Hi, everyone welcome to part two of our series on polycystic ovarian syndrome. Today, we’re going to cover some of the lifestyle factors as well as some of the other treatment modalities we might use other than when you’re trying to fall pregnant. We’re going to do a separate video, which will follow after this, on how we can assist you in falling pregnant if you are struggling with polycystic ovarian syndrome. So, let’s start off by talking about the elephant in the room and that’s losing weight. Obviously doctors always get the bad reputation, we don’t want you to smoke or drink. We want you to lose weight, use sunscreen, all of those sort of boring things.

But we’re asking you to do this with polycystic ovarian syndrome for a very specific reason. We know that weight can negatively impact not only your metabolic syndrome. So, remember your cholesterol, your insulin levels, your blood pressure, all of those aspects. But it can also interfere with ovulation and it’s very important to try and lose some weight. And we usually put this at about 5% of your body weight to try and get you down to a healthy BMI. Now, if you look on the internet, there’ll be a million apps and a lot of little calculators that you can use to work out your BMI. You just need to know your height as well as your weight. And there are very specific categories that we can put you into based on this.

So, if you have a BMI that works out to between 18 and 25, that’s considered normal. Above 25 is considered overweight and above 30 is considered obese, above 35 is considered morbidly obese. Now these words often have a lot of really negative connotations with them. We’re not saying any of these words as a form of medical judgment, we’re just trying to make sure that we know where we’re starting so we can get you to a healthier place. When we’re faced with this whole concept of trying to lose some weight, it can be very overpowering, inundating, and you might think I just can’t do this, let me give up.

So, let’s start off with a very small target. You can get on the scale tomorrow morning, once you’ve woken up before you’ve had anything to eat or drink and work out what five to 10% of that would be. So, for example, if you weigh a hundred kilos, let’s start off trying to lose between five and 10 kilos. This will not only be really helpful in terms of your cholesterol, your insulin levels, the metabolic syndrome, but it’s also potentially going to help you ovulate on your own. If pregnancy is the goal, then remember we don’t want to go into pregnancy from a bad position. We want to make sure that the weight is down, all of the other problems, such as your insulin levels or blood pressure are well controlled. So, we can set you up for an uneventful pregnancy and minimize the risks in your pregnancy.

So, I’m just going to start this section of, by reminding you that we are not dieticians, we are not exercise physiologists, so we can tell you exactly how to exercise and what diet to eat. It’s always a good idea to consult a dietician because a lot of weight loss is about 80% what you eat. So, your abs are made in the kitchen is a common phrase and that’s very true controlling what you eat is very important, the other 20% is exercise. Luckily at the moment with the lockdown, there are a lot of resources that are available that can help you with exercising at home. So, in case you can’t access the gym in the future, or you can’t afford a gym membership, or the area that you live in is just not suitable to go out and exercise. You will be able to find a lot of these resources online, whether it’s Instagram, whether it’s the internet, whether it’s Facebook. A lot of trainers are offering some advice and some workouts that you can do from the comfort and safety of your own home.

So, where do we start diet wise? Well, the ESHRE society, which is our European Society for Fertility that we often refer to, recommends decreasing your calorie intake by about 30%. There are a lot of apps online, one example is my fitness pal, which is completely free. You can track what you’re eating in a day and it can be quite enlightening to actually see what you’re eating and what your daily intake of calories are. We don’t want you to get too obsessive with counting calories, so it’s always a good idea just to use this as a baseline and to figure out how you can modify your diet the best. Again, a dietician is always going to be the most helpful resource for this. So, their advice is drop your calories by about 30%. Other people would say aim for a calorie deficit of about 500 calories. When it comes to moving around one commonly cited goal is 10,000 steps.

What the ESHRE society has recommended patients with PCOS use to lose weight is 250 minutes of moderate intensity exercise a week. So, if we break that up, you’re looking at about 50 minutes of moderate intensity exercise, five times a week. If you have more into vigorous exercise, such as running or high intensity interval training, you can do five sessions of 30 minutes a week. This is their advice again, we are not exercise specialists, so we follow our society guideline advice on this. Okay, so now we’ve got you losing weight, our goal is now to make sure blood pressure is under control your cholesterol is looking good. We’re avoiding any problems with you becoming a type two diabetic or having insulin resistance. Let’s deal with the next set of problems.

So, one of the next big issues that people complain about are terrible periods when it comes to polycystic ovarian syndrome. Sometimes what can happen is if you don’t have a regular period and you go two to three months between cycles, you can actually build up quite a thick lining. And that means when you do get your period, you might suffer a very heavy period with lots of clots. It can last anywhere from sort of 10 days to two weeks to three weeks and then it’s gone again for two to three months. This is obviously not something that we want. You can see from my first video on polycystic ovarian syndrome, we do want you either cycling regularly to try and prevent future health risks. Alternatively, we might want to treat the periods if they are a big problem by taking them away with something such as a Mirena.

So, our options for trying to control your periods, if they are a problem or if they are very irregular, well, this will depend on whether you’re trying to fall pregnant or not. Someone who’s trying to fall pregnant will obviously not want to go into a contraceptive pill, but this would usually be our first line treatment. We can use a variety of pills and the important thing to remember about a contraceptive pill is that they are kind of like shoes. You might be more into wedges or high heels or sneakers, the same way is not every kind of shoe is your style. Not every kind of pill will fit every woman. So, it’s important if you have had a bad experience with not liking one of your pills, talk to your doctor about this. There is probably a better pill for you, and we can fiddle around and find the one that works for you.

Before we continue with the contraceptive pill, let’s chat about some of the other options. One of the options that most people will have heard of is something called Provera. Now Provera is a form of progesterone and this we often prescribe for about 12 days every month. Very easy way to remember to take it as you start it on the first of every month. And you take it every single day until the 12th of every month. What will happen is once you stop taking the pills, after a couple of days, you will have a withdrawal bleed. Now this doesn’t make you ovulate, all we are doing is providing the progesterone that your body isn’t making, because you’re not ovulating. And this way you can have a regular period every month.

Another contraceptive option if you’re not trying to fall pregnant and you really just don’t want to have a period is to use a Mirena. Now, Mirena is an intrauterine device that we can put in in the rooms. It’s a contraceptive device, but it’s also used to treat abnormal bleeding. We can fit this in the rooms and then you can decide how long you want to keep it in for up to five years. It can provide contraception and most women will actually stop having a period on it. For the first few months you might have spotting here and there, but most of the time, this will actually take away the period.

Now, remember this isn’t the same as not having a period on your own, because what we are actually doing is thinning out the lining using the Mirena device so that you don’t build up the lining to bleed away every month. When it comes to the contraceptive pill your doctor will ask you a couple of questions to make sure that this is a good idea for you. We don’t want to give the contraceptive pill to someone who’s at an increased risk of clotting. So, if you have ever had any clotting before, so in the form of a DVT, or if you have a family history of a clotting disorder, then we definitely don’t want to give you the contraceptive pill. We also want to make sure that you are not too overweight, because this can increase your risk of cardiovascular problems. We also want to make sure that you’re not smoking, and we want to make sure that we’re not dealing with sky high cholesterol. So, we will do a couple of checks before we start you on a contraceptive pill.

So, what are the benefits for polycystic ovarian syndrome when we start you on a contraceptive pill? Well, it can also help us address two other really tricky concerns in terms of acne and in terms of hair on the body, you don’t like. So, while different pills work in different ways, what the majority of the pills will do is decrease a hormone called LH, which is secreted by the brain. And that hormone is very important for making your androgens, so it will reduce the level of androgens in the body. What that will do is help clear up acne that’s related to high androgen levels and will help to decrease the rate of growth of excess body hair.

Bear in mind when we start a contraceptive pill for these reasons, it’s not a quick fix. So, both acne and excess hair growth will take a little while to respond. In fact, we always recommend having a look again at six months and seeing if you’re happy with the response or not. If in six months you are still not happy with the response you are seeing, then we will start adding an extra medication. Remember, even though it feels like hair grows overnight, it’s actually a very slow process. So, it does take a while for the medication to be able to affect the hairs that are growing. When we add extra medication and what we might do is switch you to a specific pill called Diane. It comes in a few other forms and other commonly used one is called Jeanette, which actually has a specific medication, a type of progesterone. And that specifically decreases your testosterone levels.

We might add in a blood pressure medication in very low dose called spironolactone. And what that does is it also decreases the amount of androgens you are making. There are a variety of other medications that we can use. Some are safer than others, but we do have extra options when it comes to boosting the effect of the pill. But we’re not going to jump straight into those off the bat, simply because we want to see the effect the pill will have first. Also, we’re always very cautious about giving you any anti testosterone medication without a reliable form of contraception. Because what we don’t want is that you fall pregnant with a male baby, and we’re giving you anti testosterone medication, and this might affect your male baby.

We also need to set some realistic expectations; we can’t completely eradicate hair growth. Remember hair growth can be different from one patient to the other. So, I’ve seen patients who need to shave daily. Um, some other patients might just have a few hairs that bother them and impact their self-esteem. Just remember that I can’t completely eradicate all of that hair just using medication alone. You will still need to use things such as waxing, bleaching, threading, but another really good option is to find out about laser therapy. Remember that laser therapy is not a one session, fix all your problems. It is also a long-term commitment, but it will take usually a couple of sessions to see a good result. The nice thing about laser therapy is it is a more permanent solution.

Another drug that is often used is something called Metformin or Glucophage. Now what this does is it drops your insulin levels. So, some patients might have very high insulin levels. We don’t really want you walking around with very high insulin levels. It’s not good for you. So, what we might do is start you on one of these medications they’re usually used for diabetes. Don’t worry we’re not classifying you as a diabetic. What we also might do is send you for something called an oral glucose tolerance test. Now, what this does is test how your body responds to glucose. So, you’ll be asked to go into the lab. First thing in the morning, before you eat to drink, they’ll check your sugar level, the blood test they’ll then give you some sugar water to drink, and they’ll measure your response to this. Usually at one hour and two hours, this helps us identify people who are having impaired glucose tolerance. Now what that means is you’re not really good at dealing with sugar. Those are the patients who are most likely to benefit from being on Metformin, as well as patients who have a very strong family history of diabetes or previously had diabetes in a pregnancy, or might have other risk factors for diabetes.

So, as you can see, we do have a lot of strategies to deal with all of the things that come with polycystic ovarian syndrome so we can manage your period. We can manage the acne; we can manage the excess hair growth. But we’d really do need to make sure it all starts at home with weight loss and a healthy lifestyle. We’re not sprinting, this is a marathon we’re looking for a lifestyle change. We don’t want you to starve yourself, lose weight just to try and get down to a goal and then forget all about it and put on the weight again.

This is something we talking about long term, making sure that we are setting up for the healthiest life and when you are pregnant, making sure we’re going into a pregnancy in the right state of health so that we can look after this baby and make sure that the baby you take home is a healthy baby without complications.