When women meet at PCOS gatherings, they are quickly confronted by one of the great challenges of modern medicine: why apparently similar people in similar circumstances have different health outcomes. True, in having PCOS, they share the same diagnosis. But that’s often where the similarity ends.
Your PCOS symptoms are apt to vary according to your genes, age, lifestyle, and medical treatment. It makes you more vulnerable to some very serious illnesses such as diabetes, heart disease, and even cancer, but it does not condemn you to any of them. If you have IRS and PCOS, you’re especially susceptible— on the the flip side, controlling IRS is the best way to protect yourself from those other conditions, and you’ll lessen your PCOS symptoms in the process. In this chapter we will look briefly at what a woman with PCOS needs to know about diabetes, heart disease, and uterine cancer in order to actively avoid them.
Type 2 diabetes, also known as adult-onset diabetes, is by far the most common kind of diabetes mellitus. In type 1 diabetes, the pancreas does not secrete insulin and the condition occurs usually in children or young adults of normal weight. In most cases of type 2 diabetes, the beta islet cells of the pancreas initially work normally, but a subsequent decline in their function leads to diabetes. At the time that type 2 diabetes is diagnosed, a number of potentially silent complications often have already occurred, but these can be reduced significantly with appropriate treatment and weight loss management.
Many women who know or guess they are insulin resistant have no idea that they are at increased risk for type 2 diabetes. Of the more than 16 million Americans who have type 2 diabetes, at least 90 percent are insulin resistant.
Before you reach the type 2 diabetes stage, you are likely to pass through two prediabetic stages: impaired fasting glucose and impaired glucose tolerance.
I regularly see patients with a fasting glucose of only 90 to 110 mg/dL that a two-hour glucose tolerance test shows to have impaired glucose tolerance. This is an important reason for doctors to do a glucose tolerance test in the initial workup of virtually every patient with PCOS.
With impaired glucose tolerance, your baseline fasting glucose lab test often yields a result of 110 to 125 mg/dL, but you may have a blood glucose level of 140 to 199 mg/dL or even higher after a two-hour glucose tolerance test.
When your fasting blood glucose is 126 mg/dL or more, you most likely have type 2 diabetes, which is confirmed by a two-hour blood glucose level of 200 mg/dL and above with the oral glucose tolerance test.
This progression from insulin resistance to type 2 diabetes can be put as follows.
Insulin Resistance → Impaired Fasting Glucose and/or Impaired Glucose Tolerance → Type 2 Diabetes
Over a six-year follow-up period of women with impaired glucose tolerance, those who also had PCOS were more than five times likely to make the transition to type 2 diabetes.
In the Nurses’ Health Study, in which the health of 101,000 women was followed for eight years, women with irregular periods (80-85 percent of them most likely had PCOS) were twice as likely to progress from impaired glucose tolerance to type 2 diabetes as women with regular periods. This occurred regardless of the women’s weight.
So if you have PCOS, what’s your risk of prediabetes and diabetes? Weight counts. By thirty years of age, obese women with PCOS have a 30 to 40 percent risk for impaired glucose tolerance and later type 2 diabetes. By forty years of age, with no treatment, this risk rises to 45 to 50 percent.
Medical professionals who treat people with diabetes often say that it might not kill you, but it does make you vulnerable to something else that will. Cardiovascular trouble is only one of many such complications. High blood sugar associated with diabetes modifies proteins and further promotes inflammation in coronary and other major arteries. Diabetes also helps produce oxidants that enable LDL to cause inflammatory arterial damage. For these and other reasons, type 2 diabetes is now recognized as an independent risk factor for heart disease and makes diabetic women as likely to have heart disease as men.
To lower their risk of cardiovascular disease, the American Diabetes Association suggests that people with diabetes older than age forty who have a total cholesterol level of 235 mg/dL or higher (as most do) should seriously consider taking statins and other cholesterol-lowering drugs, sometimes with the addition of ezetimibe (Zetia).
The American Diabetes Association also recommends a target blood pressure level of less than 130/80mmHg. About 70 percent of adult diabetics exceed this level, often because they do not take their medications regularly, suffer from drug interactions, or have difficulty taking drugs. People with diabetes who do not have kidney disease can benefit from most medications to lower high blood pressure. A combination of an angiotensin converting enzyme (ACE) inhibitor and diuretic can be highly effective. While less effective in lowering blood pressure, an angiotensin receptor blocker (ARB) may be the best treatment for those with possibly associated kidney disease.
Unless they have been instructed otherwise, people with diabetes derive cardiovascular benefits from aspirin (which is a blood thinner) taken daily, and/or a 1-gram omega fish oil capsule taken twice daily.
Many women with PCOS develop type 2 diabetes and diabetes-related cardiovascular problems, such as heart attacks and strokes. These major health problems may help to put PCOS-related skin and hair problems into perspective. Of course there’s no reason for you to endure either. When you get a reliable diagnosis, you can take charge of both.
Although few specific studies have been made, all evidence points to the conclusion that women with PCOS are at high risk for cardiovascular disease. In the Nurses’ Health Study previously mentioned, women with a history of irregular periods (most probably because of PCOS) were found to have twice the risk of developing or dying of a heart attack as women with normal periods.
The AACE called attention to three lines of evidence in a position paper in 2004, of which I was one of the authors.
1. If you have PCOS, you are at a substantially higher risk for developing a combination of impaired glucose tolerance, type 2 diabetes, and serious heart problems. The AACE recommends that all women with PCOS be screened for diabetes as early as possible.
2. Women with PCOS frequently have cardiac risk factors of various kinds (such as blood lipid abnormalities, elevated inflammatory markers, and high blood pressure), and often several simultaneously. These multiple risk factors are regularly diagnosed as IRS, and are associated with an increase in visceral fat (central obesity or apple shape).
3. Imaging studies have revealed that women with PCOS are more likely to have anatomic and functional abnormalities related to cardiovascular problems than similar women of the same age. These include coronary calcifications and carotid artery arteriosclerosis.
The first steps in preventing these serious conditions is recognizing you have PCOS and getting proper treatment. If you have PCOS, you need to always keep in mind that you run a high risk for developing type 2 diabetes and cardiovascular disease. In this regard, you need to carefully watch out for two things: (1) IRS; (2) silent cardiovascular disease. Diabetic women with PCOS cannot rely on the heart-protective effects of estrogen before menopause. You can reverse some of the risk with early diagnosis and treatment. Your lifestyle should include weight loss and exercise, avoidance of tobacco, and correction of lipid abnormalities and high blood pressure. In the second part of this book, we go into the details of what you can do to protect your health, feel better, and enjoy life to the fullest.
Women with PCOS are several times more likely than other women to develop uterine cancer, caused by high male hormone levels that result in a lack of ovulation. Lack of ovulation in turn results in a lack of shedding of the uterus lining in regular periods. The uterus lining thickens as a result, a condition known as hyperplasia.
Uterine cancer, also called endometrial carcinoma, is the most common female reproductive system cancer in American women. It affected 34,000 women in 1996. This cancer of the uterine lining is most often associated with obesity, as well as high blood pressure, type 2 diabetes, and not having been pregnant. Not ovulating most of the time (anovulatory cycles), as is typical in PCOS, leads to unopposed effects of estrogen on the endometrium, which can lead to endometrial hyperplasia, a precursor to cancer. Although a relatively small number of women develop uterine cancer, you should take preventive measures to minimize the risk. An early diagnosis of PCOS and treatment to end prolonged intervals between menstrual cycles are major preventive steps. Prolonged absence of menstrual cycles is a major symptom and risk factor for uterine cancer in women with PCOS. Drugs known as progestational agents can trigger shedding of the endometrial lining of the uterus. Periodic use of these drugs may reduce this complication significantly.
A Mayo Clinic study revealed a threefold higher incidence of uterine cancer in anovulatory women, many of whom probably had PCOS. A study by the Centers for Disease Control and Prevention reported a fivefold increased incidence of uterine cancer in women with PCOS. Although typically occurring in women approaching or after menopause, uterine cancer or hyperplasia can occur in younger women, even some in their teens. Almost all younger women with uterine cancer have PCOS. The good news is that in younger women with PCOS, this kind of cancer is relatively benign and has a good prognosis.
For women with PCOS who have uterine cancer, treatment is commonly successful after an outpatient surgical procedure called dilatation and curettage (D & C), followed by high-dose progesterone therapy. Younger women often do not need a hysterectomy. Follow-up evaluation by a gynecologic oncologist should include periodic biopsies of the uterine lining. If progesterone treatment cannot reverse the uterine cancer, a hysterectomy may be necessary.
Treatment with insulin-sensitizing agents (such as metformin), oral contraceptives, and weight loss minimize the risk of uterine cancer in women with PCOS. The encouraging data on oral contraceptive use in normal women also show that it decreases the risk of uterine cancer by 50 percent.
As I hope I’ve made clear throughout Part I, my aim is not to alarm you with the associated risks of PCOS, but to drive home the importance of taking control. The fact that you’re reading this book and educating yourself about PCOS is an important first step. In Part II I’ll discuss what you can start doing for yourself today, beginning with finding a doctor who can be your guide.