 20 years ago.

And that's very positive.

Now the thing you have to think about is you have the syndrome, maybe your mom had the syndrome.

You're going to have a child, and your daughter may have those same issues.

But as you have alluded to, we will know a lot more by then.

>>Lori Banks: That's right.

Well thank you so much for coming on the show and talking about something that I had never heard of, but clearly a lot of people have or may have and they're born with it, and there's treatment out there.

So, thanks.

Dr. Nelson, it was great to have you on the show again.

Thanks for coming by.

>>Dr.

Mildred Nelson: Thanks.

>>Lori Banks: Good to see you.

>>Dr.

Mildred Nelson: You're welcome.

>>Lori Banks: Production of Being Well is made possible in part by: Sarah Bush Lincoln Health System, supporting healthy lifestyles.

Eating a heart healthy diet, staying active, managing stress, and regular checkups are ways of reducing your health risks.

Proper health is important to all at Sarah Bush Lincoln Health System.

Information available at sarahbush.org.

Dr. Ruben Boyajian, located at 904 Medical Park Drive in Effingham, specializing in breast care, surgical oncology, as well as general and laparoscopic surgery.

More information online, or at 347-2255.

>>Singing Voices: Rediscover Paris.

>>Lori Banks: Our patient care and investments in medical technology show our ongoing commitment to the communities of East Central Illinois.

Paris Community Hospital Family Medical Center.

HSHS St. Anthony'’’s Memorial Hospital, delivering health care close to home.

From advanced surgical techniques and testing, to convenient care for your family.

HSHS St. Anthony?s makes a difference each and every day.

St. Anthony'’’s.

Where you come first.

[music plays]