QuestionI am 34 yr. old married mother of two. I am presently taking Wellbutrin to quit smoking (down to 10-12 a day and still trying!) I never experienced much pms until I had children, got worse after second child at age 27. My cycles seem to be normal 28-29 days like clockwork, and I assume I ovulate due to increase in mucous discharge on about day 14. I have felt fatigued most of the time, hardly ever wake feeling well rested, even after 7 or 8 hours. I have extremely oily skin which started getting worse in late 20's or so, with occasional pimple/blackheads. Around age 30 started to have hirsutism on chin and now get a few coarse hair on neck and upper cheek (under eyes) and of course upper lip area. I did go for 5 sessions of laser treatments which didn't seem to help much, if any. For the last 6 months I have noticed more gas, bloating and the bloating isn't until near the end of the day. My stomach feels firmer, tight and I feel heavier. Other symptoms include frequent need to urinate, but always small amounts, (especially during pms), weight gain in last 5 years where usually could eat anything without gaining and lose easily after having kids, occasional hypoglycemia, varicose veins in legs within last couple years, cold extremities and easily chilled in general, constipation is sometimes problem as well. I do go for annual pelvic exams and pap smears. Since age 30 have been mentioning symptoms to different family doctors I have had. They've checked estrogen, testostrone and thyroid each time and said normal. Recently I saw a new doctor who ordered these hormone tests, plus prolactin, fsh, thyroid, etc. My DHEA came back extremely high at 9.7 umol/l and he said estrogen was abit low at 14 pmol/l, but cycle wise test done at end of a period (day 5) and he said estrogen can flucuate. We are still waiting for testostrone results which were taken August 19. I am scheduled for pelvic/endovaginal exam in one month. Does DHEA also flucuate with the menstral cycle like estrogen? He also referred me to a gynocologist, not sure yet when. I have been checking symptoms on the net and seems to lead either to adrenal or ovarian causes. Are there other tests you would recommend or advice on what I should do? Thank you so kindly, Lori in Canada
Answerbefore reading the end of your statement I was going to ask you to check this hisutism and some of other symptoms.
you will need to do a full pituitary , ovarian and adrenal gland hormone check out some has been done already and a ct or MRI of your ovary, pituitary and adrenal gland.
there is something going on and it is not related to any of your period stage but more a tumor of one of the part that I mentionned above or just an hormonal imbalance of one of the triangle
also check for an anemia but I think it was done already
but if it was the ovary you will have problem in your period but do not eliminate this area
Serum testosterone may be elevated in PCOS and is invariably substantially raised in virilization tumours. Patients with hisutism and normal testosterone level frequently have low levels of sex hormone binding globulin (SHBG), leading to high free androgen levels. SHBG can be measured in some centres.
Other androgens. Androstenedione and DHEA sulphate are frequently elevated in PCOS, and even more elevated in congenital adrenal hyperplasia and virilizing tumours.
17-x-Hydroxyprogesterone is elevated in classical CAH (congential adrenal hyperplasia), but may be apparent in late-onset CAH only after stimulation.
Gonadotrophin levels. LH hypersecretion is a consistent feature of PCOS, but the pulsatile nature of secretion of this hormone means that an increased LH/FSH ratio is not always observed on a random sample.
Oestrogen levels. Oestradiol is usually normal in PCOS, but oestrone levels (which are rarely measured) are elevated due to peripheral conversion. Levels are variable in other causes.
Ovarian ultrasound. The most consistent investigation in PCOS is ovarian ultrasound, although a skilled observer is necessary. The typical ultrasonic features are those of a thickened capsule, multiple 3-5mm cysts and hyperechogenic stroma. It should also be noted that prolonged hyperandrogenization from any cause may lead to polycystic changes in the ovary. Ultrasound may also reveal virilization ovarian tumours, although these are often small.
Serum prolactin. Mild hyperprolactinaemia is common in PCOS but rarely exceeds 1500mUL-1.
If a virilization tumour is suspected clinically or after investigation, then more complex tests may include dexamethosone suppression tests, CT or MRI or adrenals, and selective venouse sampling catheters.
DIFFERENTIAL DIAGNOSIS
Most patients presenting with a combination of hirsutism and menstrual disturbances will be shown to have polycystic ovary sydrome, but the rarer alternative diagnoses should always be born in mind, and excluded with appropriate investigations if suspected. This includes late-onset CAH (early-onset, raised serum 17-x-OH-progesterone), Cushing's syndrome (look for other clinical features) and virilization tumours of the ovary or adrenals. (severe virilization, markedly elevated serum testosterone).
The extent of investigation will depend on clinical context. In many cases a single serum testosterone may be sufficient to exclude rare causes. Urine free cortisol should be measured if Cushing's syndrome is a clinical possiblity and 17-x-OH-progesterone if early onset or family history suggests congenital adrenal hyperplasia no your case.
your symptoms are a new finding so the info below might not be your case or it might be your case:
POLYCYSTIC OVARY SYNDROME (PCOS):
Polycystic ovary syndrome (PCOS) is a medical condition in which women experience irregular or absent menstrual bleeding, increased hair growth, infertility, and excessive weight gain. This syndrome was first described in 1935 by Drs. Stein and Leventhal, and for many years PCOS was known as the Stein-Leventhal Syndrome. Women wth PCO have enlarged ovaries containing multiple small cysts which have led to the descriptive term, polycystic ovaries. PCOS is comprised of several clinical features, each of which may be present to a lesser or greater degree. Some women have been found to have polycytic ovaries without associated abnormalities of menstruation, hair growth, weight gain or infertility. These womem do not have Polycystic Ovary Syndrome. Thus, not all women with polycystic ovaries have PCOS, but all women with PCOS have polycystic ovaries.
The abnormal hormone action seen in PCOS can best be understood by first discussing the normal hormone patterns required for ovulation. There are two hormones secreted by the pituitary gland in the brain. They are FSH (follicle stimulating hormone) and LH (luteinizing hormone). FSH acts on the ovarian follicle to stimulate maturation of the egg or ovum. At the time of ovulation, there is a surge of LH which in part is responsible for rupture of the follicle and release of the egg. The ruptured follicle then becomes the corpus luteum. Under stimulation of LH, the cells that make up the corupus luteum undergo a luteinizing process. In the patient with PCOS, a variety of any of these hormones may be produced at an abnormal level, perpetuating incomplete follicular development without consistent ovulation. Since the hormonal system operates as a feed-back loop, when any hormone is at an abnormal level, all related hormones are affected. Specifically, LH levels can be higher than normal resulting in an increased LH/FSH ratio, with stimulation of the ovarian follicle but not resulting in maturation and release of the egg. The elevated LH levels stimulate luteinization of the cells surounding the follicle, which results in a shift in ovarian hormone production towards increasing testosterone levels and indirectly a change in estrogen levels. This feeds back on the LH/FSH production and can affect the normal ratio. Therefore, not only are there the peripheral effects of increased testosterone production (increasing hair growth) but also menstrual dysfunction.
Women with PCOS have normal reproductive organs such as the uterus and fallopian tubes. Their ovaries each contain multiple small cysts around the periphery, each ovarian cyst generally measuring less than 8 mm diameter and easily seen by pelvic ultrasound. These cysts do not appear to grow and usually remain small. They do not require surgical removal and are not associated with an increased risk of ovarian cancer.
The symptoms of PCOS: -Menstrual irregularities (either no menses or very heavy bleeding) -Impaired fertility, usually due to the woman's inability to ovulate regularly -Miscarriage rates are higher due to elevated LH level on egg development and uterine lining -Hair & Skin problems (increased hair growth and acne from elevated testosterone) -Obesity (about 50% of women with PCOS are obese) -Abnormal Insulin Action (PCOS patients have a greater long-term risk of developing diabetes mellitus) -Heart Disease (PCOS women may be at a long-term increased risk of heart disease due to the unfavorable lipid profile produced by elevated androgens) -Breast milk secretion (30-40% of PCOS patients have an elevated serum prolactin level). Prior to initiating fertility treatment, other factors which impact fertiity are usually evaluated. These factors include tubal patency, pelvic anatomic relationships, assessment of semen and sperm function, cervical mucous quality, presence of immunologic causes of infertility and uterine anatomical abnormalities. In women with PCOS, failure to ovulate is the usual reason for not achieving pregnancy.
Treatment of PCOS: In cases where ovulation is irregular or absent, medication can be used. The most common agent is clomiphene citrate (Clomid, Serophene), which is generally taken daily from days 3-7 of a cycle. Ovarian follicle development is usually monitored with a combination of home urinary LH testing, and office ultrasound examination. An intrauterine insemination is frequently advised because of clomiphene's adverse effect on a woman's cervical mucous quality. Additional endometrial support may be promoted with the use of progesterone or HCG injections. There is a mildly increased rate of multiple pregnancy with clomiphene (6-7%) but there is no increased risk of birth defects. The majority of womn who conceive on clomiphene will do so in the first 4 cycles. If clomiphene fails to successfully induce ovulation and/or pregnancy, then a group of injectable hormone preparations, known as gonadotropins, may be employed.
There are two types of gonadotropin preparations available. One contains both FSH and LH, the other only FSH. Although both types of gonadotropins work well in women with PCOS, many fertility specialists prefer to use the products which contain primarily FSH (Metrodin). Therapy includes daily injections, with careful monitoring of ovarian follicle development by serum estradiol hormone measurements and pelvic ultrasound examinations. When optimum growth and development of the follicle(s) has occured, administration of human chorionic gonadotropin (HCG) is administered to stimulate release of the egg(s) from the follicle(s). The risk of multiple pregnancy is increased with gonadotropin therapy (16-18%), and women with PCOS given gonadotropins are at an increased risk of an uncommon but potentially serious condition known as Ovarian Hyperstimulation Syndrome. This situation arises if an excessive number of follicles are stimulated. Avoidance of Ovarian Hyperstimulation Syndrome is best achieved by careful monitoring of ovulation induction. This is the reason that virtually all fertility specialists are available 365 days a year for office ultrasound and clinical monitoring for all patients on gonadotropins.
Laparoscopic laser 'drilling' of the ovarian capsule is another treatment for PCOS. This usually results in resumption of regular ovulatory function. In some cases, regular ovulation persists for some time, whereas in other patients, irregular or absent menstrual function recurs.
In Vitro Fertilization (IVF) may also be offered to women with PCOS who wish to conceive after other treatment strategies have failed. Success (pregnancy) rates with IVF in PCOS patients are generally excellent, although a higher risk of Ovarian Hyperstimulation exists, especially in IVF patients who become pregnant.
In summary, PCOS is the most common cause of menstrual irregularity in reproductive-aged women and its occurrence may be associated with a variety of clinical symptoms, including infertility. There are known long-term health risks associated with PCOS.
hope this answer your question and please keep me update on the finding
thanks
dan
