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Thread: Do I have PCOS?

  1. #1
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    Oct 2010
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    Default Do I have PCOS?

    This is a question for the expert, I'm scratching my head as to whether I have PCOS or not.

    My history
    1)regular ovulation, though long cycles (34 days)
    2)I'm thin, history of diabetes in family, but I'm insulin sensitive (low levels of hormone, normal blood sugar)
    3) Polycystic ovaries on ultrasound (around 17+ follicles per each ovary)
    4) DHEAS elevated-251
    5) Testosterone tested twice
    first-17 ng/ml
    second 83 ng/ml
    6) most confounding- AMH is low (1.1 ng/ml- reference range for testing lab is 1.23-8 ng/ml)
    Note: tested 2 weeks after D&C from second missed miscarriage
    7)low Vitamin D3 (16 ng/ml)

    Do I have PCOS?? I've conceived twice, pregnancy has ended in losses (first normal karyotype, second turners XO)

    I cannot decide if I have low ovarian reserve (based on the lowish AMH) or PCOS. Nothing is adding up, but one thing seems likely- I have bad egg quality, we just have to figure out what the cause is. I'm a scientist myself, I'm looking at all the clues and I'm stumped.

  2. #2
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    Oct 2008
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    Justlooking30,

    You have to remember that the hormonal changes that women experience with PCOS fall within a wide spectrum. Do you have PCOS? Well, there are diagnostic criteria to give you that diagnosis: 1) irregular menses (34 days is long, but not considered irregular); 2) elevated androgen levels or noticeable clinical effects of hyperandrogenism (abnormal sexual hair growth--hirsutism); and/or 3) polycystic appearing ovaries (which you have).

    Depending on the lab used and the normal reference range, the testosterone level of 83 may be elevated, or at least near the high normal range. This would be a measurable sign of hyperandrogenism, and with PCO appearing ovaries and long cycles, you may have a hormonal situation that is within the specturm of PCOS, but you likely do not have classic PCOS (no menses, facial hair growth.) Because of the pregnancies you have had and the fact that yoru menses are regular (albeit long), you are ovulatory, but can you have oocyte growth and ovulation that may be affected by the hormonal changes leading to the PCO appearing ovaries? You definitely may.

    Even though your measured insulin level is normal, this does not indicate you have normal insulin sensitivity. But, insulin abnormalities are only seen in about 65% of women with true PCOS, so there are other unknown causes that may have led to the hormonal situation that you are currently in. AMH levels, while intriguing, are not helpful in your situation. DHEAS can be elevated with PCOS, but it is not a concerning elevation--the range for DHEAS is quite wide.

    So, if you have had no difficulty conceiving, then you have no ovulatory issues leading to infertility. You have had one explainable miscarriage, due to an abnormal karyotype, and one unexplained loss. Some studies have suggested that women with PCOS have a higher likelihood of miscarriage, and that this may be more related to insulin resistance, but the data is inconclusive. Some studies have suggested that treating a possible insulin resistance can improve the likelihood of a continuing pregnancy, and often this is tried (metformin is safe in early pregnancy). But what no one can know is if the long menses and hormonal changes causing the appearance of your ovaries is cause by something that might be affecting egg quality and likelihood of a normal, continuing pregnancy. That is a concern, and often this is addressed in the same manner that we address PCOS--medications to "normalize" your menses, and consideration of metformin use to potentially increase your likelihood of a continuing pregnancy.

    Egg issues are always a concern, especially as you move past 35 years old. I don't know your age, but if you are over 35, this alone increases the likelihood of a miscarriage due to the same type of chromosomal problems associated with your second loss.

    With PCO appearing ovaries, it is unlikely that you have a true decreased ovarian reserve, despite AMH levels (again, AMH is not helpful in your situation.) With advancing age, there is always oocyte quality concerns despite the number of oocytes present or stimulated to grow. But consideration of some treatment to address the abnromalities (long cycle, PCO appearing ovaries, possibly elevated T level) is always something to consider.

  3. #3
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    Oct 2010
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    Thank you for that very detailed response.

    Its reassuring to hear that my problem is probably not bad egg quality reflective of a low ovarian reserve. I'm only 31, so bad eggs because of age was not on my radar.

    I tend to clutch at straws, but I was struck by how low my Vitamin D3 levels were. Interestingly, this article suggests a link between AMH levels and Vitamin D3, this study shows Vit D3 binds to the AMH promoter and stimulates its production. If I can get your medical opinion on whether you think there could possibly be a link between abnormal vitamin D3 levels and AMH, I'd be most obliged.

    I plan to correct my D3 levels and see if there are any changes, either in AFC and AMH, and will also include metformin 3 months before the next conception. How long would you suggest I continue it after conception?

    Just anecdotally, somebody I know with a high AFC who miscarried her first pregnancy said metformin drastically reduced her antral follicle count, and her next pregnancy was a success.

  4. #4
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    Oct 2010
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    I also wanted to ask, will women not insulin resistant when put on metformin run a risk of becoming hypoglycemic?

    I have a very strong family history of type 2 diabetes hence I was shocked that I'm actually pretty insulin sensitive, lower than normal levels of insulin were maintaining blood glucose at optimal levels in the fasting tests.
    My other question was- should I get a glucose tolerance test done as well?

  5. #5
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    The use of metformin does not lead to hypoglycemia in women who are not insulin resistant. It is a good drug in that respect.

    Again, there are no good tests to truly know if you will respond to a combination of clomiphene and metformin. A fasting insulin level is not very helpful, and it is good that your glucose levels are normal--you do not have diabetes. With a family history of type II DM, there still may be insulin resistance issues--but that is not a diagnosis that is easy to arrive at. Even the "gold standard" tests (such as a euglycemic clamp test) set arbitrary cut offs for what is considered normal. There is not an insulin resistance level above which problems arise more often, like blood pressure measurements, cholesterol, or blood sugar.

    So determining or understanding if you are insulin resistant really has little bearing on your goals. If you ovulate with some form of ovulation induction, you can conceive. If clomid alone does not work, adding metformin may help--regardless of your measurements of insulin resistance. If that doesn't work, then more expensive and time consuming injections will always induce ovulation in women with PCOS--these medications can lead to the production of too many eggs, however.

    Antral follicle counts are higher in women with PCOS, due to the hormonal aberrations both within the ovary itself and from the pituitary gland. Some studies have shown that metformin can correct some of the hormonal abnromalities associated with PCOS (such as LH levels, elevated testosterone levels, etc.), and antral follicle counts can change, but not usually drastically. It is not the antral follicle count or AMH being produced by resting follicles that is a problem with PCOS--it is the other hormonal issues. Again, some studies suggest that insulin resistance can lead to an increased incidence of miscarriage, and metformin use may decrease this. It may be worthwhile to continue metformin until 12 weeks just for this reason, if it is used prior to conception. (I always continue this until 12 weeks.)

    I hope that you can ovulate more normally while on metformin, but if not, it does not mean that you do not have an ovulatory issue contributing to your difficulty conceiving.

    I don't think you have bad egg quality, but if there are ovulatory disturbances, poorer quality oocytes may be the result.

    And I do not believe your Vit D3 levels have anything to do with your reproductive situation. You should be on a prenatal vitamin, which will provide all the vitamins you need for pregnancy, including the recommended dose of D3. The upregulation of AMH in a cell culture system does not mean that low levels lead to a down regulation of AMH production in a normal physiologic system.

    A lot of information here, but I hope it helps

  6. #6
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    Quote Originally Posted by DrWilliams View Post

    And I do not believe your Vit D3 levels have anything to do with your reproductive situation. You should be on a prenatal vitamin, which will provide all the vitamins you need for pregnancy, including the recommended dose of D3. The upregulation of AMH in a cell culture system does not mean that low levels lead to a down regulation of AMH production in a normal physiologic system.

    A lot of information here, but I hope it helps
    Thank you Dr. Williams for your very informative answer. About Vitamin D, I have to draw your attention to a recent study in Fertility and Sterility, which suggests that vitamin D is indeed important with respect to reproduction.

    http://www.ncbi.nlm.nih.gov/pubmed/19589516

    There are also many studies out there with suggest that this vitamin is low in about 40% of women with PCOS, it may actually be a contributing factor.

    This is not my field of study (i'm an immunologist) but I have to say, reproductive science is a fascinating one, and a very rapidly evolving one!

    I do have to get my levels corrected- 16 ng/ml is clinically deficient, I would be very interested in seeing if any of the tested parameters (AFC, androgens, AMH etc) change with this.

  7. #7
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    Oct 2008
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    Thanks for the post. It is interesting, but measurements of follicular fluid levels with correlation to pregnancy are relatively meaningless. You can only measure those levels after an egg retrieval, and whether it is elevated or not does not help allow any changes that can increase your likelihood of success. Here is a study that demonstrated that elevated levels were detrimental to success: http://www.ncbi.nlm.nih.gov/pubmed/20667111

    Until more data is available, measurement of Vit D levels are purely speculative, and continued supplementation with the daily recommended IU of vitamin D is all that is currently necessary.

    Keep checking the data though--as more information is obtained, current practices may change.

  8. #8
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    Well, I have some data of sorts I feel should share.

    3 weeks ago, we had tested AMH to confirm the PCOS diagnosis. This was shockingly low at 1.1 ng/ml. This was even more shocking since my antral follicle count had been been very high just 4 months ago.

    Since at that same blood draw I had also discovered a vitamin D deficiency (16 ng/ml), I took massive doses (60000 IU weekly) for 2 weeks and gave blood again.

    Not surprisingly, vitamin D levels were increased though I was bit startled to find them already in the high range, at 70 ng/ml. The shocker was the AMH- now it was 5.18 ng/ml, over a 4-fold increase!

    Unless the first test was goofed up very badly, this was a very interesting find, not to mention that it was one that gave me a lot of relief!

    I now believe that vitamin D *might* contribute to AMH production though of course, I agree with you entirely that more studies need to be undertaken to prove (or disprove) that vitamin D has a role in anything fertility related, from PCOS to poor egg quality to anything pregnancy-related.

    Also this was interesting to me, my testosterone levels fell from 85 to 26 ng/ml between the 2 blood draws 3 weeks apart. Usually my hormone levels never change much from test to test, my physiological parameters are remarkably consistent.

    I only have polycystic ovaries (reconfirmed in a second ultrasound with a AFC of 30) and a now high AMH to back the PCOS diagnosis. I don't have PCOS symptoms, no insulin resistance, cannot even conclude I have elevated testosterone and low LH (my LH to FSH ratio is actually around 0.5!)

    Still, I'll take metformin for a few months before I conceive and see if that changes anything.

  9. #9
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    Those are interesting findings. I have yet to see a study that describes AMH levels 2 weeks after a miscarriage, although some studies of AMH changes during pregnacy are documented. Some do show a change, but AMH is supposed to vary little during the menstrual month, unlike FSH. So, it may be that now is a more accurate measurement of your baseline AMH. Regardless, I do think you have some of the physiologic changes associated with PCOS, and your reproductive difficulties may be due to these changes. I hope metformin alone helps--it always can. Based on your age and other findings, I think you have an excellent chance to have a normal, continuing pregnancy, and I hope it happens with miminal treatment. But if not, I am confident that other ovulation inducing agents will increase your likelihood of success.

  10. #10
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    I know this thread is old, but I had to add my experience. I have had diagnosed PCOS for over 20 years. A few years ago my endocrinologist tested my Vit D levels and had me start a theraputic dose for 8 weeks (10K IU once a week). My levels did increase but fell off after a few months. I decided to add Vit D3 to my daily vitamin regime. I noticed that my weight stayed within the same range for a couple of years, my PCOS symptoms ie hair growth, was under control and I felt "normal" for once. I was even getting my cycles at regular intervals 28-30 days without birth control pills. However, I never connected taking Vit D with all of this.

    After going through some personal rough patches I stopped taking care of myself the way I used to. I wasn't taking the Vit D and my cycles were becoming non existing, even taking the routine 200 mg of Prometrium for 10 days didn't bring on my period. My gyn suggested that I could be peri-menopausal. After all, I was about to turn 40 and PCOS can cause early onset (her words, not mine). I refused to believe it. I wanted to go back on bcp, but with all the stress that was going on I developed a low case of high blood pressure. So bcp were not an option. Then I came across an online article about a small study by the Mayo Clinic, PCOS and effects of Vit D.

    It all came together. The Vit D had some connection those years ago to my cycles being regular. Just before the new year (2011), I started taking 10K IU of Vit D3 again, just for the first week. After that I have kept to taking 5K IU of Vit D3 daily. I had my cycle start after 32 days. On it own! Without Prometrium. Now into month 2, I figured how could it hurt if I tracked to see if I was going to Ovulate. I've been taking my temp and did home OPK tests. Amazing on cycle day 15 I had a positive OPK test. I know that doesn't guarantee I actually ovulated, but the surge was detected and negative the next 2 days.

    Now I'm just waiting to see how my temps progress and what day my next cycle will begin. The proof is obvious that my Vit D3 levels have something to do with my PCOS. Even my hair growth has decreased 90%.

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