IS IT POLYCYSTIC OVARIAN SYNDROME?

 

Dr Steven R. Goldstein is an Obgyn in Manhattan that has seen very young patients come in with their mothers and present with a diagnosis of Polycystic Ovarian Syndrome (PCOS). They are requesting a second opinion. If you have been told you have PCOS, then there is some information you should know.

 

PCOS affects roughly five to fifteen percent of women of reproductive age but many of the cases go undiagnosed. Many of those diagnosed are in their twenties or thirties. Here’s a bit of history on PCOS.

 

In 2003 there was The Rotterdam Criteria for the Diagnosis of PCOS, at that time the consensus was if a women had two of the following three characteristics she could be labeled as having PCOS. They were 1) irregular menses, 2) increased androgens (either in their blood or clinical manifestations), and 3) more than twelve follicles in their ovary on ultrasound.

 

Today, as the resolution of transvaginal ultrasound has increased, as many as 50% of women will have more than twelve follicles in their ovary! And many young women will be having slight irregularity to their menses as their cycle “matures.” Their menstrual cycle is still slightly irregular because of the fact that the hypothalamic-pituitary-ovarian axis has not yet matured. And if patients are extremely young, they may have what Dr Goldstein refers to as “multicystic ovaries” instead of polycystic ovaries.

 

Typically, the women who were thought to have PCOS would be obese, have male pattern hair growth (especially on the chin), and bloodwork showed increased androgens (testosterone and an entity know as DHEA-S). These recent patients seen by Dr Goldstein who were diagnosed by other physicians to have PCOS were 1) not obese, 2) had no evidence of increased androgens, either clinically or in their blood, and 3) were extremely healthy.

 

It has been Dr Goldstein’s experience that the overwhelming majority of such patients, as they get into their mid- and later twenties, ultimately have very normal menstrual cycles, normal fertility, and no increased risk of insulin resistance or diabetes. 

 

Upon examination, none of these recent cases truly had PCOS itself. What they had was not unusual for late adolescence (women in their teens and even early twenties).  The problem is someone performed an ultrasound and they had multiple small follicles in their ovary, and thus, were told they had polycystic ovarian syndrome. 

 

In the opinion of Dr Goldstein, a Gynecologist in Manhattan, it is important as to how the follicles are arranged in the ovary. In the original description of polycystic ovarian syndrome, the follicles were all very peripheral and often were referred to as a “string of pearls,” the appearance of small follicles around the edge of an ovary.  This is what points to Polycystic Ovarian Syndrome (PCOS).

 

Women cannot be diagnosed as having PCOS with just an increased randomly distributed number of follicles. There must be the string of pearls pattern.

 

If you have been told that you have Polycystic Ovarian Syndrome (PCOS) and would like a second opinion, schedule a consultation with Dr Steven R. Goldstein MD, a leading Manhattan Obgyn

 

OVARIAN MASSES AND CANCER

 

 Doctor Steven R. Goldstein MD  is a Gynecologist in NYC who advocates for regular ovarian and cervical cancer screening, particularly for those with a personal or family history of these diseases. In his writings Dr Goldstein elaborates on the statistics that show the high survivability rate if ovarian cancer is detected early.

 

There is confusion among women about ovarian cysts and cancer. Many are told they have an ovarian cyst, become very fearful and insist that they want it out before it “becomes cancer”. While a normal reaction, let’s examine the relationship between ovarian cysts and ovarian cancer. 

 

Ovarian cysts never become ovarian cancer. These “functional cysts” consist of those that are formed prior to ovulation and called “follicular cysts” and those that are formed after ovulation from a small amount of bleeding into the area of ovulation. These are called “haemorrhagic cysts”. Neither of these are tumors and will not become cancerous. Now let’s look at Ovarian Tumors.

 

OVARIAN TUMORS AND CANCER

 

Cystic changes in ovaries that are not functional or dysfunctional would be considered a “new growth” (not an ovarian cyst) and represents a tumor, however, most of these tumors are benign while some may be malignant. It is important to note that with ovarian tumors they are benign or malignant from the start.

 

Therefore, if we can reliably diagnose an ovarian mass as being benign the chances of it transforming into malignancy are virtually zero. How is this diagnosis done?

 

It is done Sonographically by using painless Transvaginal ultrasound using the color flow doppler feature to assess blood flow within the pelvic organs. This helps to distinguish if it is truly suspicious, and perhaps needs surgical removal, or if it shuld be left alone. Dr Goldstein, a NYC Gyn, is one of the most highly regarded individuals in the field of gynecologic ultrasound. Here is what he looks for:

 

1)    the lack of any solid area coming off the cyst wall, and

2)    the lack of any vascularity as measured by color flow Doppler ultrasound.

 

Tumors need blood to grow, to divide, to invade, and the lack of any vascularity on color flow doppler means a lack of blood flow. This is an extremely reassuring sign. When people have what appear to be benign growths of ovaries, rather than remove them, we continue to watch them and be sure that they maintain those sonographic features that are reassuring of their benign (non-cancerous) nature.

 

If you have been told you have an ovarian cyst or an ovarian mass (tumor) and need to be screened for ovarian cancer, perhaps a consultation with Dr Steven R. Goldstein MD, a leading Gynecologist in NYC may be in order. Dr Goldstein uses transvaginal ultrasounds with color flow doppler and state of the art radiology to provide painless,  screening for ovarian cancer, the examination of ovarian masses and to look at ovarian cysts. A former Director of Gynecologic Ultrasound at NYU Langone Medical Center, Dr Goldstein personally performs all transvaginal ultrasounds. He does not rely on a technician or use reports to diagnose patients.

 

 

 

 

EXERCISE AND MISSING PERIODS

 

 Dr Steven R. Goldstein is co author of the book “Could it be….Perimenopause?” and the textbook on Perimenopausal Gynecology. He is a Perimenopause Specialist in NYC. Dr Goldstein has been in private practice for over 25 years in New York City. One of the issues women in Perimenopause experience is a missing period. However, it is not just perimenopause that can cause this, one of the reasons for missing a period could be exercise.

 

Exercise is vital to health and even more vital as we age. For women, it is important to their bone and muscle health as they age. However, exercise while generally helpful to you, can cause menstruation to come to a halt if you go at it in a way that’s extreme.

 

There are many women who get into exercise with a vengeance for the first time in their thirties or forties. Perhaps its discovery of a new spinning class, or a particularly fun aerobics teacher or falling in love with high intensity exercises. Or maybe it’s a desire to see if at this point in life one is still fit enough to run a marathon.

 

This new regimen is stressful to the body. Once your body fat level dips too low, there’s a good chance your period will stop. Your body is not producing enough estrogen for ovulation to occur. A rapid weight loss for many reasons, mainly fad diets, can also cause your period to stop. So can a large weight gain. Fifteen pounds may not do it, but extreme weight change can. Weight gain can also raise insulin levels, which can stimulate the body androgens, hormones that produce male or masculine characteristics.

 

It is particularly important to seek treatment if you have gone without your period for six months if you aren’t pregnant, lactating or in menopause. You want to guard against possible bone loss (from low estrogen), and overstimulation of the endometrial lining (from high estrogen) which is one cause of endometrial cancer. Hormone therapy is often recommended for athletes who find themselves in this situation.

 

Nine times out of ten, if you are between the ages of thirty five and fifty, the answer to your missing period is Perimenopause, a transition state to menopause where “irregular becomes regular” regarding periods. If you are a woman in your late thirties or forties and having irregular periods and/or irregular bleeding then perhaps a consultation with a Perimenopause Specialist in NYC, may be in order.

 

Dr Steven R. Goldstein specializes in the use of transvaginal ultrasounds and sononysterograms to examine the uterine lining. This is important because the uterine lining tells a “story”. It doesn’t just tell of the physiology of the uterus, but of its function and can help provide more information on the gynecological health of perimenopausal women. Dr Goldstein is also a past President of the International Menopause Society, past President of the North American Menopause Society, and a Certified Menopause Practitioner.

 

MENOPAUSE AND ESTROGEN DEPRIVATION

 

 Menopause Specialist in NYC Dr Steven R. Goldstein is a past President of the International Menopause Society, past President of the North American Menopause Society, a Certified Menopause Practitioner and co-author of the books “Could it be….Perimenopause?” and “The Estrogen Alternative”.  

 

There are very real medical issues that accompany estrogen deprivation after there is no more ovarian function (the medical definition of menopause). Other higher order primates live a very short time after they stop reproducing. My patients will spend more than 40% of their lives in a post reproductive state. There are very real consequences medically of the lack of estrogen production that menopause brings.

 

Loss of bone mass occurs quite rapidly, and osteoporotic fractures are a significant medical issue as the population ages more and more. A 50-year-old woman who does not already have cancer or heart disease has a life expectancy of 91. If a woman suffers a hip fracture her chances of being dead within the next year are 20–30% and she has a 25% chance of never living independently again.

 

There are also serious changes in the vagina as a result of a lack of estrogen. A change in the normal bacteria causes diminished production of lactic acid and thus the pH will change dramatically, as does the cell count. This leads to dryness and lack of normal lubrication which, in patients who are sexually active, can result in severe discomfort.

Almost all of you are aware of the symptoms of hot flashes and night sweats, the most common of the menopausal transition. Fortunately, for the majority of women, these will ameliorate by 4–5 years, although some women will have these indefinitely. In addition, lack of estrogen can result in joint pains.

 

After the Women’s Health Initiative published its findings in 2002 showing that estrogen plus progesterone therapy caused an increase in breast cancer and heart disease, 50% of women stopped their hormones immediately but 25% went back on. The most common reason for resuming was hot flashes and night sweats as you would think. The second most common reason was joint pains. Furthermore, menopause, with its lack of estrogen, on average causes an increase of 15 -20% in total cholesterol and LDL cholesterol (the bad cholesterol). In addition, estrogen helps promote lean body mass and after menopause women tend to accumulate more fat centrally (that old “midriff bulge”).

 

I am not trying to medicalize menopause. However, we cannot ignore the effects of estrogen deprivation on a variety of organ systems especially as women are living longer and longer. There are new approaches to replacing estrogen without the use of progesterone. As evidenced by the Women’s Health Initiative, it is the addition of progesterone in order to protect the uterus that seems to be the culprit in causing most of the negative findings. These new approaches are, in my opinion, much safer than what we’ve done for the past half century. They involve combining the estrogen Premarin with a different category of drug than progesterone. That category is SERM (selective estrogen receptor modulator). There are a number of SERMs already on the market for breast cancer prevention and prevention and treatment of osteoporosis. 

 

In summary, yes menopause can and should be a time of healthy aging and continued productivity and personal satisfaction indefinitely. The pros and cons of replacing estrogen need to be individualized and discussed on a case by case basis. 

 

If you are a woman going through Menopause or approaching Menopause, then a consultation with Dr Goldstein, a hormone specialist in NYC, may be in order