PCOS Specialist

Introduction – PCOS Specialist in Montgomery County, Maryland

As a PCOS specialist in Montgomery County, I focus on providing specialized care to those dealing with PCOS, using a comprehensive, evidence-based approach.

Conveniently located in Rockville, my practice offers virtual and in-person services, extending support to nearby areas such as Chevy Chase, Bethesda, North Bethesda, Potomac, North Potomac, Gaithersburg, Germantown, Frederick, Silver Spring, Northern Virginia, Howard County, Anne Arundel, and the Eastern Shore of Maryland, ensuring comprehensive care.

My aim is to improve the health and quality of life in our community by offering personalized therapies for managing polycystic ovarian syndrome (PCOS).

Definition and Overview

PCOS is a complex hormonal disorder that affects women from puberty through menopause, typically between ages 15 and 45. Onset is commonly observed in the late teens and early twenties. PCOS is characterized by elevated levels of androgens (male hormones) and insulin resistance, along with dysfunctional ovulation. Features include irregular menstrual cycles, disrupted ovulation, and the formation of small cysts on enlarged ovaries. Key symptoms comprise acne, infertility, and the incidence of male-pattern hair growth and baldness. Additionally, PCOS is associated with metabolic disturbances, heightening the risk of developing type 2 diabetes (DM2) and cardiovascular disease (CVD).

Prevalence

PCOS is a common endocrine condition that affects females of childbearing age. It is important to emphasize that PCOS does not pertain to individuals before experiencing menarche or after entering menopause. The global prevalence of PCOS ranges from 5% to 20%, with variations observed across different populations and diagnostic criteria. The occurrence of PCOS is influenced by a combination of factors, including genetic predisposition, lifestyle choices, and ethnicity.

Pathology

Irregular menstrual cycles and hormonal imbalance play a central role in the expression of PCOS. Elevated androgens and insulin resistance are additional key contributors to this condition, preventing the maturation of ovarian follicles. This abnormality leads to the formation of cysts instead, ultimately interfering with ovulation and causing infertility.

Although the exact cause of PCOS remains unknown, a combination of genetic and environmental factors plays a significant role. Furthermore, polycystic ovarian syndrome has implications beyond reproductive health, affecting metabolic and cardiovascular well-being.

Key Endocrine Glands Contributing to PCOS:

  • Ovaries: They can produce excessive levels of testosterone, leading to symptoms such as hirsutism, acne, and male-pattern baldness. Additionally, the ovaries develop multiple small cysts due to immature follicles that do not release eggs during the menstrual cycle. This process can lead to irregular menses, failure to ovulate, and infertility.
  • Adrenals: Similar to the ovaries, adrenal glands can overproduce DHEA, another form of androgen, albeit weaker. The mechanism behind this is not presently understood.
  • Pituitary: Abnormally elevated LH, relative to FSH, further stimulates the formation of follicular cysts in the ovaries.
  • Pancreas: In response to insulin resistance, a common occurrence in PCOS, the pancreas may increase insulin production and release. Subsequently, hyperinsulinemia can amplify androgen production, increasing the risk of developing metabolic disorders such as DM2 and CVD.

Diagnosis

The diagnosis of PCOS involves a combination of clinical, laboratory, and imaging assessments. The key components in making the diagnosis of PCOS include:

  • Irregular or absent menses.
  • Reduced or lack of ovulation.
  • Elevated levels of androgens determined by laboratory testing.
  • Symptoms or signs caused by elevated androgens.
  • Multiple ovarian cysts observed on ultrasound.
  • Exclusion of other conditions that can cause similar symptoms.

1990 NIH Criteria

The 1990 National Institutes of Health (NIH) criteria for diagnosing PCOS are functional and practical. The criteria require the presence of all three conditions:

  1. Ovulatory dysfunction, characterized by reduced or absence of ovulation.
  2. Laboratory or clinical signs of hyperandrogenism, including high serum testosterone or DHEA sulfate levels or symptoms such as hirsutism, acne, or male-pattern baldness.
  3. Exclusion of other disorders that could mimic PCOS symptoms, such as congenital adrenal hyperplasia or androgen-secreting tumors.

2003 Rotterdam Criteria

The 2003 Rotterdam definition for diagnosing PCOS is broader but perhaps less functional. It allows for a more comprehensive and flexible diagnosis by incorporating ultrasound findings. This definition requires the presence of at least two out of the first three criteria, with the fourth one being necessary:

  1. Polycystic ovaries observed through ultrasound, characterized by the presence of multiple small follicles.
  2. Ovulatory dysfunction manifested by reduced or absent ovulation.
  3. Clinical or biochemical signs of hyperandrogenism, such as acne, hirsutism, or elevated blood testosterone or DHEA sulfate levels.
  4. Ruling out other conditions that may mimic PCOS symptoms, such as hypothyroidism or hyperprolactinemia.

Importance of Excluding Competing Diagnosis

Before diagnosing PCOS, physicians must rule out other illnesses that can cause similar symptoms. This is an important component of both the 1990 NIH and 2003 Rotterdam Criteria. Key conditions that need to be excluded are:

  • Thyroid Disorders: Hypothyroidism or hyperthyroidism can cause menstrual irregularities resembling PCOS.
  • Hyperprolactinemia: Elevated prolactin levels can disrupt menstrual cycles.
  • Non-classic Congenital Adrenal Hyperplasia (NCAH): This genetic disorder can result in excess androgens and symptoms like hirsutism and acne.
  • Cushing’s Syndrome: Certain adrenal or pituitary tumors can lead to excessive cortisol, elevated androgen levels, and insulin resistance.
  • Ovarian or Adrenal Tumors: These are rare conditions that cause excess androgen production and symptoms resembling PCOS.
  • Hypothalamic Amenorrhea: Physiological disruptions from stress, low weight, or excessive exercise can affect the menstrual cycle.
  • Medication-Induced: Certain drugs, like corticosteroids or psychotropics, can impact menstrual regularity, weight, and insulin sensitivity.

Types of PCOS:

PCOS manifests in various phenotypes based on underlying hormonal imbalances and symptom expression. The basic phenotypes are listed below. The list significantly expands, especially with the 2003 Rotterdam Criteria, when considering permutations of these basic components.

  • Hyperandrogenic
  • Non-Hyperandrogenic
  • Ovulatory
  • Non-Ovulatory
  • Cystic ovaries
  • Non-cystic ovaries
  • Insulin resistance
  • Non-insulin resistance

The three common and relevant PCOS phenotypes are:

  • Hyperandrogenic & Non-Ovulatory: This is the classical type according to the 1990 NIH criteria. It is characterized by elevated androgen levels, leading to symptoms such as acne and hirsutism, along with irregular menstrual cycles or absence of ovulation. 
  • Hyperandrogenic & Ovulatory: Defined by signs and symptoms of elevated androgen levels but with regular menstrual cycles, indicating normal ovulation.
  • Non-hyperandrogenic & Non-Ovulatory: Marked by minimal or absent signs of elevated testosterone or DHEA sulfate, yet exhibiting irregular or absent menstrual cycles.

The numerous traits of PCOS reveal its underlying complexity. The variety of phenotypes underscores the importance for the endocrinologist to customize diagnosis and treatment to suit each individual’s unique concerns.

Symptoms:

While PCOS symptoms have been discussed throughout this article, it is beneficial to provide a concise summary in this section. Polycystic Ovary Syndrome presents with a diverse range of symptoms, including irregular menstrual cycles characterized by prolonged, heavy, or absent periods. Clinical indications of hyperandrogenism, such as acne, hirsutism (excessive hair growth), and male-pattern baldness, are commonly observed. 

Women affected by PCOS may encounter challenges in conceiving due to absent, reduced, or inconsistent ovulation. Some individuals may exhibit polycystic ovaries, detectable through ultrasound. Additionally, the presence of insulin resistance contributes to weight gain and an elevated risk of type 2 diabetes and cardiovascular disease. It is crucial to recognize the variety of PCOS presentations, as not all individuals manifest the same combination or severity of symptoms.

Complications:

PCOS can lead to various complications affecting both reproductive and metabolic health. Some of the long-term consequences include:

  • Endometrial Cancer: PCOS can cause the endometrium (the uterine lining) to overgrow due to prolonged lack of ovulation. This overgrowth, resulting from increased exposure to estrogen compared to progesterone, increases the risk of endometrial cancer.
  • Infertility: PCOS can affect ovulation by causing irregular or absent menstrual cycles, making conception challenging.
  • Obesity/Weight Gain: Individuals with PCOS often experience weight gain, which can worsen symptoms and increase the risk of complications like diabetes, heart disease, and chronic kidney disease.
  • Gestational Diabetes: Pregnant women with PCOS face a higher risk of developing gestational diabetes, impacting both the mother and the baby.
  • Type 2 Diabetes: Insulin resistance, a common feature of PCOS, can contribute to the development of hyperglycemia, which may lead to type 2 diabetes over time.
  • Cardiovascular Disease: Individuals with PCOS are at a higher risk of developing cardiovascular problems such as high blood pressure, cholesterol issues, and heart disease.
  • Fatty Liver Disease: Insulin resistance associated with PCOS may contribute to Non-Alcoholic Fatty Liver Disease (NAFLD), a condition in which excess fat accumulates in the liver and can progress to more advanced liver diseases such as NASH, fibrosis, and cirrhosis.
  • Sleep Apnea: PCOS has been linked to an increased risk of sleep apnea, which is characterized by pauses in breathing during sleep.
  • Mood Disorders: An association exists between PCOS and mood disorders such as depression and anxiety.

Evaluation:

The PCOS evaluation is a comprehensive process involving a combination of medical history, physical examination, and various diagnostic tests. The initial step includes gathering a detailed health background, during which the endocrinologist explores information related to menstrual cycles, reproductive history, and any symptoms indicative of elevated androgen levels, such as acne or hirsutism. Family history of PCOS or related conditions is also considered at this time.

Next, a physical examination is performed to evaluate visible signs of PCOS, such as hirsutism (excessive hair growth), acne, and signs of male-pattern baldness. Additionally, blood pressure measurements and a body mass index (BMI) assessment are typically included in the examination.

Blood tests play a central role in the evaluation process. Hormone levels, including androgens, luteinizing hormone (LH), and follicle-stimulating hormone (FSH), are measured to identify imbalances. Glucose and insulin concentrations are quantified to assess for possible insulin resistance, and thyroid function tests may be performed to rule out hyper or hypothyroidism.

A pelvic ultrasound is a valuable diagnostic tool according to the 2003 Rotterdam Criteria. It is used to visualize the ovaries. In PCOS, the ovaries may appear enlarged, and multiple small follicles (cysts) may be present. The ultrasound helps confirm common PCOS features and aids in excluding other potential causes of ovarian abnormalities.

Additional tests may be utilized based on a person’s symptoms or to rule out other conditions. For instance, a lipid profile may be conducted to check triglyceride and cholesterol levels, especially in someone with associated obesity or insulin resistance. 

It is critical to emphasize that there is no single test for a definitive PCOS diagnosis, and the evaluation process is tailored towards an individual’s symptoms and medical circumstances. Once diagnosed, the endocrinologist collaborates with the patient to create a personalized treatment plan, which may include lifestyle modifications, symptom management with medications, and, if necessary, fertility treatments. Regular follow-up and monitoring are essential to address any long-term health risks associated with PCOS.

Laboratory Testing:

Extensive laboratory testing is a mandatory part of the comprehensive evaluation for PCOS. It assesses key hormonal and metabolic imbalances associated with PCOS. The essential tests are outlined below:

  • Androgens: These hormones include total testosterone (TT), free testosterone (FT), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEAS). Androgen measurements can aid in both diagnosing and managing PCOS.
  • LH and FSH: The LH/FSH ratio is often examined. An elevated ratio may indicate dysfunctional ovulation, providing valuable insights for diagnosing PCOS.
  • Insulin and Fasting Glucose: These measurements help evaluate insulin resistance and metabolic disturbances commonly observed in PCOS.
  • Hemoglobin A1c (HbA1c): This test indicates average blood glucose levels over the past 3 months, aiding in understanding longer-term states of insulin resistance and hyperglycemia. It is particularly useful in prediabetes and type 2 diabetes.
  • Lipid Profile: Evaluation of triglycerides, non-HDL cholesterol, and LDL cholesterol is crucial for assessing insulin resistance and cardiovascular risk associated with PCOS.
  • Thyroid hormones: TSH, FT4, and FT3 are critical for proper metabolism and helpful in ruling out thyroid disorders that may mimic PCOS symptoms.
  • Prolactin: It is important to rule out high prolactin levels because they can emulate PCOS symptoms and affect menstrual regularity.
  • 17-hydroxyprogesterone (17-OHP): This test is useful for assessing congenital adrenal hyperplasia, a rare condition that can present with symptoms similar to those of PCOS.
  • Anti-Mullerian Hormone (AMH): Elevated AMH levels, often seen in PCOS, are measured to assess ovarian reserve and fertility.

Therapy and Management:

Management of PCOS involves a multifaceted approach that addresses various aspects such as hormonal imbalance, insulin resistance, and associated symptoms. The treatment plan is often individualized based on specific symptoms and the needs of each person. The primary goal of PCOS therapy is to regulate menstrual cycles, manage symptoms such as hirsutism and acne, address fertility concerns, and minimize long-term health risks. Here are the key components of PCOS management:

Lifestyle:

  • Weight Management: Maintaining a healthy weight is crucial for most women with PCOS, as excess weight can worsen symptoms. Even modest weight loss can improve hormonal balance and increase the likelihood of regular ovulation.
  • Balanced Diet: Adopting a balanced and nutritious diet can help regulate insulin levels. Patients need to focus on whole foods, fiber, and complex carbohydrates while limiting refined sugars and processed foods.
  • Regular Exercise: Physical activity improves insulin sensitivity and aids in weight management. Incorporating regular exercise into a daily routine promotes overall health, beyond managing PCOS symptoms.

Fertility:

  • For those trying to conceive, fertility medications like Clomiphene or Letrozole may be prescribed to induce ovulation. They stimulate the production and release of LH and FSH hormones. 
  • In more complex cases, assisted reproductive technologies (ART) such as in-vitro fertilization (IVF) may be used.

Irregular Menses:

  • Progestin therapy may be used to induce regular menstrual cycles, prevent endometrial hyperplasia, and thereby reduce the risk of uterine cancer — a serious long-term complication of PCOS.
  • Lifestyle adjustments, weight control, and medications can contribute to improved menstrual regularity, as mentioned above.

Cosmetics:

  • Laser hair removal and other methods can be used to manage hirsutism.
  • Topical or oral medications such as oral contraceptive pills, spironolactone, or doxycycline may be prescribed to address acne.

Emotional Support:

  • Given the potential impact of PCOS on mental health, emotional support, and counseling can be beneficial. 
  • Addressing anxiety, mood disorders, and concerns related to body image can improve the overall well-being.

Medications:

Oral Contraceptives (OCPs): 

OCPs play a critical role in managing PCOS by addressing hormonal imbalances and associated symptoms. Composed of artificial estrogen and progestin, OCPs effectively regulate menstrual cycles. Additionally, OCPs help reduce androgen levels, minimizing symptoms like hirsutism and acne. This is achieved by suppressing the release of LH and FSH from the pituitary gland. The anti-androgenic properties of certain progestins (synthetic progesterone) in OCP formulations can further contribute to reducing androgen-related expressions. Beyond symptom management, OCPs also have a preventive role in reducing the endometrial hyperplasia and thus the risk of uterine cancer.

Anti-Androgen Medications (AAMs): 

AAMs are important in managing PCOS by reducing the effects of elevated male hormones. Medications like spironolactone or cyproterone acetate block androgen action, alleviating symptoms such as hirsutism, acne, and male-pattern baldness. Spironolactone, in particular, is commonly prescribed due to its triple action as a testosterone reducer, blocker, and diuretic. AAMs are often used alongside oral contraceptive pills to comprehensively control hormonal imbalances and improve cosmetic concerns in women with PCOS.

Metformin: 

Metformin can play an essential role in managing PCOS by addressing insulin resistance. As an insulin-sensitizing medication, Metformin improves the body’s response to insulin, thereby lowering serum insulin concentration, which in turn can lead to reduced androgen levels and improved metabolism. By enhancing insulin sensitivity, Metformin can help regulate menses, promote ovulation, and improve hyperandrogenic symptoms such as hirsutism and acne. Additionally, Metformin may aid in weight loss and reduce the risk of developing type 2 diabetes, both of which are common in individuals with PCOS. In summary, Metformin serves as a valuable therapeutic option in the comprehensive approach to PCOS care, addressing both its reproductive and metabolic aspects.

GLP1 agonists: 

GLP-1 agonists, such as Mounjaro, Zepbound, Ozempic, Wegovy, Trulicity, Saxenda, Victoza, and Rybelsus, play a potential role in managing PCOS. While primarily indicated for type 2 diabetes and obesity, these medications offer benefits beyond glycemic control. GLP-1 agonists can aid in weight management and improve insulin sensitivity, addressing key features of PCOS. They can also help improve metabolism, thus preventing the development of prediabetes, type 2 diabetes, and cardiovascular disease. Additionally, weight loss associated with GLP-1 agonists can restore hormonal balance, menstrual regularity, and fertility in PCOS. However, specific research on using these medications exclusively for PCOS is limited, and their use should be thoroughly discussed with a physician. Regular observation is essential to evaluate benefits and potential side effects.

Follow-Up:

Regular monitoring by a multidisciplinary team — which includes an endocrinologist, primary care physician, gynecologist, fertility specialist, nutritionist, and personal trainer — is critical for assessing the effectiveness of the treatment plan, adjusting medications, and addressing emerging symptoms. PCOS management is a dynamic process that may evolve over time due to changing life circumstances and individual responses. A patient-centered, collaborative approach involving various healthcare providers can offer comprehensive care for individuals with PCOS. Regular follow-ups are key to ensuring ongoing support tailored to the individual’s needs.

Summary:

As a PCOS specialist in Rockville, I am dedicated to providing specialized care for individuals affected by this condition. I use a comprehensive approach grounded in medical evidence and clinical expertise to enhance my patients’ overall well-being with personalized therapies. Ultimately, my aim is to optimize the health and quality of life for community members dealing with polycystic ovarian syndrome.

Dr. Tashko

Dr. Tashko is an ABIM board-certified endocrinologist with additional certifications in lipidology, hypertension, and obesity medicine. He delivers personalized, holistic care to patients in Montgomery County, Maryland.