“Now is a great time; every day is great time to make a lifestyle improvement and know that there is a payoff that comes with that, regardless of having the PCOS diagnosis.”
-Dr. Rashmi Kudesia
Menopause is increasingly on my mind.
As I enjoy my mid-forties, menopause is looming in my immediate future.
I have a lot of questions, starting with, “How will menopause affect me, as a woman with PCOS?”
Dr. Rashmi Kudesia, a nationally respected reproductive endocrinologist, accomplished lecturer, and author of numerous scientific research articles and manuscripts in leading medical journals offers answers. In our recent podcast, she answered many of my burning questions about PCOS and menopause and offered her analysis of current PCOS/menopause research. In fact, she answered many of the questions that PCOS Divas frequently ask me about the topic. Listen in as we discuss
- Why women with PCOS and lifelong irregular menstrual cycles often have regular cycles as they approach menopause
- The differences between women with and without PCOS as they transition into menopause
- Whether there is an increased risk of cancer, heart disease and type II diabetes as we age
- The latest protocol for using Metformin, Letrozole, and Clomid
- Whether women with PCOS have a lengthened reproductive span
- Recommendations for hysterectomy
A complete transcript follows.
Dr. Kudesia is a board-certified Reproductive Endocrinology and Infertility specialist, practicing at Houston IVF in Houston, Texas. She joined Houston IVF in 2018 after practicing in New York City, where she was named a “New York Super Doctors Rising Star” in 2016 and 2017.
After completing her Baccalaureate degree in Biology & Medicine magna cum laude from Brown University, she received her M.D. with honors from the Duke University School of Medicine, where she was selected into a clinical research training program co-sponsored by the National Institutes of Health. Her residency training in Obstetrics & Gynecology at the New York Hospital-Weill Cornell Medical Center was followed by subspecialty training in Reproductive Endocrinology and Infertility (REI) at the Albert Einstein College of Medicine-Montefiore Medical Center, alongside a Masters’ of Science degree in Clinical Research Methods. She subsequently served as a Clinical Assistant Professor at the Icahn School of Medicine at Mount Sinai, as well as the Research Rotational Director for the REI fellowship, and Medical Director of the Brooklyn office of the Reproductive Medicine Associates of New York.
Dr. Kudesia is a Fellow of the American College of Obstetricians and Gynecologists, and an active member of the American Society for Reproductive Medicine (ASRM), Society for Reproductive Endocrinology and Infertility, Androgen Excess & Polycystic Ovary Syndrome Society, and American Medical Association (AMA). She has served in multiple local and national leadership roles in organized medicine, including her current positions as Secretary of the ASRM Women’s Council Executive Board and the ASRM delegate to the AMA Young Physicians’ Section.
Dr. Kudesia has also presented scientific research at national and international conferences, and has received multiple awards and grants for her work. She has published peer-reviewed articles and book chapters, including in leading journals such as Fertility & Sterility and the American Journal of Obstetrics & Gynecology, as well as editing a theme issue on reproductive medicine for the American Medical Association Journal of Ethics. Her current areas of focus include improving in vitro fertilization cycle prognosis, polycystic ovary syndrome, LGBT fertility, and fertility awareness, counseling, and access to care. She actively promotes women’s health and wellness on social media via Twitter, Facebook, and Instagram.
Amy Meddling: Hello and welcome to another addition of the PCOS Diva podcast. This is Amy Meddling. I’m your host. I’m a Certified Health Coach and the Founder of PCOS Diva. Today we’re going to discussing a topic that seems to be really on the minds of a lot of divas and that is what happens with PCOS and menopause? I know there’s a lot of conversation around managing PCOS during our reproductive years and we wonder, you know, what happens during perimenopause and beyond to menopause? I’ve heard a lot of interesting reports from PCOS divas who have been having hysterectomies because their doctors have advised them once they are done having children, let’s remove your ovaries and it will kind of take care of your PCOS symptoms. I have a wonderful article on my site and I’ll link to that from Dr. Felice Gersh, kind of explains that hysterectomies will not cure PCOS. We’re going to kind of talk a little bit more about what a woman with PCOS entering those perimenopause years and menopause should really think about and need to know. I’m just thrilled to be speaking with Dr. Rashmed Kudesia today, so welcome, Dr. Kudesia.
Dr. Kudesia: Thank you so much, Amy.
Amy Meddling: For sure. I just wanted to let people know a little bit about you. I met you recently at the American Society for Reproductive Medicine (ASRM), their annual conference. You were giving a talk about this exact subject, PCOS and menopause. I thought that your talk was fantastic. You really mined a lot of the existing research and then sort of presented the fact based information from studies regarding women and menopause and PCOS. I was thrilled that you agreed to come on and talk to us about your findings.
Dr. Kudesia: Thank you so much, Amy, for having me. This is a really exciting opportunity. As you mentioned, I did give this talk at ASRM because, as you were saying, there’s a lot that we don’t understand about PCOS in general, but particularly as we get sort of later on in our reproductive years and into the perimenopause, there is really even more of a gray area in there. Part of what I was really motivated to do a couple of years back was to go through and do an evidence-based review of what do we know. I’m really excited to share that with you today and hopefully get that information out to as many people as possible. I have a sort of variety of different areas that I think about that are relevant issues, as relates to PCOS and we’ll just kind of go through them one by one and highlight some of the most relevant issues that women might experience as they go through this phase of their lives. So the first thing that we always think …
Amy Meddling: Let me … Dr. Kudesia, let me just interrupt quickly. Just to give listeners kind of your background so they know that you are a reproductive endocrinologist and your specialty is infertility and you treat patients at the RMA of New York in the Brooklyn office. You specialize in treating couples who are trying build their families and you are well recognized among your peers for providing detailed and expert compassionate care. You’re a graduate of Duke University and you are an accomplished lecturer and author and you’ve written numerous scientific research articles and manuscripts in leading medical journals and you’ve presented many research findings at national meetings, including ASRM. Go ahead. Sorry to interrupt you there, but just wanted to let everybody know your background.
Dr. Kudesia: Of course. Thank you. So, yes, definitely. As a reproductive endocrinologist, I do see most of my patients are in sort of in their reproductive years, but a large part of my job is sort of helping prepare people for sort of what happens after they leave my office. PCOS is my specific area of interest, so like I said, this was really interesting question to me and I’m definitely excited to share what I’ve found out there so far.
I think the first area of question is essentially what are the actual symptoms of PCOS and how do those change as we get older. So, the first way to think about it is what are the main diagnostic criteria for having PCOS? The first thing that many of us think of is obviously what happens with the woman’s periods. We know that normally at the time of diagnosing PCOS, we expect there’s going to be in most women either irregular or no periods at all, so the thing that gets difficult is that as we get into the perimenopause, somewhere between 65 and 77% of perimenopausal women are going to be reporting cycles that are sort of out of the normal range. That becomes a pretty common thing to be finding in perimenopausal women in general.
However, interestingly, for women that have PCOS, the opposite tends to happen. After having had potentially irregular menstrual cycles through most of their lives, women might actually find that their cycles tend to become more regular as they approach menopause and that would be sort of contrary intuitive, perhaps especially at that time in their life, a woman has a new gynecologist and comes in and says oh my periods are now coming every 28 days. That might not give a raise of suspicion of oh, does this women have a potential history of PCOS? It is important to remember that if you’re having a new healthcare provider perhaps in the late 40’s and at that time if your cycles are regular, but you have a history of having had irregular menses for most of your life, that would be an important detail to mention.
In light of the fact that the patterns seem to be so different for women that have PCOS, there essentially was a large consensus workshop that came together and that was called The Stages of Reproductive Aging Workshop or the STRAW workshop, and they met and actually had a ten years later meeting again and they concluded that given that our understanding of how menstrual cycles change in the perimenopause in women that have PCOS, the criteria they sort of put forward for predicting when the menopausal transition might happen, shouldn’t be applied to women with PCOS and they really highlighted the fact that we need more research to characterize patterns in women with PCOS, as they transition into menopause. So, that’s sort of the one kind of area of things.
The other aspect or one of the other diagnostic criteria is what we call hyperandrogenism or high levels of the male hormone, the androgen hormones. The way that we test that when we’re trying to make diagnostic information about PCOS is to either look from a laboratory perspective to do certain assays for those different androgen hormones or to actually just look clinically and say does the women have a history of having excess hair on the face or the body, something we call hirsutism or are they having problems with really severe acne or are there other things that indicate that there are high circulating levels of these hormones? Hirsutism or having the excess body hair is really one of the most troublesome things to women that have PCOS.
Unfortunately, that does seem to persist even through the menopause and so we know that, again, that is one of those things that as women age, in general, their androgen levels rise relative to their estrogen levels and so many perimenopausal women that don’t have PCOS for the first time start to notice more of a male pattern of hair distribution or have some pesky chin hairs or whatnot, but for women that have PCOS, we found that was a really good longitudinal study that looked at women that had PCOS over 21 years and among many other outcomes that it looked at, it found that women that had PCOS had a 44% incidence of having hirsutism when they were in their reproductive years and a 64% prevalence of having it in their menopausal years. When we compare that to women that were matched by age, but did not have PCOS, we found that in the reproductive years, they had a 6% prevalence, so that’s 6% compared to 44% for women that had PCOS. As the non-PCOS women went through menopause, that incidence was at 9% and that was compared to 64%, so you can see that for women that have PCOS certainly as they go through the menopause, there’s definitely a higher rate of having that troublesome hirsutism.
The reason that that may persist is there some question of what are the actual changes in the hormones that are happening at that time? We know that actually though there are a lot of limitations of doing hormonal testing in menopausal women because of the limits of the tests that we have. They aren’t able to be as specific and sensitive at defining levels below our ranges, which is where we tend to be when we get into that age range, but what we know so far is that it does seem that despite this disparity, that women with PCOS continue to expert more hirsutism and more of these troublesome symptoms, the hormone levels are falling just not as much as we might like. Multiple studies of women with PCOS do demonstrate that there have been reductions in testosterone levels, the other androgen hormone levels, and they actually do come down to levels that are very similar to women that don’t have PCOS, but because those levels rise in women that do not have PCOS and all women as we get to the menopause, like I said, all women are experiencing some of these androgenic symptoms.
So if we looked at multiple women- two different women, one that had PCOS, and one that didn’t, at the this range, we would know that the androgen levels for the PCOS woman have fallen significantly, but despite that there still seems to a relatively significant rate of there being excess hair. So, it has been reported …
Amy Meddling: Can I interrupt quickly?
Dr. Kudesia: Sure, please.
Amy Meddling: Did you find any studies androgenic alopecia or acne and how that relates to the androgen rising or falls of androgen in menopause?
Dr. Kudesia: That’s a great question and unfortunately, you know, I think androgenic alopecia or sort of that male pattern baldness is one really, really troublesome symptom of PCOS that has been really under-researched. I think right now there are a number of people that I can think of that are trying to do more work at looking at that even at reproductive aged women, but there hasn’t been much, you know, looking at … there hasn’t been any study that I’ve found that looked at those issue of acne and alopecia as they get through to the menopause and what happens with that. My supposition would be that, again, despite the patterns of hormones that we see and our hope that, okay, the hormone levels become comparable to women that don’t have PCOS perhaps we would hope that the symptoms would as well, but looking at what has been pretty firmly established in the hirsutism, sort of aspect of things, I would say that unfortunately I think for whatever reason that we don’t understand, some of those patterns and physiology already seem to be pre-established in these women and there’s not anything to suggest that, unfortunately, that all of a sudden these issues might resolve themselves. Which is really frustrating.
Amy Meddling: Yeah.
Dr. Kudesia: One of the thoughts may be, and this is again a study finding that needs more corroboration, though the overall levels of these hormones may be falling, there are some indications that the free level or the free androgen index, which is another way of looking at the actually biologically active components of these male hormones, may remain elevated in women that have PCOS as they go through menopause. So, it may be that perhaps even though the overall levels are falling, if we compare women that have PCOS versus not at the menopause, that biologically active component may still be higher and that might explain some of this disparity in why it persists even though we are going through the menopausal transition. But, we definitely still need more work to be done in this area so we can help guide what are appropriate expectation.
So, the other aspect whenever we think about the male hormones, obviously, we’re also wondering what’s going to happen with the female hormones, the estrogen. The estradiol and estrogen levels are generally higher in reproductive aged women with PCOS, but they also tend to fall to levels that, when they have been measured, are comparable to menopausal women that don’t have PCOS. These patterns are really a part of the normal ovarian aging process, so normally our estrogens are produced by our ovaries as we go through our normal menstrual cycle and so, as the ovary ages at a rate that is really individual in each woman, we expect that the estrogen levels are going to change and as we ovulate less and less, and less robustly as our egg quality goes down with age, those estrogen levels will be falling sort of gradually as well. Not only that, the ovarian component of estrogen is changing as we get older, but also the adrenal gland, which sits right above our kidneys and is also responsible for making a lot of hormones also ages as well. There is changes in the hormone production coming from that adrenal gland as well in both those ages as both as those hormones age, there is that shift in the estrogen and androgen balance in women as they go through menopause.
Basically, I would summarize all of that to say in general, both female and male hormone levels are falling in women as they go through the menopause, but that in women in PCOS it seems that elevated level of male hormone level relative to female seems to persist, at least if we look at the free androgen index in some of the ways that manifests clinically. That is sort of the way I would summarize that. Like I said, with the caveat of the testing that we have available so far.
Amy Meddling: Right, right. Well, tell us about metabolic consequences of PCOS and the risk of Type II Diabetes and even cardiovascular disease. What are the risk factors as we … it is a big risk factor for women with PCOS, but how does that change going into menopause? Is it still a risk? Are we still at risk? Yeah, go ahead.
Dr. Kudesia: I think this is one of the most interesting aspects of this whole questions and so what we know is that even in young women, teenager, and certainly through the reproductive years, having PCOS, independent of being overweight or obese, is associated with multiple metabolic disruptions, like impaired glucose intolerance, Type II Diabetes, having abnormal cholesterol and lipid profiles, etc. We know that conversely again, when we look at menopausal women who are going through the menopausal transition, we know that the risk for cardiovascular disease in all women starts to go up at that time and so initially, my concern and I think for many people, concern in general would be, okay, if as a women that has PCOS you’ve had higher risks of all of these things throughout the reproductive years, does that put you at even higher risk as you go through that sort of that stressful period of menopause which is a time of concern for all women.
I think this is what’s a really interesting aspect of what we know so far is that essentially if we look at the different markers of cardiovascular health, for example, we see that, in general, basically women that have PCOS in a way their risk level sort of seems to taper off to the point where women that don’t have PCOS in many regards seem to be catches up in terms of their risk profile, so for example, if we look at young women that have PCOS.
In general, they have a higher rate of obesity, a higher waist to hip ratio, which is a measurement that tries to quantify where the fat is distributed and we understand that if it’s waist fat or trunk fat, it’s a higher risk metabolic speaking than lower extremity or other places of fat distribution. At that time, they also have higher rates of metabolic syndrome and other cardiovascular risk factors, but by the time those menopausal transitions, that incident of increased waist hip ratio etc. pretty much comes to a level that we see in women that don’t have PCOS and the studies that have looked at this so far, have found there’s no significant difference in the incidence of obesity and waist hip ratio in women that have a history of PCOS compared with control women. Again, like I’m saying, at this point, our understanding is that with some of these things essentially, the risk for non-PCOS women seems to catch up to the risk that women with PCOS have had sort of from a lifelong perspective.
There are a lot of other patterns that have been looked at in terms of a lot of inflammatory markers and the lipid profiles and all of those things that we’re worried about as we go through the reproductive years and again, you know, in looking at lipid profiles for example for one thing, in women that are perimenopausal is been suggested that again these findings and the lipid profile getting worse as we get older is more related to our aging process then the pre-existing PCOS diagnosis. In one study that looked at this, after they adjusted for PCOS … this study particularly by a group led by Elting, found that a variety of conditions, like having high insulin levels, bad lipid profiles, and high blood pressure, were all more strongly related to having obesity rather than having PCOS. I would summarize it to say that PCOS may not increase the baseline heart disease risk factors in women that are aging over and beyond that which is part being either obese, if you already are, or being perimenopausal. Unfortunately, we need more studies to look at this. I think it’s very frustrating because we know that, again, I really try to go myself out of my way to tell my young patients it’s really important to watch your diet and exercise from a young age on forward and to try to avoid the morbidities that come along with uncontrolled PCOS, so Type II diabetes, etc.
All the longitudinal studies have shown that there’s not an increased of heart attack or stroke or basically having very severe morbidity or mortality from PCOS in the post-menopausal years. What I don’t want people to think is okay well, I guess that means that there’s no risk to me. I think that the way I would interpret this data is to say that if we can just help women that have PCOS avoid those morbidities, avoid gaining too much weight, avoid developing Diabetes, and really bad heart disease during those reproductive years, by the time they get to the menopause, their risk is really reduced relative to their reproductive years where having PCOS was such a risk factor, and then at that point, the average age of menopause is 51, so they’re in their early 50’s and I would say, okay, if we’ve been able to for these many years, decades, avoid all of these bad co-morbidities, now your essentially at the same risk of any other perimenopausal woman and again, we just have sort of the normal diet and exercise lifestyle recommendations.
Amy Meddling: That’s really good news, especially for me. I’m going to be 45 next year, so I’m really approaching that 51 average quickly, but knowing that all of the lifestyle changes that I made through my 30’s and 40’s are really going to put me … I’m not going to be at a greater risk for a cardiovascular event, really eases my mind. As long as I keep up with my lifestyle change. What about …
Dr. Kudesia: I think there’s a lot of hope there, yeah. I think that is … there’s a lot of reasons to be hopeful. I think that people feel … when I tell them at age 20 something that you really have a lifelong situation of needing to really be on top of your diet and exercise, sometimes people feel very burdened or depressed by that news, but I think that the good news here is that if we can just be vigilant in those early years and avoid developing early Diabetes in the 30’s or 40’s, that by the time if you’ve established that healthy lifestyle, then you really should be fine. There’s no higher risk of having heart attack or stroke that we’ve found so far, so I think that is really encouraging and hopefully motivating finding for younger women.
Amy Meddling: I’m not sure if you’ll be able to answer this question, but I think women are wondering about like what is the protocols for the Metformin? Is this something they should be taking into perimenopause and menopause? I’m sure you have to look at the patient, but do you know is there any like specific protocol for Metformin for women with PCOS as they age?
Dr. Kudesia: Sure. That’s a great question. I think in general historically in many providers minds there’s this equation that PCOS equals Metformin, and I would really encourage people to move away from that because it’s not indicated for everybody. Metformin definitely is a drug that has significant side effects. For a lot of people it gives them a lot of gastrointestinal disturbances and it’s not super pleasant to be taking. What I would say now, so it used to be that we used Metformin even for women who were trying to conceive as way of helping stimulate ovulation and nowadays we know that there are better medications for that and that has been well studied. Nowadays I would say probably that Letrozole is the number one medication for helping someone to ovulate, aside from obviously talking about lifestyle management and the potential for if we can get to a healthier weight perhaps the periods will come back regularly, cycle regularly on their own, but if aside from that from a medication perspective … go ahead.
Amy Meddling: Just to back up quick, for those who don’t … I think Letrozole … I know Dr. Lagrow has done a lot of work with the studies on Letrozole versus Clomid, but for those haven’t heard of that pharmaceutical, could you just give a quick overview?
Dr. Kudesia: Of course, yeah. Letrozole, essentially what it is, it’s in a class of medications called aromatase inhibitors and aromatase is the enzyme essentially that converts the androgens into the estrogens and so what it does is essentially by inhibiting that process, tricks the brain into seeing a relatively lower level of estrogen and because, as I mentioned in the very beginning, estrogen normally comes from the ovaries. It’s made by the growing follicles, the brain sees that as oh, there’s not any follicles growing and in response to that sends out a little bit more of follicle stimulating hormone to the ovary to try to push it a little bit harder to grow a follicle. By taking Letrozole essentially what we do is sort of help the brain to stimulate the ovary a tad bit harder so that it’s more likely to actually grow an egg and then actually reach the time of ovulation. The nice thing about Letrozole compared to Clomid, there’s probably two main things.
One, especially for younger women in general, Letrozole often times will just stimulate one follicle to grow rather than multiple, which particularly for really young women is always a concern because we are aiming for that healthy singleton pregnancy, so that’s nice. Also, Clomid tends to have an anti-estrogenic effect on the endometrium or the lining of the uterus, so sometimes women that are taking Clomid can have really thin linings and find it difficult to get pregnant for that reason, but Letrozole doesn’t seem to be causing that side effect. That’s another big advantage. The big trial that’s called the PPCOS II Trial, actually published their main findings in the New England Journal of Medicine last year, showing that or maybe it was earlier this year, showing that in women that have PCOS, Letrozole is superior to Clomid in terms of live birth rates and conception rates and even ovulation rates. That tends to be my first go to nowadays for ovulation induction. So, given …
Amy Meddling: I’m glad you mentioned that. I just want to say, I’m glad you mentioned that because I don’t think that’s really out in mainstream yet, and I think it’s going to be up to women listening to really go and advocate for yourself. I’ll have to get an article about that on the site with the research so you can bring the Pub Med studies into your doctor and show them.
Dr. Kudesia: Yeah.
Amy Meddling: Since we’re on the topic of ovulation, was there anything in your research that indicated that women with PCOS had an increased or lengthened reproductive lifespan or they were ovulating longer than their non-PCOS counterparts?
Dr. Kudesia: Right, so that’s another interesting question. Again, we know that throughout the reproductive years in general, women with PCOS have a higher what we call an ovarian reserve or number of eggs that there could be and so our normal measures of ovarian reserves are the antral follicle count, so looking by ultrasound how many follicles are there, looking at the follicle stimulating hormone level, looking at the Anti-Mullerian Hormone (AMH) level and so, all three of those markers of ovarian reserve tend to be higher in women that have PCOS and so in studies that have tried to model it out in a population level, each of those models seems to suggest that, in general, women who have PCOS would have approximately two years longer in terms of their reproductive lifespan. However, when people have actually looked at it instead of just modeling it out, they haven’t found that so far.
Right now, I would say it’s really unclear whether the reproductive lifespan is lengthened or not because though when we model it out it seems like it should really be that women are seeming to have higher ovarian reserve throughout their reproductive years, and so therefore wouldn’t you think that they should go through menopause a bit later. No study has actually conclusively demonstrated that, so whether it’s due to perhaps at the end of the reproductive years there’s an even higher, faster rate of ovarian depletion in women that have PCOS, that might be one explanation. Hard to know, but I would say that the other thing is that even though when those ovarian reserve numbers are really good, as we get into our 40’s and beyond, the egg quality and a chance of there being chromosomal issues, also starts to become significant. I wouldn’t want women in their 30’s that have PCOS that go for ovarian reserve testing that have awesome numbers to think okay, well I can keep putting this off if I want to have children because my numbers look great because it doesn’t seem like the reproductive lifespan will necessarily be longer and certainly having PCOS does not do anything to protect against the normal age related increase in chromosomal issues with ovaries and with eggs as we age. I think that’s an important message.
Amy Meddling: Thank you for bringing that up.
Dr. Kudesia: Yeah, no problem. If we could go back to your prior question about Metformin, I just wanted to answer that more clearly. So I think that Metformin really in general for reproductive age women the goal should be to use it in women that are either overweight or obese to try to prevent or slow down the progression to Type II Diabetes, and I think that that’s … and that’s strictly the most kind of conservative criteria for who’s the best candidate. For some women, it can be very helpful. I have had patients that really were able to lose weight a lot more easily when they were on Metformin, and so for that indication, it seems to have a role, not that it’s effective for everyone or not that everybody tolerates it well, but that might be the indication.
Again, as we get older, that impact of should you be taking Metformin beyond the menopause and so on and so forth, I don’t think it’s necessarily indicated because at that point, like I said, from a metabolic standpoint, it seems that again, people, all women are sort of coming to a more level playing field and at 50, if you’ve managed to get through the majority of your reproductive years, etc., without developing Type II Diabetes, I think it’s safe to say if you come off the Metformin and continue a relatively healthy lifestyle, it’s not an overwhelming risk. At that point, that’s what we essentially have tried to prevent, is an early development of Type II Diabetes and so, you know, I don’t think that continuing on Metformin for the rest of one’s life kind of makes the most sense.
Amy Meddling: Okay. Anything else that you feel you want to get the message out from looking at the data and the research regarding menopause and PCOS?
Dr. Kudesia: Sure. I think, you know you mentioned in the beginning, that there seems to be some incidence of unnecessary surgery that’s either being done or being recommended. The question is okay, what to do with women as we’re getting menopausal and this really barbaric notion that if we just take out the ovaries or take out the uterus that we have somehow fixed the problem. We have those organs for a reason. They contribute a lot throughout our lifespan, so under no circumstances is there really an indication to say oh, well you have PCOS, therefore we should be removing X, Y, or Z. So really if we think about what is the data or what is the reasons. I would think that from a hormonal perspective or perspective of are these organs somehow contributing to a worse risk profile from metabolic disease? We’ve covered that, so I wouldn’t say there’s any indication that there’s any sort of protective role of taking out the ovaries for somehow improving the metabolic risk profile of women that have PCOS.
The other question one might think is okay, is there a higher risk of cancer or is there something from an oncologic perspective that would lead someone to recommend that? What we know in general is that for women that have PCOS, if they have really irregular cycles, basically what happens is that the lining on their uterus can be exposed to a lot of estrogen overtime because of the fluctuating estrogen levels, without the protective effect of progesterone, which is produced after you actually ovulate, so for younger women, there is a risk if you’re not having regular cycles or if you’re not on some sort of hormonal treatment to induce regular cycles, that there could be a risk of hyperplasia, overgrowth, or eventually cancer, of the lining of the uterus, but … and so the overall risk to PCOS women of endometrial cancer is definitely higher than women who don’t have PCOS, but if this is managed appropriately, you can generally really avoid having to have a hysterectomy.
This is really something that women need to know, that they really need to be having some sort of bleeding, approximately every three months on average. Whether that’s through taking birth control or taking Provera every now and then or whatever your normal cycle is. However it happens. Or potentially having an inter-uterine device in place. Any of these ways. There are so many different ways to manage this, but as long as someone’s having fairly regular bleeding, that’s an appropriate way of managing the irregular cycles and trying to do our best to prevent endometrial cancer. I would never recommend someone to just have a hysterectomy prophylactically. It’s a big surgery. Obviously, there are maybe … could be some very specific cases where that might make sense, but by and large, it’s not.
In regards to ovarian cancer, there is literally one study that showed that maybe there was a slightly higher rate of ovarian cancer in women that have PCOS, but I would say that’s very weak evidence. I don’t think there is any indication based on an oncologic perspective that we need to be taking out uteri or ovaries just because a woman has a diagnosis of PCOS. If someone gets that recommendation and there’s not some other mitigating factor, some other reason, then I think people should be feeling empowered and push back a little bit and say well, really specifically for my case, why would you recommend this surgery? Because to me, on a blanket, as a blanket recommendation, it doesn’t seem to make sense.
Amy Meddling: Yeah and be your own advocate. Again, be a Diva at the doctor and get a second opinion. Thanks for sharing what you’ve learned about PCOS and menopause. I think it’s definitely a topic that I would love to see more studies done because I think there’s a lot more women with PCOS with diagnoses that are aging and we want more information. I’m very grateful to you for taking the time to do the research for us.
Dr. Kudesia: Sure. My pleasure. There’s just so much there. I think there are a lot of things that women struggle with with PCOS throughout their years, even things like per sleep or per quality of life or higher levels of anxiety and depression. There’s a lot of things that are out there and those are all … as it turns out, many of them are issues that women struggle with in the menopausal years as well and so there’s a lot of questions that I have and I’m sure that many other people have about does that risk compound as we put those two things together and what can we do make it healthier and easier to make that transition. I totally agree. Hopefully there is much more research coming out and I am part of some sort of groups of people that are thinking of looking into this specific question more, so hopefully within the next few years we will have a few more answers and a few less questions.
Amy Meddling: So, I also wanted to ask you. I like to ask our experts to leave us with a message of hope and I know as a reproductive endocrinologist and infertility specialist, meeting with couples every day… tell us what message of hope can you leave with us, to women with PCOS.
Dr. Kudesia: That’s such a great question. I love that way of thinking about things. In general, as a fertility specialist, my perspective when I have a patient or couple sitting in front of me is to sort of acknowledge that they never really wanted to have to be in my office, and so what are the things that I can tell them that make whatever diagnosis they may or may not have less stressful.
With regards to PCOS, I would say that it’s quite, like I said, it’s quite a lot of news to get this diagnosis and to then be told that it may have potentially have fertility ramifications and it may have lifelong metabolic ramifications, but I think that what the research indicates is that similar to any other person, if you really from a young age, make those lifestyle changes, really pursue a healthy lifestyle with good diet, with getting good exercise, and sort of mitigating developing the overweight, the obesity, that then turns into the Type II Diabetes, etc., that you can really prevent there being any long term increases in your overall serious morbidity or, God-forbid, mortality, as you get older.
I think that as a physician, for me, having that mentality or that outlook of prevention is really important. I think there is a lot of hope looking at this data to say, again, if we make those implement those changes at a young age, that there’s no reason to think that this diagnosis somehow gives you not even a death sentences, but even a really horrible prognosis for being healthy in your older years.
Again, I think that’s great news and I hope that it’s motivating and inspiring to young women and to middle age women throughout really every phase of the lifespan to say okay, now is a great time, every day is great time to make a lifestyle improvement and know that there is a payoff that comes with that, regardless of having the PCOS diagnosis.
Amy Meddling: Yeah and I know like for me, I consider PCOS a wake-up call. It was really an opportunity for me to take charge of my health, and I can tell you I’m healthier today because of PCOS … because of my PCOS diagnosis. Thank you so much, Dr. Kudesia, for sharing your good news with us today.
Dr. Kudesia: My pleasure.
Amy Meddling: And thank you everyone for listening. I look forward to being with you again next time. Bye-Bye.