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Ovarian ailment under radar
Doctors stand accused of giving poor treatment to women with a common fertility problem. Kellie Bisset reports
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April 01, 2006
SARAH Plaskitt thinks she's had a lucky escape. Diagnosed with a condition called polycystic ovarian syndrome, or PCOS, two years ago, Plaskitt was told by her doctor not to worry as it was a common condition and ``come back and see me when you want to get pregnant''.
But she did worry, and after insisting on a specialist referral she discovered she had such high insulin resistance _ where the body responds less well to the hormone insulin, which regulates blood sugar _ that she was about two years away from developing diabetes. The 30-year-old advertising strategy planner now has things under control, and considers herself fortunate she did not experience some of the more severe symptoms of the syndrome, which affects more than one in 10 Australian women.
It's a hormonal disorder with symptoms such as infertility, obesity, acne, excessive hair growth on the face, chest and stomach, irregular or absent periods and numerous ovarian cysts (polycystic ovaries). Sufferers can have all or only some of these symptoms and many don't even realise they have the condition until they try to have children. Plaskitt sought medical advice because she kept putting on weight, despite eating a healthy diet and doing regular exercise.
``For a lot of women this has an awful stigma _ they are overweight, hairy and can't get pregnant _ it is an awful thing,'' she says. ``I was amazed to discover people who have it or who know someone who has it, and they have never been tested for insulin resistance.'' Insulin resistance causes most cases of PCOS and can be treated if recognised, with a combination of diet, exercise and relatively benign drugs. But despite this, many women with the condition who seek a doctor's help when they can't get pregnant are being referred to expensive and invasive IVF services instead.
Some estimates put the proportion of women who have PCOS who seek IVF treatment at between 30 and 40 per cent. But there is an argument that IVF is being offered way too early.
``The vast majority of women (with PCOS) don't need it,'' says Sydney endocrinologist Warren Kidson. ``Unfortunately there are a lot of women who are offered IVF long before (other therapies). It's not just expensive, it's very stressful physically and emotionally.''
The national medical director of Monash IVF, Gab Kovacs, agrees. ``IVF is not the first line of treatment, that is for sure, but unfortunately some of my colleagues would put women into IVF more quickly than I would.'' However, Professor Kovacs says some patients with polycystic ovaries might have other factors causing their infertility, such as endometriosis, and this is one reason for offering them IVF treatment.
Reproductive technologies such as IVF cost the community $79 million a year, a fact not lost on Health Minister Tony Abbott when he proposed limits last year on the number of cycles funded under Medicare. The government scrapped the plan after public outrage.
President of the Polycystic Ovarian Sydrome Association of Australia (POSAA) Sabra Lane believes much money could be saved if more doctors used IVF as a last resort for PCOS.
Part of the problem, Kidson says, is that gynaecologists treat the syndrome as a fertility issue and endocrinologists treat it as a metabolic disorder. This often means that young women aren't informed about potentially major metabolic problems such as a 50 to 60 per cent risk of type 2 diabetes.
``A lot of doctors _ especially gynaecologists and some GPs _ have got their heads in the sand on PCOS,'' says Kidson, a visiting specialist at Sydney's Prince of Wales Hospital and the Royal Hospital for Women. ``They ignore the long-term health risks of these women and give short-term treatments either to give them regular periods, improve their acne or excess hair and send them off to IVF, but they really need tests for insulin resistance, which is the cause of 85 per cent of it.''
Insulin resistance is linked to a higher risk of type 2 diabetes, high blood pressure, cholesterol problems and heart disease.
There are also hereditary factors at work: sisters of PCOS sufferers have up to a 50 per cent chance of having the disorder.
Both Kidson and Kovacs agree women with PCOS should have their cholesterol levels checked and be given a simple glucose tolerance test. Evidence shows that lifestyle changes such as exercise, diet and weight loss are a vital first step in lowering insulin levels and treating the fertility problems associated with PCOS (Human Reproduction 1998;13:1502-5).
But after that it gets tricky, and experts disagree over the best way to proceed.
Gynaecologists often prefer to use a drug called clomiphene citrate, which can achieve pregnancy rates of 40 per cent to 50 per cent.
For those not trying to conceive, they often prescribe the oral contraceptive pill which helps control the acne, regulate the woman's cycle and suppress the high levels of androgens (male hormones) that cause the excessive hair growth.
However, endocrinologists lean towards a drug called metformin, which has also been found to establish regular menstruation and improves fertility and hirsutism. Importantly, it also lowers insulin levels and can help in weight loss.
Kidson says to get the best results it is vital that doctors combine metformin with lifestyle changes rather than simply relying on the drug alone, but many endocrinologists aren't doing this.
He also argues that clomiphene simply stimulates a system that is dysfunctional, ``a bit like pushing down on the accelerator of a car that still has the hand-brake on''.
The days of offering the pill to everyone to regulate their cycle are over, Kidson says, pointing out that the pill has been shown to increase insulin levels. However, Kovacs doesn't agree there is enough evidence to prove the low-dose pill is harmful.
The POSAA is pushing for national guidelines on diagnosis and treatment. Kidson thinks this is a great idea, but given the divisions of opinion he thinks a national consensus might be a tough ask.
