Polycystic Ovary Syndrome (PCOS) FAQ

Sam Thatcher, M.D., Ph.D. was a medical pioneer in the field of PCOS and one of 2 other top specialists in the world. Sam was an amazing person, a big bear of a man standing six foot eight but very shy, humble and with a wonderful sense of humor - he was also a frient to INCIID almost from it's inception. His first thought was always for his patients and how he could serve them best. This PCOS FAQ was created as a result of INCIID's collaboration with Sam. At INCIID's urging Sam also wrote: PCOS: The Hidden Epidemic.

How common is PCOS?

Polycystic Ovary Syndrome affects an estimated 5-10 percent of women of childbearing age and it is a leading cause of infertility. It is the most common endocrinopathy among reproductive age women. As many as 30 percent of women have some characteristics of the syndrome.

What are the symptoms of PCOS?

Women with PCOS may have some of the following symptoms:

Amenorrhea (no menstrual period), infrequent menses, and/or oligomenorrhea (irregular bleeding) — Cycles are often greater than six weeks in length, with eight or fewer periods in a year. Irregular bleeding may include lengthy bleeding episodes, scant or heavy periods, or frequent spotting.
Oligo or anovulation (infrequent or absent ovulation) — While women with PCOS produce follicles — which are fluid-filled sacs on the ovary that contain an egg — the follicles often do not mature and release as needed for ovulation. It is these immature follicles that create the cysts.
Hyperandrogenism — Increased serum levels of male hormones. Specifically, testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEAS).
Infertility — Infertility is the inability to get pregnant within six to 12 months of unprotected intercourse, depending on age. With PCOS, infertility is usually due to ovulatory dysfunction.
Cystic ovaries — Classic PCOS ovaries have a "string of pearls" or "pearl necklace" appearance with many cysts (fluid-filled sacs). It is difficult to diagnose PCOS without the presence of some cysts or ovarian enlargement, but sometimes more subtle alterations may not have been recorded, or are not recognized as abnormal, by the ultrasonographer.
Enlarged ovaries — Polycystic ovaries are usually 1.5 to 3 times larger than normal.
Chronic pelvic pain — The exact cause of this pain isn't known, but it may be due to enlarged ovaries leading to pelvic crowding. It is considered chronic when it has been noted for greater than six months.
Obesity or weight gain — Commonly a woman with PCOS will have what is called an apple figure where excess weight is concentrated heavily in the abdomen, similar to the way men often gain weight, with comparatively narrower arms and legs. The hip:waist ratio is smaller than on a pear-shaped woman — meaning there is less difference between hip and waist measurements. It should be noted that most, but not all, women with PCOS are overweight.
Insulin resistance, hyperinsulinemia, and diabetes — Insulin resistance is a condition where the body's use of insulin is inefficient. It is usually accompanied by compensatory hyperinsulinemia — an over-production of insulin. Both conditions often occur with normal glucose levels, and may be a precursor to diabetes, in which glucose intolerance is further decreased and blood glucose levels may also be elevated.
Dyslipidemia (lipid abnormalities) — Some women with PCOS have elevated LDL and reduced HDL cholesterol levels, as well as high triglycerides.
Hypertension (high blood pressure) — Blood pressure readings over 140/90.
Hirsutism (excess hair) — Excess hair growth such as on the face, chest, abdomen, thumbs, or toes.
Alopecia (male-pattern baldness or thinning hair) — The balding is more common on the top of the head than at the temples.
Acne/Oily Skin/Seborrhea — Oil production is stimulated by overproduction of androgens. Seborrhea is dandruff — flaking skin on the scalp caused by excess oil.
Acanthosis nigricans (dark patches of skin, tan to dark brown/black) — Most commonly on the back of the neck, but also but also in skin creases under arms, breasts, and between thighs, occasionally on the hands, elbows and knees. The darkened skin is usually velvety or rough to the touch.
Acrochordons (skin tags) — Tiny flaps (tags) of skin that usually cause no symptoms unless irritated by rubbing.

Is PCOS a Syndrome or a Disease?

PCOS is generally considered a syndrome rather than a disease (though it is sometimes called Polycystic Ovary Disease) because it manifests itself through a group of signs and symptoms that can occur in any combination, rather than having one known cause or presentation.

Are there are other names for PCOS?

Other names for Polycystic Ovary Syndrome are Stein-Leventhal Syndrome, hyperandrogenic chronic anovulation, functional ovarian hyperandrogenism, and Polycystic Ovary Disease.

What causes PCOS?

The exact cause of PCOS is unknown. There are studies being conducted to see if there may be a genetic link — that PCOS is passed along in families. Just as one might have a genetic predisposition to diabetes, one might also have a disposition to PCOS.

The above analogy to diabetes seems appropriate as many current studies into PCOS are focusing on the body's ability to process insulin. A growing collection of data suggests that elevated insulin levels are unhealthy and contribute to increased androgen production, worsening PCOS symptoms from cosmetic issues to infertility, and eventually increasing the risk of certain cancers, diabetes and heart disease.

It is also possible that PCOS may be caused or worsened by valproate, a medication used to treat seizures, but it is hard to say if it is the epilepsy per se or the agent used to treat it that brings about the PCOS symptoms in some women. The condition may be improved by switching to another medication.

Is there a cure for PCOS?

No, it is a condition that is managed, rather than cured. Treatment of the symptoms of PCOS can help reduce risks of future health problems.

What kind of doctor can diagnose and treat PCOS?

Any type of doctor familiar with PCOS might make the diagnosis, but the disorder is complicated and may be best treated by a specialist. Those having difficulty getting pregnant should see a reproductive endocrinologist, while long-term management by an endocrinologist should be considered. A general practitioner or an OBGYN may treat some women with the syndrome, but someone who specializes in endocrine disorders may be more familiar with treatment options and recent studies on PCOS. A list of fertility specialists is available on INCIID and PCOSupport.org has a list of doctors familiar with PCOS.

How should one prepare for initial medical appointment to discuss PCOS?

Write down any questions before the appointment. It is usually faster and more orderly to have a list, no matter how long it may get. Many questions will be answered in the general course of conversation.
Gather up any appropriate or requested medical records — follow through and make sure the doctor gets them before the appointment, or bring them. (Sending in advance is generally preferred.) If the visit is for fertility reasons and one has already done a hysterosalpingogram (HSG, x-ray test of the uterus and tubes), a copy of the actual film is preferred to the printed interpretation or report.
Be ready to supply family history, especially about insulin resistance, diabetes, lipid abnormalities such as high cholesterol, obesity, high blood pressure, heart disease, and infertility. Include information from both parents and their families. PCOS characteristics may be passed down from either side of the family.
Familiarize oneself with the symptoms of PCOS and discuss any concerns with the doctor.
If looking for help in getting pregnant, consider bringing in basal body temperature (BBT) charts to initial evaluation.
See if it would be helpful to arrive for the doctor's appointment in a fasting state, and clarify any other requirements.

What are some questions to ask the doctor?

The purpose of the following list of questions, and this entire FAQ, is to help women have better communication with their doctors, not to substitute for diagnosis, treatment, and frank discussion with one's own physician.

What specific tests are used to confirm PCOS?
What tests are done to confirm insulin resistance and/or diabetes?
Are insulin-sensitizing medications prescribed for insulin resistance, or only for diabetes?
What recommendations or medications, if any, are typically given for the symptoms of PCOS, such as weight gain/obesity, acne, hirsutism, balding, lack of menses, high cholesterol, high blood pressure, and insulin resistance?
After initial diagnosis of PCOS, what kind of future monitoring is recommended?
Is treatment of PCOS similar among different doctors in this practice?
Will diet and exercise information and support be provided?
What kind of birth control is recommended for women with PCOS?
What kind of treatment is offered to women with PCOS who are trying to conceive?
Is weight loss in obese patients a requirement before any stage of fertility treatment? For example, would one be allowed to try Clomid, but not allowed to pursue in vitro fertilization?
Can insulin-sensitizing medications be used while trying to conceive?
Can insulin-sensitizing medications be continued in pregnancy?
Which medications used to reduce PCOS symptoms, such as those for acne and hirsutism, can be continued while trying to conceive or when pregnant?

Is there one definitive test to diagnosis PCOS?

At this time, there is no single definitive test for PCOS. This is because no exact cause of PCOS has been established yet. This is why there is a wide-range of opinion on how to diagnose and treat PCOS.

How should PCOS be diagnosed?

PCOS should be diagnosed based on physical exam, ultrasound of the ovaries, and the results of various blood tests. Diagnosis is made based on having several of the symptoms listed above. There is some disagreement in the medical community about the diagnostic criteria to be used. Some doctors suggest that at least three of the symptoms must be present to diagnose PCOS, others may make the diagnosis on the basis of fewer criteria (often emphasizing lack of ovulation), while others believe that PCOS is a diagnosis of exclusion — meaning if there are hormonal abnormalities for which no other explanation can be found, PCOS is presumed. Since there is no consensus as to how PCOS is defined or diagnosed, there should be little surprise when a variety of opinions emerge on how this problem should be treated!

How are polycystic ovaries diagnosed by ultrasound?

An ultrasound of the ovaries is usually done transvaginally — where a probe is placed into the vagina to gain view of the ovaries. In some cases, an abdominal ultrasound may be needed as well, but this tends not to give as clear a view.

A classic PCOS ovary is enlarged and has a "string of pearls" appearance, where the pearls are the cysts. Usually ultrasound diagnosis of polycystic ovaries is made if there are at least 8-10 cysts that are less than 10mm in size on each ovary. It is not known how long each individual cyst will last, or what caused the arrested development of the follicle leading to the formation of the cyst in the first place. The polycystic ovary tends to be enlarged to 1.5-3 times the size of a normal ovary and often has an increase in the stromal tissue in the center of the ovary and around the follicles. Both the cysts and the stroma produce hormones, so the more cysts and the more stroma, the more likely one is to have other signs and symptoms of PCOS.

Is it possible to have polycystic ovaries without having the syndrome?

About 20-30 percent of women will have the appearance of polycystic ovaries, while only an estimated 5-10 percent of women would be diagnosed as having Polycystic Ovary Syndrome as based on signs and symptoms. It may be best to consider the finding of polycystic ovaries as a possible sign of PCOS, but not to rely on this as the sole criterion in making a diagnosis.

A large percentage of women with polycystic ovaries have at least some subtle hormone alterations, even if they do not clearly exhibit other signs of the syndrome.

Is it possible to have PCOS without having cysts?

This is another area of some disagreement among medical professionals. Most women with PCOS will in fact have the polycystic ovaries for which the syndrome is named, but it is possible to be diagnosed with the syndrome without this particular symptom. Some doctors diagnose PCOS based on the appearance of other physical symptoms or hormone abnormalities, regardless of ultrasound findings.

It is difficult to make a firm diagnosis of PCOS without the presence of either an increased number of small cysts or ovarian enlargement. Polycystic ovaries may not have been recorded as an official finding on an ultrasound even though they were seen. Often ultrasounds have been performed to exclude pathology and may not have diagnosed minor increases in cystic structures or ovarian enlargement. Some ultrasonographers may consider the milder forms of PCOS as variations of normal. Ovarian enlargement is not always associated with ovarian cyst development, but still can be a variant PCOS. In other words, if one has the signs and symptoms of PCOS it is likely that there is some alteration in the appearance of the ovary, even if it has not been recognized.

What blood tests should be done to diagnose PCOS?

Much of the bloodwork that should be done in diagnosing or ruling out PCOS is the same as abasic fertility workup; however, there are a couple of additional tests for insulin resistance that should be added, as well as some cholesterol screening to evaluate general health status because of the future risks associated with PCOS. A good basic screening would include:

Fasting comprehensive biochemical and lipid panel;
2-hour GTT with insulin levels (also called IGTT);
LH:FSH ratio;
Total testosterone;
DHEAS;
SHBG;
Androstenedione;
Prolactin and
TSH

What are normal values for the blood tests?

Note: Values are laboratory dependant, so while this list is provided as general information, one needs to ask her own doctor to explain the results based on individual lab standards. This is provided for discussion purposes only, not for self-diagnosis. Please note the units of measure as these also vary from lab to lab.

Hormone Levels
Hormone to test	Time to Test	Normal Values	What value means
Follicle Stimulating Hormone (FSH)	Day 3	3-20 mIU/ml	FSH is often used as a gauge of ovarian reserve. In general, under 6 is excellent, 6-9 is good, 9-10 fair, 10-13 diminished reserve, 13+ very hard to stimulate. In PCOS testing, the LH:FSH ratio may be used in the diagnosis. The ratio is usually close to 1:1, but if the LH is higher, it is one possible indication of PCOS.
Estradiol (E2)	Day 3	25-75 pg/ml	Levels on the lower end tend to be better for stimulating. Abnormally high levels on day 3 may indicate existence of a functional cyst or diminished ovarian reserve.
Estradiol (E2)	Surge/hCG day	200 + pg/ml	The levels should be 200-600 per mature (18 mm) follicle. These levels are sometimes lower in overweight women.
Luteinizing Hormone (LH)	Day 3	< 7 mIU/ml	A normal LH level is similar to FSH. An LH that is higher than FSH is one indication of PCOS.
Luteinizing Hormone (LH)	Surge Day	> 20 mIU/ml	.
Prolactin	Day 3	< 24 ng/ml	Increased prolactin levels can interfere with ovulation. They may also indicate further testing (MRI) should be done to check for a pituitary tumor. Some women with PCOS also have hyper-prolactinemia.
Progesterone (P4)	Day 3	< 1.5 ng/ml	.
Progesterone (P4)	7 dpo	> 15 ng/ml	A progesterone test is done to confirm ovulation. When a follicle releases its egg, it becomes what is called a corpus luteum and produces progesterone. A level over 5 probably indicates some form of ovulation, but most doctors want to see a level over 10 on a natural cycle, and a level over 15 on a medicated cycle. Some say the test may be more accurate if done first thing in the morning after fasting.
Thyroid Stimulating Hormone (TSH)	Day 3	.4-4 uIU/ml	Mid-range normal in most labs is about 1.7. A high level of TSH combined with a low or normal T4 level generally indicates hypo-thyroidism, which can have an effect on fertility.
Free Triiodothyronine (T3)	Day 3	1.4-4.4 pg/ml	Sometimes the diseased thyroid gland will start producing very high levels of T3 but still produce normal levels of T4. Therefore measurement of both hormones provides an even more accurate evaluation of thyroid function.
Free Thyroxine (T4)	Day 3	.8-2 ng/dl	A low level may indicate a diseased thyroid gland or may indicate a non-functioning pituitary gland which is not stimulating the thyroid to produce T4. If the T4 is low and the TSH is normal, that is more likely to indicate a problem with the pituitary.
Total Testosterone	Day 3	6-86 ng/dl	Testosterone is secreted from the adrenal gland and the ovaries. Most would consider a level above 50 to be somewhat elevated.
Free Testosterone	Day 3	.7-3.6 pg/ml
Dehydroepi-androsterone Sulfate (DHEAS)	Day 3	35-430 ug/dl
Androstenedione	Day 3	.7-3.1 ng/ml
Sex Hormone Binding Globulin (SHBG)	Day 3	18 — 114 nmol/l	Increased androgen production often leads to lower SHBG
Fasting Insulin	8-16 hours fasting	< 30 mIU/ml	The normal range here doesn't give all the information. A fasting insulin of 10-13 generally indicates some insulin resistance, and levels above 13 indicate greater insulin resistance.

Blood Glucose Levels
Type of test	Time to Test	Normal Values	What value means
Fasting Glucose	8-16 hours fasting	70-110 mg/dl	A healthy fasting glucose level is between 70-90, but up to 110 is within normal limits. A level of 111-125 indicates impaired glucose tolerance/insulin resistance. A fasting level of 126+ indicates type II diabetes.
Glycohemoglobin / Glycosylated Hemoglobin (HbA1c)	anytime	< 6 %	An HbA1c measures glucose levels over the past 3 months. It should be under 6% to show good diabetic control (postprandial glucose levels rarely going above 120). Good control reduces the risk of miscarriage and birth defects.

Cholesterol, Triglycerides and C-Peptide
What to test	Time to Test	Normal Values	What value means
Triglycerides (TG)	8-16 hours fasting	< 200 mg/dl	Borderline high is 200-400, high is 400-1000, and very high is >1000. Elevated levels are a risk factor for coronary artery disease.
Cholesterol Total	8-16 hours fasting	< 200 mg/dl	A level of 200-239 is borderline high, and a level 240+ is high. Increased levels are associated with increased risk of heart disease.
low-density lipoprotein cholesterol (LDL)	8-16 hours fasting	< 160 mg/dl	This is the "bad" cholesterol. In someone with one risk factor for heart disease, <160 is recommended, with 2 risk factors <130, and those with documented coronary heart disease the target is <100
high-density lipoprotein cholesterol (HDL)	8-16 hours fasting	> 34 mg/dl	This is the "good" cholesterol which may be increased through a healthy diet and exercise. The HDL level is usually estimated by taking total cholesterol and subtracting LDL, rather than by direct measure.
C-peptide	8-16 hours fasting	0.5 to 4.0 ng/ml	Levels increase with insulin production.
Creatinine		<1.4 mg/dl	Levels 1.4 mg/dl and higher may indicate renal (kidney) disease or renal dysfunction.

Some doctors will suggest an oral glucose tolerance test in addition to the tests above for insulin resistance.

What does an abnormal test value mean?

Nearly all patients with PCOS will have at least some subtle laboratory abnormalities, though the levels may not be outside normal limits. Lab values that are at the upper or lower end of the normal range may show a tendency toward a problem rather than a discrete abnormality. It may be a pattern within the group of tests that points to PCOS, rather than one or more values outside the normal limits.

Usually a hormone level that is marginally elevated is associated with a dysfunction, while a severe elevation or suppression may be more likely to be pathologic (a physical cause, such as an adrenal tumor).

It is important to note that many lab reference ranges were probably set irrespective of PCOS, and often are set based on screening for a certain abnormality. For example, the range of normal on a fasting insulin test may be set to screen for an insulinoma (an insulin-producing tumor in the pancreas), rather than to check for insulin resistance.

Does it matter when hormone tests are performed?

Most endocrine tests should be performed within a few days after a spontaneous or induced menstrual period. These tests may be misleading if oral contraceptives are being used. Glucose, insulin and lipid evaluation should be done in the morning after fasting for at least 8 hours, but less than 16 hours. Accurate glucose and insulin testing requires the patient to be in good health. Progesterone levels to confirm ovulation should be done seven days after suspected ovulation.

How often should tests be repeated?

Most of the blood work, unless monitoring a fertility treatment cycle, does not have to be repeated unless there is abnormal result. Most infertility clinics will repeat basic labs annually.

How important is the LH:FSH ratio?

The emphasis doctors place on the ratio of luteinizing hormone (LH) to follicle stimulating hormone (FSH) varies. Most pre-menopausal women have a ratio close to1:1. In PCOS, the LH level may rise above the FSH, sometimes significantly. Any case where the LH is higher may be suggestive of PCOS and further investigation may be warranted. Some doctors say that an LH:FSH greater than 2:1 or 3:1 indicates PCOS.

Are PCOS and hypothyroid related?

No. It may be that PCOS and thyroid disease are both common, so will sometimes be seen in the same patient.

A good number of PCOS patients have under-active thyroid glands. Since many of the symptoms are the same, evaluation of the thyroid gland with a blood test for thyroid stimulating hormone (TSH) should be a part of the evaluation for PCOS. The TSH is almost always the only test needed to evaluate thyroid function.

Likewise, PCOS should be evaluated in the patient with under-active thyroid gland.

What are the long-term health risks associated with PCOS?

PCOS is associated with increased risk for endometrial hyperplasia, endometrial cancer, insulin resistance, type II diabetes, high blood pressure, high cholesterol, and heart disease.

What kind of monitoring is recommended?

Even if pregnancy is not desired, women with PCOS should be sure to have their blood sugar, insulin, cholesterol and triglycerides checked once per year. Those who are also hypothyroid should also monitor TSH to make sure medications are working properly.

What is endometrial hyperplasia and how can risk be reduced?

Endometrial hyperplasia is a thickening of the endometrium with the finding of abnormal cells — a pre-cancerous condition. It is diagnosed through an endometrial biopsy where a thin catheter is threaded through the cervix and a small sample of the lining is removed. A pathologist reviews the tissue and results are not available immediately. The key to reducing risk is to make sure to have some kind of "bleed" in which the lining of the uterus is shed at least every 3 months, preferably more often. This can be accomplished through the use of birth control pills or progesterone/progestins for period induction.

What can be done to reduce the risk of endometrial cancer?

The primary way to reduce the risks of cancer is to have regular menses one way or another. Whether it be through the use of oral contraceptive, progesterone or progestins for period induction, or otherwise regulating hormone levels so that one doesn't go longer than a couple of months without shedding the uterine lining. There is no guaranteed way to prevent cancer, but one can minimize the risk.

What if induction of menses fails?

If using progesterone or progestin (Provera, Aygestin, and Cycrin) after a negative pregnancy test fails to induce menstruation, one should have a second pregnancy test before further treatment. It may be that the lining was not thick enough to shed, in which case using estrogen followed by progesterone/progestin, or birth control pills, may work for bringing on a period.

What are insulin resistance, diabetes, and the other impairments of insulin and glucose metabolism?

One of the complicating factors of understanding the blood sugar and insulin issues associated with PCOS is all the different names out there. Below is a brief description of the various terms and there is more information under the insulin connection section.

Insulin Resistance is when a fasting insulin level is greater than 10 mIU/ml. There are some other testing methods used. Some would say a fasting glucose:insulin ratio less than 4.5:1 indicates insulin resistance. Another method is doing a glucose tolerance test and checking insulin along with blood sugar. If the insulin level at 2 hours is 5 times the fasting level, insulin resistance is diagnosed. The most common testing is the fasting level. Central obesity is considered a risk factor for insulin resistance.

Hyperinsulinemia is when insulin levels are high in relation to glucose levels. It goes along with insulin resistance. Hyperinsulinemia in PCOS correlates with increased cardiovascular risk independent of obesity.

Impaired Fasting Glucose is when the fasting glucose level is greater than or equal to 110 and less than 126 mg/dl. This level may signal insulin resistance and is a future risk factor for diabetes.

Impaired Glucose Tolerance is when a person has a 2-hour glucose tolerance test result greater than or equal to 140 but less than 200 mg/dl (some would suggest lowering the upper limit to 180). This indicates a future risk factor for diabetes.

Diabetes is when a person has a fasting blood sugar equal to or greater than 126 mg/dl, or a 2-hour GTT level greater than or equal to 200 mg/dl dl (some would suggest lowering the upper limit to 180). This should be confirmed by a second test.

What can be done to reduce the risk of type II diabetes?

The best way to reduce the risk of type II, non-insulin dependant (NIDDM) diabetes mellitus is through careful food choices, exercise, and weight loss in overweight individuals. Insulin-sensitizing medication may also help prevent or delay the onset of diabetes. These medications can increase the likelihood of pregnancy, and may reduce effectiveness of oral contraceptives, so precautions should be taken by anyone not wishing to get pregnant.

What are normal levels for cholesterol and triglycerides?

The table below includes standard fasting levels. The LDL cholesterol target level is reduced in those who have risk factors. With one risk factor, the target is less than 160 mg/dl, with 2 factors the target is less than 130 mg/dl, and those with heart disease have a target level less than 100. Insulin resistance, diabetes, obesity, and family history are some of the risk factors, so those with PCOS should have a target range of less than 130.

Cholesterol and Triglycerides
Type	Normal	Border-line High	High	Very High	Low
Total Cholesterol	< 200 mg/dl	200-239 mg/dl	240+ mg/dl
HDL Cholesterol	> 35 mg/dl				< 35
LDL Cholesterol	< 160 mg/dl
Triglycerides	< 200 mg/dl	200-400 mg/dl	400-1000 mg/dl	400-1000 mg/dl

What can be done to help improve cholesterol and triglycerides?

The best way to improve levels is through diet, exercise and weight loss for those who are overweight. In some cases, medications may be used to lower cholesterol levels, but those attempting pregnancy should not use these. Exercise can be particularly beneficial as it can help increase good cholesterol and helps the body metabolize sugar.

What is dyslipidemia?

Dyslipidemias are disorders of lipoprotein metabolism, including lipoprotein overproduction or deficiency. These disorders may be manifested by elevation of the serum total cholesterol, low-density lipoprotein (LDL) cholesterol and triglycerides concentrations, and a decrease in the high-density lipoprotein (HDL) cholesterol concentration.

What is hyperlipidemia?

Hyperlipidemia is an elevation of lipids (fats) in the bloodstream. These lipids include cholesterol, cholesterol esters (compounds), phospholipids and triglycerides.

What can be done about high blood pressure now and in the future?

This again is an area where diet, exercise and weight reduction in overweight individuals may help lower blood pressure and perhaps lessen the need for medication. Research also suggests that lowering salt intake and increasing consumption of foods containing certain minerals, such as potassium and magnesium, can help. There are many prescription medications that can be used to lower blood pressure as well, including diuretics, beta blockers, and calcium channel blockers. Anyone who is trying to get pregnant should discuss which medications are safest with their physician, and try to get good control on safe medications before attempting a pregnancy.

What can be done to reduce the risk of heart disease?

Reducing heart disease risk follows the same pattern for reducing insulin resistance, balancing cholesterol, and lowering blood pressure — it all involves managing PCOS to minimize current symptoms and attempt to delay or prevent worsening of the underlying conditions that lead to heart disease. This can be done through careful food choices, exercise, weight loss in overweight individuals, and through careful selection of medications.

What is the connection between insulin resistance and PCOS?

At least 30 percent of women with PCOS are insulin resistant, although some investigators claim a much stronger association exists. Hyperinsulinemia produces hyperandrogenism by stimulating ovarian androgen production and by reducing serum sex-hormone binding globulin (SHBG). This can heighten PCOS symptoms. Reducing insulin resistance through the use of insulin-sensitizing medications can restore ovulatory function in many women with PCOS. It appears that even some patients who do not test as being insulin resistant may benefit from these medications.

How are insulin resistance and diabetes diagnosed?

Insulin resistance should be diagnosed by measuring insulin levels — fasting levels alone, or with a glucose tolerance test plus insulin (sometimes called an IGTT). Diabetes may be diagnosed based on blood glucose levels alone.

What is the glucose tolerance test (GTT) and what are normal values?

An oral glucose tolerance test is done to check the body's ability to process sugar. The test begins with blood being drawn in the morning after fasting overnight (usually more than 8 hours, but less than 16). The patient then drinks a bottle of "glucola" — a special drink prepared with 75 grams of glucose (sugar). There is some variation in how many blood draws are made. Some will only check the 2-hour level, though most commonly blood draws are made at 1 hour, 2 hours, and 3 hours. Some labs will also draw at 30 minutes, and/or at 4 hours. Normal values are:

Glucose Tolerance Test — Glucose and Insulin Values
Time	Normal Glucose Values	Normal Insulin Values	What the Results Mean
Fasting	< 126 mg/dl	< 10 mIU/ml	Normal glucose results are 70-90, 111 or over is impaired, 126 or over is diabetic. Insulin levels above 10 show insulin resistance.
½ hour	< 200 mg/dl	40-70 mIU/ml	A truly normal glucose response will not exceed 150.
1 hour	< 200 mg/dl	50-90 mIU/ml	Some want to lower the threshold on glucose to < 180 to identify early stages of diabetes. Insulin > 80 shows insulin resistance, or a level 5 times that of the fasting level (i.e., a fasting of 11 followed by a 1 hour > 55)
2 hours	< 140 mg/dl	6-50 mIU/ml	A truly normal glucose response is 110 or lower. Insulin > 60 is IR.
3 hours	< 120 mg/dl
4 hours	< 120 mg/dl

To get a reliable result, a patient should be in good health (not even a cold), and fasting level should be done without taking anything but water by mouth — no smoking, no medications, no coffee, no gum, no toothpaste, etc. — for 8-16 hours before the test.

Will following a low-carbohydrate diet affect the results of a fasting insulin test?

Because following a low-carbohydrate diet may lower fasting insulin test results, it is usually recommended that one adhere to a diet that is not carbohydrate restricted for two to three days prior to testing in order to ensure accuracy. Some doctors and labs have specific diet requirements, so patients should request specific instructions if none are given.

What is a glycohemoglobin/glycosylated hemoglobin (HbA1c) test and what do the results mean?

This test is done to monitor a person's average blood glucose level over the past 3 months or so. Unlike fasting and postprandial (after meal) tests that only give a value for a slice of time, this test gives an average over time. It is not usually used to diagnose impaired glucose tolerance or diabetes, but rather to assess glucose control. Glucose attaches itself to hemoglobin, the protein in red blood cells that carries oxygen. Since blood cells remain in circulation for 2-3 months, the HbA1c level is a good measure of average glucose level during this time period.

A healthy level is less than 6 percent. When a level gets above 6 percent, it indicates some high blood sugar levels. Higher levels may indicate risk for organ and nerve damage. In someone who is trying to get pregnant, it is important to have blood sugar under control as elevated levels increase the risk of serious birth defects.

Can lean women be insulin resistant or type II diabetic?

While insulin resistance is frequently accompanied by excess weight, there are thin women who are insulin resistant or type II diabetic. Unfortunately, lean women may not have as much success reducing insulin resistance through lifestyle changes as their overweight counterparts, but diet modifications and increased exercise often provide some benefit.

How do insulin-sensitizing medications work?

Metformin/Glucophage works primarily by suppressing hepatic glucose production, increasing glucose utilization in peripheral tissues. It may also reduce intestinal glucose absorption. Since it does not stimulate production of insulin, it does not cause hypoglycemia if used alone (though hypoglycemia may result if used with insulin, a sulfonylurea, or with consumption of an excessive amount of alcohol). Metformin is metabolized by the kidneys.

The thiazolidinediones (glitazones or TZDs) — troglitazone (Rezulin, which was taken off the market on March 21, 2000), rosiglitazone maleate (Avandia) and pioglitazone hydrochloride (Actos) — work primarily by improving sensitivity to insulin in muscle and adipose (fat) tissue and also by inhibiting hepatic glucose production. They are metabolized by the liver and excreted into the bile.

If hypoglycemia is experienced on either type of medication, it is most likely due to insufficient caloric intake, rather than a direct result of the medication. These medications may also help improve cholesterol and triglycerides levels, and may restore ovulation in premenopausal women with PCOS or diabetes.

What are the side effects of insulin-sensitizing medications?

Metformin hydrochloride (Glucophage) — Gastrointestinal problems such as diarrhea, nausea, vomiting, abdominal bloating, flatulence, and anorexia are the most common reactions. Usually the side effects are dose dependant and diminish over time. Starting with a low dose and building up to the desired maintenance level may help. The biggest risk, though very rare (1 in 33,000), of metformin is the possibility of lactic acidosis (a buildup of lactic acid in the blood). Symptoms of lactic acidosis include feeling weak, muscle aches, trouble breathing, lightheaded or dizziness, or suddenly developing slow or irregular heartbeat.

Rosiglitazone maleate (Avandia) — The most commonly reported side effects include upper respiratory tract infection, injury, and headache. Use of this medication may contribute to weight gain. Because Avandia is in the same class of medications as Rezulin, it may reduce effectiveness of oral contraceptives. (Clinical trials indicated that administration of Rezulin and birth control pills containing ethinyl estradiol and norethindrone may lower the plasma concentrations of both hormones by approximately 30 percent, which could result in loss of contraception. Therefore, a higher dose of oral contraceptive or an alternative method should be considered if pregnancy is not desired.) Avandia is generally considered safer than Rezulin and less likely to cause liver damage, but it also has not been on the market as long. Liver testing is recommended ever two months the first year of use, and quarterly thereafter.

Pioglitazone hydrochloride (Actos) — The most commonly reported side effects include upper respiratory tract infection, headache, sinus infection, muscle soreness, tooth disorder, and sore throat. It may cause mild to moderate swelling (edema) and decrease in blood count (anemia) in some patients. The prescribing information indicates that the effect of Actos on oral contraceptives has not been studied, but because of its relation to Rezulin it is recommended that patients not wishing to become pregnant exercise additional caution regarding contraception. Like Avandia, Actos is generally considered safer than Rezulin as far as liver toxicity is concerned, but it is also newer on the market and not used by as many people. Liver testing is recommended ever two months the first year of use, and quarterly thereafter.

What testing should be done before prescribing insulin-sensitizing medications?

A comprehensive biochemical panel that includes liver enzymes and alanine transaminase (ALT) should be performed before metformin or one of the thiazolidinediones (Avandia, Actos) are taken. If there are liver or kidney abnormalities, caution should be used and the benefits weighed before choosing to use these medications.

What is the maximum dosage of metformin?

The maximum recommended dose of metformin is 2550 mg per day (3 x 850 mg pills). The usual dose in diabetics is 1000 mg twice daily. Studies with metformin for patients with PCOS usually use 500 mg three times a day or 850 mg twice daily.

What kind of monitoring should be done while on insulin-sensitizing medications, and how often?

Fasting blood sugar, insulin and HbA1c measurements should be performed periodically to monitor glycemic control and the therapeutic response to medication.

With metformin, it is recommended that kidney function tests be repeated periodically.

For those using Avandia or Actos, ALT levels should be checked every two months for the first year of therapy, and quarterly thereafter.

Liver function tests should also be obtained if one has symptoms suggestive of hepatic dysfunction, such as jaundice (yellowing of skin and whites of eyes), nausea, vomiting, abdominal pain, fatigue, anorexia, or dark urine.

Can metformin be used along with one of the glitazones?

Because metformin and glitazones work in different ways to improve insulin utilization, they may have a synergistic effect when used together. Treatment with more than one medication often increases side effects, costs, and necessary monitoring, so should only be considered after use of a single medication fails to get the desired result (lowering of insulin and androgen levels, and restoration of cycles).

How do doctors decide which medications, or which combination of medications to use?

For the treatment of PCOS, especially among women trying to conceive, most doctors would start with the older and safer metformin therapy and only switch to or add one of the glitazones if metformin alone is not working, or if the side effects are intolerable. In patients with kidney problems, one of the glitazones may be the first course of treatment. Other considerations include the fact that the safety of Rezulin is currently being questioned in the U.S., and ACTOS and Avandia are Pregnancy Category C medications that should be stopped when pregnancy is achieved.

How long do the nausea and diarrhea last after starting metformin?

Usually symptoms lessen over time and go away with long-term use (usually after 3-4 weeks at the same dose). If diarrhea and nausea continue, one should make sure to take the medication in the middle of a meal. Also consider diet — the uncomfortable side effects may be prolonged by a diet that is high in carbohydrates and/or high in fat. Reducing both may lessen symptoms.

Is diet modification needed in addition to taking insulin-sensitizing medications?

The medications themselves may help, but lifestyle changes are beneficial. It is generally recommended that patients taking metformin or one of the glitazones reduce carbohydrate intake and increase exercise to aid in glucose metabolism and possible weight loss in those who are overweight. Seeking a consult with a registered dietician and beginning a structured exercise program are central to an effective therapeutic plan.

Is there any benefit to using insulin-sensitizing medications to treat lean PCOS patients or those who do not test as being insulin resistant?

Some doctors do give insulin-sensitizing medications to patients with PCOS, including lean women, whether or not they test as clearly being insulin resistant. Though studies are needed to firmly establish the benefit, many patients appear to experience improvements in symptoms and cycling. The cause of this improvement is unclear.

Is it safe to consume alcoholic beverages while on metformin?

Drinking alcohol while on metformin is not recommended, though not completely banned either. One may feel the effects of the liquor sooner and become intoxicated more easily. It also increases the risks of hypoglycemia. Alcohol may work with metformin to increase blood lactate levels, increasing the risk of lactic acidosis.

What is Syndrome X or Metabolic Syndrome?

Syndrome X, also called Metabolic Syndrome or Insulin Resistance Syndrome, is a combination of insulin resistance or diabetes, dyslipidemia, hypertension, and central obesity.

What is the difference between Syndrome X and PCOS?

One of the biggest differences is that both men and women can have Syndrome X, while men cannot have PCOS. Syndrome X involves a cluster of symptoms found within the larger scope of PCOS symptoms — it is this metabolic disorder that contributes most to heart disease.

Is everyone with PCOS also considered to have Syndrome X?

No. To be diagnosed with Syndrome X, one must have insulin resistance, hypertension, obesity and dyslipidemia. It is possible to have PCOS without having all of these symptoms, and some women with PCOS may not appear to have any of them.

Do all women with PCOS suffer from infertility?

The answer to this depends on the criteria used to diagnose PCOS. If a main criterion is anovulation, then by definition women with PCOS would have fertility problems. It is possible to have the appearance of polycystic ovaries and be fertile, but having the syndrome usually does impact fertility adversely.

Is it possible to have regular cycles without ovulating?

Yes, but the reasons for this happening are poorly understood. Some women seem to have a regular bleed regardless of ovulation, so one should look beyond cycle length to determine ovulation. See http://www.staging.inciid.org/fertinews/pcosnormal.html

Are basal body temperatures reliable in women with PCOS?

Women with PCOS who are mostly anovulatory will have erratic BBTs — some say it will look like the Rocky Mountains. If a woman with PCOS has an ovulatory cycle, the BBT chart should show a thermal shift, but it may be a bit harder to read. Some doctors see more value in charting than others, and one should follow their own physician's advice.

Are ovulation predictor kits reliable for women with PCOS?

It depends on whether the woman has high LH levels. A woman with elevated LH may consistently get positive tests or get erratic readings. Most women will show some kind of line in the result window of a test since LH is always present — it is important to note that a positive result is as dark or darker than the control line. The Clearplan Fertility Monitor notes that it is unreliable for women with PCOS. It's a good idea to check with one's doctor for suggestions on home monitoring.

Will losing weight jumpstart fertility in overweight patients with PCOS?

It may, but it doesn't always. There are lean women with PCOS. Weight loss may help reduce insulin resistance, resulting in spontaneous or improved ovulation. Quick weight loss may cause more harm than good, so slow weight loss is best. Losing 10 percent of one's body weight should be enough to show some improvement in symptoms.

Is it safe to follow a low carbohydrate diet while trying to conceive?

It depends on the diet plan followed. Most doctors would stress a lifestyle change — a change in types of food consumed — over a reduced-calorie diet. Several of the more popular plans are outlined in the weight section below.

Does Clomid work for women with PCOS?

Clomid may work for PCOS women, but only about 40 percent of those who ovulate on it will get pregnant. A good trial is three to four ovulatory cycles. Most doctors would recommend not doing more than six cycles total of Clomid.

Which injectable fertility medications work best for women with PCOS?

Many doctors will suggest FSH-only medications for women with PCOS as LH levels are already elevated.

Does PCOS lower egg quality?

It is possible that PCOS may reduce egg quality — perhaps because of abnormally high insulin levels, or because of the delayed ovulation (to which insulin resistance may contribute).

What is the benefit of adding steroids such as dexamethasone or prednisone to ovulation induction medications?

The steroids are used to help lower androgen levels, particularly DHEAS. This may help ovulation induction. However, use of steroids should be carefully implemented, since insulin resistance is generally worsened by these medications.

Is progesterone support needed in women with PCOS?

Women with PCOS frequently have low progesterone levels. The best solution is to strengthen ovulation, as opposed to progesterone supplementation alone without investigating follicle development through ultrasound monitoring and estradiol levels. Supplementation may still be desirable as it probably cannot hurt, and might help.

Can insulin-sensitizing medications be used in conjunction with ovulation stimulation drugs?

Yes. The use of insulin-sensitizing medications while trying to conceive is becoming more common, and many doctors will introduce ovulation stimulation medications such as clomiphene citrate, FSH-only injectables, or FSH/LH injectables. The greater debate right now is when to stop the medications when pregnancy is achieved.

How long a trial should one give insulin-sensitizing medications before adding ovulation stimulation medications?

A good trial period for insulin-sensitizing medications is 3-6 months. Someone with borderline insulin elevations may require a shorter duration of therapy than a woman with a strikingly high level. If ovulation does not resume after 3-6 months, or pregnancy is not obtained, one might consider adding fertility medications. It may also make sense to re-check fasting glucose and insulin levels to see if the insulin-sensitizing therapy is working or if adjustments in treatment should be made.

Do insulin-sensitizing medications improve egg quality in IVF?

The follow-up for women taking insulin-sensitizing agents who subsequently undergo IVF/ET is currently limited. No controlled data exist (yet) that proves whether or not normalization of insulin levels has an important effect on oocyte quality, but some generalizations suggest this may indeed be the case. It does appear that use of metformin may increase the number of mature eggs retrieved.

For example, among many diabetics both insulin and glucose are elevated. The incidence of congenital anomalies is well known to be higher in these patients. This means something is adversely affecting development with bad perinatal results. At the gamete (egg) level, similar blocks to normal growth may also exist.

Should metformin be discontinued before doing a hysterosalpingogram (HSG)?

Patients should go off metformin for several days prior to any x-ray procedure in which iodinated compounds will be used, including the hysterosalpingogram where contrast dye is injected into the uterus (note: this is a different procedure than a sonohystogram where saline is injected into the uterus before an ultrasound).

The reason for this recommendation is that the kidneys clear both the dye and metformin. It should not be a problem if renal function judged by creatinine and blood urea nitrogen (BUN) tests is normal. Renal function testing should be performed before metformin is started, and periodic screening is prudent. Many of the users of metformin are older diabetics with altered kidney function, and this is added precaution.

Does PCOS increase the risk of ovarian hyperstimulation?

Yes. Because of the tendency for women with PCOS to produce many small follicles, the trick to avoiding hyperstimulation is getting a few follicles to mature without an army of smaller ones. Caution should be used with medications, starting at the lowest doses, and follicle production should be monitored by ultrasound and estradiol levels. It is possible that the use of metformin with gonadotropin-induced ovulation may reduce the risk of hyperstimulation.

Should women with PCOS who are trying to conceive take baby aspirin?

This is something that should be discussed with one's doctor, but there is some research indicating that pregnancy continuation rates in PCOS may be improved with low-dose (81 mg/d) aspirin therapy. The aspirin is used to help prevent blood clotting in the uterine lining and help increase blood flow.

What is in vitro maturation (IVM) and is it beneficial for women with PCOS?

In vitro maturation is a process in which immature eggs are harvested from a woman early in her cycle and matured in a laboratory using gonadotropins, rather than medicating the patient in order to stimulate follicle growth prior to egg retrieval (IVF). After the eggs are matured, they are fertilized and resulting embryos are transferred to the uterus. While gaining publicity recently, the procedure is not really that new. It isn't widely used because the pregnancy rate with IVM is low, and the miscarriage rate is high. The primary advantages of the process are that it may work for women who are poor responders to medications, the risk of hyperstimulation is eliminated, and it reduces costs by lessening the amount of medications and monitoring needed. Fertilization rates in PCOS patients may be improved if they are given an hCG injection 36 hours prior to egg retrieval.

Is there a relation between PCOS and endometriosis?

Endometriosis has been reported in about 30 percent of infertile women. PCOS is the most common cause of lack of ovulation and certainly a leading cause of female infertility. Statistically, it would seem that many women would have both and this is probably the case. Both of these disorders appear to have a genetic predisposition. However, whether endometriosis is more or less common in PCOS patients and PCOS in those with endometriosis is not known. Certainly, everyone that has one of these disorders does not necessarily have the other.

The leading theory on the origin of endometriosis is a back flow of blood from the uterus through the tubes and out into the pelvis (retrograde menstruation). This theory can only partly explain the origin of endometriosis because most women have this "backward flow" each month, but endometriosis is not seen universally. The second theory of endometriosis is that the cells lining the pelvis and ovaries are transformed into endometrial cells by some internal or external stimulus. Perhaps, blood and all the growth factors it contains is a good candidate. It can easily be seen how these two theories could work together.

In one way, the PCOS patient who has very infrequent bleeding should have a decreased chance of endometriosis. In another way, estrogen levels may be chronically elevated to a level lower than those near ovulation, but high enough to cause the endometrium to proliferate as it remains unopposed by progesterone. Endometriosis can be thought of as a fire. The fuel for the fire is estrogen.

What is Luteinizing Unruptured Follicle Syndrome (LUFS) and how does it relate to PCOS?

Luteinizing unruptured follicle syndrome occurs when the follicle develops but changes into the corpus luteum without releasing the egg. It may be more likely to occur in women with polycystic ovaries since the ovaries become tougher and it is harder for the egg to escape the follicle and the ovary. In some cases of LUFS, a thermal shift will be visible on a BBT chart, and a progesterone draw seven days after suspected ovulation may show a borderline response (between 5 and 15 ng/ml). The only absolute test of ovulation is pregnancy. The use of non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen sodium (Advil and Aleve), as well as adult-strength aspirin, may contribute to LUFS. Therapeutic low-dose aspirin, also called baby aspirin, should not effect ovulation.

What is an ovarian drilling or wedge resection?

The purpose of both surgeries is the same, to reduce androgens and restore menses, but the wedge resection is rarely done anymore. The success of the wedge resection may be higher than that of ovarian drilling, but the drilling is a less invasive procedure with less risk of scarring.

The wedge resection involves doing a laparotomy (a major abdominal surgery where a long cut is made along the bikini line), and then cutting a portion (wedge) out of the ovary and stitching the ovary back together. The procedure is known to result a significant reduction in LH and androgen production. Some studies noted establishment of regular menses in more than 75 percent of patients and a pregnancy rate of about 60 percent. Unfortunately the risk of adhesions, sometimes severe, is around 30 percent.

The more common procedure today is ovarian drilling (microcautery or diathermy) done by outpatient laparoscopic surgery. A small needle is used to make 4-20 punctures in the ovary. An electric current is passed through the needle and a small portion of the ovary destroyed. Often a small amount of cyst fluid can be seen escaping as the puncture is made. Alternatively, lasers have been used for the same effect with the potential disadvantage of greater surface injury and scar tissue formation.

The success rate for ovarian drilling is generally less than 50 percent, maybe less than 25 percent, but the best answer is to ask the doctor's statistics and what outcomes are associated with his/her particular technique. The risk of adhesions still exists, but is much lower in ovarian drilling than in wedge resection. One advantage is that the surgery may be combined with diagnostic laparoscopy, chromotubation (also called chromopertubation or hydrotubation) and/or hysteroscopy.

Surgical therapy for PCOS should not be considered as a first step in treatment in part because it is unclear what the long-term effects might be. A good time to consider it would be when making preparation for a diagnostic laparoscopy or considering in vitro fertilization.

What is hyperprolactinemia and what can be done to treat it?

Hyperprolactinemia is an elevation of prolactin levels in the blood that may appear more often in women with PCOS. The elevated levels may cause breast discharge and may contribute to irregular menses. In some cases it is caused by a tumor on the pituitary gland. The first step in diagnosis is usually a blood test, and elevated levels may indicate further investigation through MRI. If the tumor is large and pressing on adjacent brain structures, it may be removed and all problems are solved. A small tumor might be treated with medications such as bromocriptine (Parlodel) or cabergoline (Dostinex — which is also shown to improve uterine perfusion. Cabergoline is often tolerated better than Parlodel, and doses are taken less frequently.

Is the miscarriage rate higher in women with PCOS?

There does appear to be a higher miscarriage rate in women with PCOS, but the exact reason is still under investigation. According to some studies, the risk of miscarriage in women with PCOS is 45 percent or more. One possibility is that early loss is associated with elevated levels of luteinizing hormone — and women with PCOS often have elevated LH levels — but the reason why it relates to miscarriage is not understood. Another possibility is that elevated levels of insulin or glucose may impede implantation or cause problems with the embryonic development. There is a clear association between uncontrolled blood sugar and pregnancy loss, but the issue of insulin resistance and elevated insulin levels is relatively new and in need of further study. There is a possibility that insulin resistance reduces egg quality. That leads to another possibility — that late ovulation (after cycle day 16) may be associated with poor follicle development and decreased egg quality.

Is there anything that can be done to reduce the chance of miscarriage in a woman with PCOS?

The primary way to reduce miscarriage associated with PCOS is to normalize hormone levels. For women with low progesterone levels in the luteal phase, improving ovulation through the use of clomiphene citrate, or injectable FSH or FSH/LH may help the problem. Addressing ovulation issues is more useful than progesterone supplementation as low progesterone is usually a symptom of a problem, such a weak ovulation, rather than the actual cause of miscarriage. Normalizing blood sugar and glucose levels may help, and lead to lower androgen levels, so use of metformin (see next question) during pregnancy is increasing. Most doctors would have patients discontinue use of the glitazones.

Can metformin reduce the chance of miscarriage?

It appears that continuing metformin use at least through early pregnancy may reduce the chance of miscarriage, especially in patients with recurrent losses. A recent abstract, "Metformin throughout pregnancy in women with polycystic ovary syndrome reduces first-trimester miscarriage" (CJ Glueck et al, J Invest Med 2000), revealed a group's experience with 59 pregnant PCOS women. Of these, 23 were kept on metformin for the long haul. The other 36 did not continue metformin in pregnancy. This is a very small sample, but the miscarriage rate was 45 percent without metformin and only nine percent with metformin. Chi-square testing showed these rates to be highly significant from a statistical point of view, but their true clinical impact must await further prospective studies. As with any medication used in pregnancy, doctor and patient must assess whether the benefit outweighs any potential risk.

Does having PCOS make pregnancy high risk?

The answer to this may depend a little on the definition of high risk. Most PCOS patients can see a regular OBGYN, or perinatologist. Anyone who is severely insulin resistant, diabetic, or has high blood pressure may need to see a high-risk OBGYN. This is an issue to be decided by doctor and patient together.

Does a pregnant woman with PCOS require special monitoring?

Some special monitoring may make sense — such as earlier gestational diabetes screening or home glucose monitoring. Beyond that it depends on the PCOS symptoms experienced by the patient before pregnancy. Anyone taking medication may require additional monitoring. Many of the issues one needs to watch for are included in routine pregnancy care. For example, a woman with borderline hypertension before is more likely to have increased blood pressure in pregnancy, but most doctors check all patients for blood pressure issues.

Is low-carbohydrate dieting healthy in pregnancy?

A diet that is very low in carbohydrates is not safe during pregnancy. If the body is too low on resources, it will burn fat for calories. A byproduct of this is ketones, and these may not be healthy for the growing fetus. It is best to follow a meal plan that allows consumption of vegetables and complex carbohydrates at each meal and snack. A couple of the plans listed in the weight section are safe during pregnancy, and consultation with a nutritionist familiar with gestational diabetes may help.

Can insulin-sensitizing medications such as metformin and the glitazones be taken during pregnancy?

It has been recognized for years that high glucose levels can have a detrimental effect on the growing fetus and most doctors would suggest diet and/or insulin injections to control this, but recently there has been discussion that high insulin levels may be just as damaging.

Continuing metformin in pregnancy is an area of controversy — some doctors won't prescribe it to women who are trying to conceive, some tell patients to discontinue metformin after a positive pregnancy test, some wait for a heartbeat, some treat through the first trimester, and others continue the medication throughout the pregnancy. There are some studies that indicate continuing the medication may reduce the risk of miscarriage. The long-term risks to the baby are not known, but many apparently healthy babies have been born to women who used metformin while pregnant. Metformin is a Pregnancy Category B drug, meaning that it has not been known to cause birth defects in rats, but there are no adequate studies in pregnant women and the choice to continue metformin should be based on whether one considers the potential benefits to outweigh the risks. This is an area where a woman and her doctor have to weigh the risks and benefits together.

As for the glitazones, Avandia and Actos are considered safe to the patient using them, but both are listed as Pregnancy Category C medications. Most doctors will ask patients to discontinue use of these medications during pregnancy.

Is someone with PCOS more likely to have gestational diabetes?

Many women with PCOS are insulin resistant, and pregnancy tends to be a time of increased glucose intolerance as well. When one combines the two, there is an increased incidence of gestational diabetes.

What is gestational diabetes and how is it diagnosed?

Gestational diabetes occurs when a woman has impaired glucose/carbohydrate tolerance during pregnancy (usually temporarily, or a temporary worsening). The main concerns are having the baby get too much sugar since the mother is not processing it herself — leading to a large baby, but perhaps with immature lungs, and some birthing difficulties — and the ketone byproduct that may be produced when the body turns to other sources, such as fat-stores, for energy.

It is usually diagnosed based on a reading of 200 mg/dl or higher on a 1-hour oral glucose challenge test where 50 grams of sugar are consumed, or based on having two parameters out of normal range on a 3-hour GTT after consuming 100 grams of glucose.

Oral Glucose Tolerance Test for Gestational Diabetes
Time	Normal Values	Gestational diabetes is diagnosed if 2 or more levels are above the normal range.
Fasting	< 105 mg/dl
1 hour	< 190 mg/dl
2 hours	< 165 mg/dl
3 hours	< 145 mg/dl

Does PCOS cause problems breastfeeding?

There are no adequate studies on the topic, but the hormone imbalances that go along with PCOS appear to reduce ones ability to breastfeed exclusively. Most PCOS women have no trouble, and breastfeeding may improve glucose tolerance a short time after giving birth.

Is it safe to use insulin-sensitizing medications while breastfeeding?

Since many medications are excreted in breastmilk, it is usually recommend that insulin-sensitizing medication not be used while breastfeeding. The effect such medications may have on the nursing baby or toddler is not known.

Will pregnancy cure PCOS?

There is no cure for PCOS, but some women do have a normalization of cycles after a pregnancy. Those who had fertility problems may find it easier to get pregnant again.

What treatments for PCOS symptoms are available?

There are many medications that can be used to control PCOS symptoms, and some may be used in combination with each other. Among the most common is the birth control pill, discussed directly below. Other anti-androgens such as spironolactone (Aldactone), Flutamide, cyproterone acetate, and Finasteride may be used to help control cosmetic issues. Corticosteroids are sometimes used as well, though their side effects may be intolerable. Women who are not seeking pregnancy can also make use of a wide variety of blood pressure and cholesterol lowering medications, in addition to insulin-sensitizing medications. The best course of action depends on individual needs.

Are birth control pills safe for women and adolescents with PCOS?

Most doctors feel that oral contraceptives are safe for women with PCOS and may even provide some health benefits. Besides regulating menstruation, birth control pills can increase sex-hormone binding globulin (SHBG) and thereby reduce circulating androgens. Different varieties may be more effective at reducing androgen levels and helping to clear acne.

Adolescents with irregular cycles should have an endocrine evaluation before being put on the pill.

Some concerns about using the pill include the possibility that it may contribute to insulin resistance, and that oral contraceptives containing ethinyl estradiol and norethindrone may not work effectively if taken at the same time as rosiglitazone maleate (Avandia), or pioglitazone hydrochloride (Actos). Use of birth control pills is also contraindicated in women who smoke and those who were exposed to diethylstilbestrol (DES)in utero.

What is the best birth control pill for women PCOS?

There is no one best oral contraceptive for all women with PCOS, but there are lots of different theories. One concern about the triphasic pills is that the low starting dose may not be enough to inhibit follicle production, and the small follicles produced can contribute to the appearance of polycystic ovaries. The monophasic pills may be more likely to halt follicle production while also reducing androgen levels, but some women do experience more unpleasant side effects on them.

What other methods may be used to induce a period?

Women who do not wish to take oral contraceptives may induce menses by taking progestins such as Provera, Aygestin, and Cycrin for 5-10 days. Insulin-sensitizing medications may also help restore normal cycles.

Can PCOS be treated with herbal supplements?

Herbal supplements are unregulated and how they may react with prescription medications is unknown. While it is unlikely that the herbs themselves will do much harm, there is a good chance they won't help either. Anyone who truly wants to medicate with herbs should see a naturopath rather than self-medicate.

Will removing my ovaries cure my PCOS?

At present, there is no cure for PCOS. The endocrine upset characterized by polycystic ovaries does not go away just because the ovaries are removed. Attention must be focused on why the ovary acted that way, and what signals called it to make 30 pellet-sized follicles at the same instant? It is possible that it might lessen symptoms, but it is a rather extreme approach that will not prove to be a cure.

Does PCOS get worse over time?

It is possible that PCOS will worsen during the prime reproductive years, ages 20-40, especially with weight gain. A healthy lifestyle is probably the best defense. It seems as women approach menopause that the severity of PCOS improves, as judged by hormonal parameters.

How should PCOS be managed after menopause?

There is very little information in medical journals about PCOS beyond the childbearing years. Right now the best recommendation is to monitor cholesterol, triglycerides, blood pressure, and glucose/insulin levels as one might for Syndrome X, and treat any minor abnormalities with diet and exercise, and more substantial alterations with medication.

Does PCOS cause obesity, or does obesity cause PCOS?

In some ways, this question is akin to asking, "Which came first, the chicken or the egg?" since it isn't completely understood, but it appears more likely that PCOS comes first. Symptoms of PCOS may be lessened by weight loss, or increased by weight gain, but the syndrome is not caused by weight or body mass. There are lean women with PCOS. The insulin resistance that is common to PCOS may play a role in weight gain and the difficulty in losing any extra weight.

Is it possible to be lean and have PCOS?

About half of women with PCOS are overweight, which means that the other half is not.

How can women with PCOS lose weight?

Usually the key to weight loss with PCOS is improving glucose metabolism and reducing insulin resistance. This may be achieved by reducing carbohydrate intake and increasing exercise level, as well as through the use of insulin-sensitizing medications. Metformin has a stronger link to weight loss than the glitazones (Avandia, Actos). It is preferable to alter eating habits without reducing caloric intake below 1800-2000 calories for long-term results.

What is a low-carbohydrate diet?

There are various forms of low-carbohydrates diets, but the basic premise is to reduce carbohydrates to below the recommended dietary allowance of 300 grams for a 2000-calorie per day diet. How much of a reduction depends on the plan followed. Possible risks of very low carbohydrate diets include kidney problems, gallstones, and ketonuria (spilling ketones in urine).

The best way to lose weight is slowly with a lifestyle change as opposed to a transitory diet one expects to end at some point. It is healthiest to lose the weight slowly, and one is more likely to keep it off this way as well.

When trying to get pregnant, it is important to consider nutritional standing before pregnancy, and whether or not a food plan can be continued once pregnancy is achieved. A diet in which ketones are spilled often, or continuously, could be harmful to the fetus.

What are the differences between the various low-carbohydrate diet plans?

Some of the authors consider the diets low-carbohydrate, others would say modified-carbohydrate, or maybe insulin-regulating . . . the primary similarity is the reduced consumption of sugars, but after that each plan has it's own set of rules laid out in a book (some offer support books as well). A brief description of several of the diet plans appear below:

Atkins: Dr. Robert C. Atkins, M.D., has a book titled Dr. Atkins' New Diet Revolution in which he explains the meal plan as well as the theories behind it. Dr. Atkins does not recommend this diet, particularly the initial phase, for pregnancy. He also suggests a lengthy list of vitamin supplements for anyone following this diet plan. The "Induction" phase — the first two weeks — is extremely low-carbohydrate. One is only allowed about 20 grams of carbohydrates from all sources in one day. That pretty much limits intake to meat, cheese, eggs and salad. Because of the extremely low carbohydrate content of this plan, it is the most difficult one for vegetarians to follow. After the induction phase, one can slowly increase carbohydrate intake by about 5 grams per day after each completed week. The fewer carbohydrates consumed, the faster the weight loss. The plan is not calorie or fat-restricted, and it is intended to put someone into ketosis. After several months carbohydrate intake may be high enough to bring one out of ketosis, and at that point it may be safe for women trying to conceive.

CAD/CALP: Drs. Richard and Rachael Heller have proposed two diet plans. The older diet book is called The Carbohydrate Addicts Diet: The Lifelong Solution to Yo-Yo Dieting, while the newer version is The Carbohydrate Addict's LifeSpan Program: A Personalized Plan for Becoming Slim, Fit and Healthy in Your 40s, 50s, 60s and Beyond, which was written based on the Hellers' continued research. These plans both call for eating one or two low-carbohydrate meals and one "reward" meal per day. The reward meal is where the two plans differ. The original diet, CAD, allowed consumption of any food during a one-hour period. The newer CALP program modifies that recommendation by suggesting a meal balanced in carbohydrates, proteins, and vegetables, but still suggests the food all be consumed in an hour or less. The time limit is in place to help control insulin production, and also reduces the problem that many carbohydrate addicts have where consumption of carbohydrates increases hunger. Because of the greater flexibility in carbohydrate consumption, CAD and CALP are reasonably easy for vegetarians to follow. The authors do not suggest using this diet in pregnancy, but those using it while trying to conceive could modify it easily by adding some carbohydrates.

The Insulin Control Diet: Based on the book The Type 2 Diabetes Diet Book: The Insulin Control Diet: Your Fat Can Make You Thin, by Calvin Ezrin, M.D., and Robert E. Kowalski, this diet is a low-carbohydrate, low-calorie plan. As with the other diets here, the goal is to decrease insulin production and convert stored fat into fuel. The calorie intake for this diet is quite low — 650 calories for women, and 850 for men. Most doctors do not recommend a low-calorie diet for pregnancy or trying to conceive, and there is a greater failure rate as one will eventually want to eat a higher calorie diet.

Protein Power: The newer book for this diet is Protein Power: The High-Protein/Low Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health — In Just Weeks! by Michael R. Eades, M.D., and Mary Dan Eades, M.D.. They also authored the older Protein Power Lifeplan: A New Comprehensive Blueprint for Optimal Health. There is a somewhat anthropological bend to this plan in discussing hunter-gatherers eating fish, meat, berries, fruits and vegetables, and limiting what early humans never knew existed — grains, refined sugars, and other concentrated starches. At first this one seems similar in restriction to Atkins, where the initial phase for those trying to lose weight is to consume less than 30 grams of carbohydrates, and the second phase calls for 55, but one is supposed to get 25 grams of fiber which can be subtracted from the carbohydrate total. It suggests supplementing with a multi-vitamin plus at least 90 mg of potassium. This diet is probably not suitable for pregnancy, and may not be good for trying to conceive.

Sugar Busters: This more moderate plan is based on the book Sugar Busters! Cut Sugar to Trim Fat, by H. Leighton Steward, Morrison C. Bethea, M.D., Sam S. Andrews, M.D., Ralph O. Brennan, M.D., and Luis A. Balart, M.D.. It may be closer to what one would expect from a diabetic diet — it allows the consumption of carbohydrates, but stresses the importance of the source. The darker, whole grains are emphasized over more processed products. It has some unusual suggestions, such as eating fruit 20 minutes before a meal or 2 hours after, but in general it is rather uncomplicated. Along with processed sugars and white starches, carrots, potatoes, beets and corn are among the short list of foods that should not be eaten. Perhaps the biggest difference between this and a standard diabetic diet is that it is less afraid of fats, though not as accepting as Atkins. This diet can be continued into pregnancy and is a good choice for those trying to get pregnant while reducing carbohydrates.

The Zone: There are a couple of books that describe this diet, includingThe Zone: A Dietary Road Map to Lose Weight Permanently: Reset Your Genetic Code: Prevent Disease: Achieve Maximum Physical Performance, by Barry Sears, Ph.D., with Bill Lawren, and Zone Food Blocks: The Quick & Easy, Mix & Match Counter for Staying in the Zone, by Barry Sears. It may be the strictest in that Sears suggests a 40-30-30 plan — meaning 40 percent of calories from carbohydrates, 30 percent from protein, and 30 percent from fat — for each meal or snack in order for the body to produce the correct amount of insulin. This diet is calorie-restricted and the number of food blocks consumed is based on a person's sex, body fat percentage, and activity level. Those who are very overweight may find the calorie restriction unmanageable, but increasing food blocks may make it easier to follow and still allow weight reduction. The diet is easy for vegetarians to follow. The Zone is probably pretty easy to adjust for pregnancy (many gestational diabetic diets are 45 percent carbohydrates) and should be safe for those attempting to get pregnant.

Can lean women with PCOS who do not wish to lose weight use a low-carbohydrate diet?

Lean women can follow a low-carbohydrate eating plan, but may need to increase the number of calories consumed in order to maintain weight. A couple of the very low-carbohydrate diets listed above would not be appropriate unless one looked straight to the maintenance section. Ideally one finds a balance that that reduces carbohydrates, but keeps caloric intake to about 2,000 calories per day.

Do diet drugs aid weight loss for women with PCOS?

There are no magic pills to help weight loss. Popular appetite suppressants such as Meridia (sibutramine hydrocholoride monohydrate) may help one lose weight, but rebound weight gain after discontinuing such medications is quite common. Also, many obese PCOS women do not overeat — the weight gain and maintenance is due to metabolic disturbances. Another type of diet medication, Xenical (orlistat), blocks absorption of fat. Neither of the medications are considered safe for pregnancy — nor is any low-calorie diet — and those trying to get pregnant would be better off following a plan similar to what they would do while pregnant.

Why is exercise so important?

Exercise can help use glucose in the bloodstream for energy and thereby help reduce blood glucose levels. It may also help the body use insulin more efficiently and will result in gradual reduction of insulin levels even if a mild but structured exercise plan is followed. It also improves circulation, builds muscles, and may aid weight loss.

How much exercise is needed in order to help?

This is a topic that really should be discussed with one's physician — especially if one has any major health concerns. Any increase in activity, whether formal exercise, pleasure walks, or increased chores, can help the body use insulin more efficiently. Most doctors would suggest at least 30 minutes of exercise three times a week for general health, and more frequent exercise if weight loss is the goal. It may help to start slowly and build up the exercise routine. Walking and working with weights, even 1-2 pound dumbbells, is often a good place to start. An alternative to formal exercise is called lifestyle fitness where one increases daily activity to improve fitness.

What are some tips for exercise success?

It's good to choose a few activities one can alternate to prevent boredom. Possibilities include walking, swimming, aerobics, biking, skiing, dancing, working with weights, and lots more. Consider choosing an exercise partner. Wear well-fitted, comfortable shoes, and appropriate clothing. Start slow and don't overdo it. Be sure to include a warm-up and a cool down as part of each exercise session. Try to keep a schedule, but allow some flexibility -- missing a day is okay, and shouldn't be a reason to give up completely. Try to exercise with entertainment — music, reading, or television.

What causes acne and what can be done to reduce it?

Acne can be caused by increased androgen levels. The androgens increase sebum — a combination of skin oils and old skin tissue — and the sebum plugs skin pores allowing bacteria to thrive and cause inflammation.

Anti-androgen medications such as spironolactone (Aldactone), Flutamide, cyproterone acetate, and Finasteride can help reduce acne, as can oral contraceptives. These medications cannot be used while trying to conceive. Accutane (isotretinoin), a prescription medication used to treat severe nodular acne that has not responded to other therapies, is also contraindicated in pregnancy or while trying to conceive as it is known to cause fetal deformities. Insulin-sensitizing medications may reduce acne by restoring hormone balance. Some over-the-counter medications may also reduce outbreaks.

What causes darkened skin patches (acanthosis nigricans) and what can be done to lighten them?

The exact cause is not known, but acanthosis nigricans is often seen in association with endocrine disorders such as insulin resistance and PCOS. This is a darkening of the skin ranging from tan to dark brown/black that commonly appears on the back of the neck, armpits, under breasts, in the groin area, and sometimes on the elbows, knees and hands. The skin is usually velvety or rough to the touch. It may look as if it is dirty and could be scrubbed off. Acanthosis nigricans cannot be cured, but individuals may see improvement if hormone balance is restored or weight loss is achieved. Some prescription medications such as Retin-A, 15% urea, alpha hydroxyacid, and salicylic acid may reduce discoloration.

What causes thinning hair on top of the head, and what can be done to prevent it?

Thinning hair is associated with elevated androgen levels. Reducing levels and restoring hormone balance may lessen hair loss. It may also be associated with hypothyroidism. Any rapid hair loss should be brought to the attention of a doctor. Treatment possibilities include using minoxidil (Rogaine), spironolactone, hair transplants, and hair weaves.

What causes excess hair on the face and other parts of the body and what can be done to prevent or remove it?

One of the more frequent cosmetic concerns among women with PCOS is the excess facial and body hair. The hair growth is triggered by either a lack of estrogen or excess androgen production.

Normalization of hormone levels may reduce unwanted hair growth, but will not remove what is already there. Birth control pills and insulin-sensitizing medications can help restore hormone balance, and spironolactone (Aldactone), a diuretic, can also be used (though not while trying to conceive as it is a Class C drug).

Another option is removing unwanted hair. Various methods are discussed below, and may be used in combination with each other.

Tweezing is inexpensive but may be time-consuming. It involves pulling out individual hairs with a pair of tweezers. It is probably best used by someone with a small amount of hair to remove. There is a risk of infection where hair has been removed.

Shaving unwanted hair is an inexpensive, quick, temporary solution. The best way to shave is to use water and some kind of shaving cream or lotion to soften the hair and moisturize the skin. Run the razor over the skin to cut the hair. This usually needs to be repeated every few days, or even every day. Razor stubble may be visible, and could cause itching or skin irritation. Contrary to what many believe, shaving does not change the texture, color, or rate of hair growth.

Bleaching works by lightening the color of dark, coarse hairs so they are harder to see, and often it also softens them a bit. It can take awhile to do, and needs to be repeated once or twice a month depending on hair growth.

Depilatories are chemical hair removal formulas that are relatively inexpensive. Use can be a bit time consuming, and probably needs to be repeated a couple of times per month. They may be hard on sensitive skin, causing burning, and don't always work on very coarse hair.

Waxing is a longer-lasting temporary solution, but can be expensive and painful. It can be done at home by melting wax on the stove or in a microwave and then spreading a thin layer over the skin in the direction of hair growth. When the wax is dry, it is peeled off against the direction of hair growth pulling out hair by the root. This is usually time-consuming and can cause skin irritation. The wax does not wash off easily. For a bit more money, this can be done at a salon. Similar to tweezing, there is a risk of infection where hair has been removed.

Sugaring is similar to waxing only cheaper and perhaps more gentle. It also may not work as well. Sugar and water are mixed into a paste and then a layer is placed on the skin, and cloth placed on top of that. When it dries, the cloth strips are peeled off removing the hairs at the roots. One advantage is that it is easy to wash any remaining solution off the skin. This solution also carries a risk of infection where hair has been removed.

Electrolysis is the most permanent solution when done correctly, but treatment needs to be done over time as not all hairs will be above the surface, and it is possible for new hair growth to begin. It helps to have hormone levels in good control before treatment as continued imbalance can contribute to new hair growth. The basic method is to zap the hair at the root with electricity. Each hair has to be done individually, so it can be time consuming, and it is fairly expensive. Home units are available where one holds the hair in tweezers while electrical pulses destroy the root. It can also be done professionally by an electrolysist using a needle to deliver electricity to the root, or with electrified tweezers similar to the home units. The needle method is more uncomfortable than the home method, and one pays by the hour. The major risks of electrolysis are electrical shock, which can occur if the needle is not properly insulated; infection from an unsterile needle or other infection control problem; and scarring resulting from improper technique.

Laser or light beam treatment can be used to burn hair off down to the root. It works mainly on dark hairs, is rather expensive, and is somewhat uncomfortable (can cause sunburn-like irritation). Some possible drawbacks are that there are about 10 different types of hair removal lasers, and not are all created equal. Three lasers have been approved by the FDA for permanent hair removal. Misuse of the laser could cause skin pigment changes. Similar to electrolysis, it helps to have hormone levels controlled before treatment for the best results.

What is a skin tag?

Skin tags (acrochordons) are benign growths that vary in appearance from smooth or rough, flesh-colored or darker than surrounding skin. They can hang from a stalk or be slightly raised above the skin. They are typically found on the eyelids, neck, armpits, upper chest and groin. They do not need to be removed unless they are irritating.

How can skin tags be removed?

A doctor can remove skin tags by freezing with liquid nitrogen (cryotherapy), electrically burning off (cautery), burning off with laser, or cutting with a scalpel or scissors. One at-home remedy is to tie off the tag with thread and let the tag wither and fall off, but it is best to have removal done by a physician.

Is there any relation between PCOS and mood swings?

While infrequently discussed by doctors, it is fairly common for women with PCOS to report prolonged periods of premenstrual syndrome-like symptoms — bloating, sore pelvic region, mood swings and headaches. Some relief may occur when hormones are regulated.

Are depression and anxiety common in women with PCOS?

This is an area where more research is needed. It does appear that many women with PCOS suffer some physical or psychological manifestations of depression. There is some medical literature suggesting a link between diabetes and depression, and perhaps that might be extended to early stages of insulin resistance. It may be that the hormone imbalances, including hyperinsulinemia and hyperandrogenism, create a physical source for depression. Medications that help restore proper hormone ratios or antidepressants may help reduce depression and anxiety attacks.

Another possible source of depression is the effect that PCOS symptoms may have on self-esteem. Skin, hair, and weight can each cause discomfort in one's appearance that damage confidence. Infertility may also lead to frustrations with one's body and the feeling it can't do anything right, or perhaps a notion that one is being punished for some past action. Miscarriages are common in women with PCOS, and the grief associated with this type of loss can be far-reaching.

Anyone who feels she is showing signs of depression should consult her doctor as well as consider seeking emotional support. Be sure to find a doctor who is willing to listen to concerns and not dismiss this potential side effect of PCOS.

INCIID has a bulletin board for this called the PCOS Café where women with PCOS can connect, discuss issues, and support each other. Also consider checking PCOSupport.

How can PCOS patients help with research?

PCOS patients may be able to participate in clinical trials, check Center Watch or PCOSupport for current listings.

Are there any new medications being considered?

More studies are being conducted to see if d-chiro-inositol increases the action of insulin leading to improved ovulatory function and reducing androgen production, blood pressure, and triglycerides.

Gillette and Bristol-Myers Squibb are currently seeking FDA approval for Vaniqa, a prescription medication cream that appears to slow facial hair growth in 70 percent of users. It is expected to win FDA approval during the summer of 2000, and be on the market sometime in fall. The medication is applied to the face twice per day in the same manner as moisturizer and works by blocking a key enzyme that makes hair grow. It must be used regularly or else hair growth will resume.

Add new comment

(If you're a human, don't change the following field)

Enter your name

Your first name.

(If you're a human, don't change the following field)

Enter your name

Your first name.

(If you're a human, don't change the following field)

Enter your name

Your first name.

Your name

Subject

feed me

To prevent automated spam submissions leave this field empty.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Math question * 2 + 1 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

Leave this field blank

Add new comment

Plain text

Single donation

Make Donation