Case #358: Confirm, Treat and Track Polycystic Ovary Syndrome

By Steven A. Foley, M.D., Contributing Physician

I first saw “Shannon” in my office in January 2010. She complained of irregular periods and weight gain along with feeling generally tired and run down. Shannon was in her mid-20s, approximately 5 feet, 2 inches, and her weight was about 60 pounds above her ideal body weight with a BMI above 34.

Shannon had been working with her primary care physician, who had prescribed birth control pills to help regulate her cycle. However, after additional testing, her physician contacted me and referred her to me for further evaluation.

Shannon had heard about the symptoms and indicators of PCOS and suspected the condition might be related to her health issues. I, too, suspected PCOS. We reviewed a PCOS checklist, the symptoms of which include:

• increased belly fat
• abnormal periods
• abnormal hair growth
• acne
• abnormal cholesterol levels

Also, using the VAP Lipid Panel, I was able to: confirm PCOS; confirm that we were treating the patient’s insulin resistance (IR); and — in coordination with CIMT — track the patient’s progress.

Our office routinely orders CIMT on patients that have low HDLc, regardless of age. It is an excellent way of following treatment for insulin resistance, especially when we don’t have absolute LDLc and HDLc levels. What we are looking for is improvement, especially in CIMT numbers. When we see that improvement, we don’t worry about absolute cholesterol levels.

Imaging
The patient’s January 2011 CIMT showed a mean composite of 0.577 and an arterial age of 45 (compared to chronological age of 26). However, her April 2012 CUS/CIMT reported a composite score of 0.473 with no soft plaque identified in the left or right bulb. Shannon’s arterial age was 28, equaling her chronological age.

Labs
Click here to view Shannon’s VAP Lipid Panel results and appropriate reference ranges from Atherotech:

• July 2010
• December 2010
• June 2011
• February 2012

Lab Results
Shannon’s initial VAP showed LDLc of 112 (high) with elevated triglycerides at 215. Although her HDLc was good at 41, HDL₂ was low at 8 (should be >15) and her density pattern was B (small, dense), which is bad. Her trigs, HDL₂ and B Pattern indicate dyslipidemia and IR. Our office did keep an eye on Shannon’s vitamin D, which was initially low, since levels appear lower in PCOS and IR patients.

The patient’s Lp-PLA₂ was 205.55 in July 2010 and at 215.88 in June 2011, which concerned me, although it is in the “moderate” risk range. For her most recent 2012 visit, Shannon’s Lp-PLA₂ was below 200 (191.48) in the “low” risk range.

Discussion
With the patient’s low HDLc, high TG and pattern size B, it’s an indication of IR; the VAP helped confirm that we were treating Shannon’s IR and PCOS. When repeat VAP testing shows those numbers changing (improving), then I have much more confidence that we are treating more than just weight, we’re treating her IR.

Shannon’s insulin was 57.2 in July 2010, 52.8 in June 2011 and by January 2012, was down to 23. With the elevated insulin level, which is very non-specific, I’m not that concerned about absolute levels, as any improvement is encouraging. Also, seeing that CIMT levels have improved over time, we know that metabolically things are improving.

In the Patient’s Terms
Shannon lost more than 30 pounds, and I now see her every few weeks to once a month to check on her progress and keep things on track. During our initial and subsequent appointments, Shannon learned a lot about nutrition, insulin basics, hormones, how food is processed and eating to control the symptoms of her condition.

I advised Shannon that she needs to continue her low-carb, high-protein diet; we have an understanding that she probably needs to stay on some level of metformin tx for her IR. I explained that I like to keep patients off medications if possible, but I believe that she has a genetic problem, and if we don’t treat it, the problem is just going to worsen again.

About Dr. Steven A. Foley
Dr. Foley is a graduate of the Indiana University Medical School. Prior to moving to Colorado Springs, he practiced obstetrics/gynecology at the Castleton Health Care Center, ClearVista Women’s Care, and Lifetime Wellness in Indiana. He joined Advanced Gynecology in 2004.

Dr. Foley is one of the foremost experts in PCOS and issues associated with it such as Insulin Resistance. He has a passion to educate the community, patients and healthcare professional about this syndrome. In addition to the variety of other procedures, Dr. Foley provides inter-stim treatment for bladder control.

He is certified by the American Board of Obstetrics-Gynecology and is a member of the American College of Obstetrics-Gynecology, Indiana State Medical Association, Christian Medical and Dental Society, and the Wesleyan Medical Fellowship. He has medical privileges at Penrose-St. Francis Hospital, Memorial Hospital, Audubon, and Premier Surgery Centers. Dr. Foley is a national speaker with Quest Diagnostics and Atherotech.

More Cobble’s Corner articles by Dr. Foley:

• PCOS Awareness and Diet
• Hope for PCOS Prevention
• Looking Forward’ to Early Screening: Case 349

Abbreviations
BMI = Body Mass Index
BP = Blood Pressure
CIMT = Carotid Intimal-Medial Thickness
CMP = Cardiometabolic Metabolic Panel
CUS/CIMT = Carotid Intimal-Media Thickness/Carotid Ultrasound
DM2 = Diabetes Mellitus Type 2
FDC = Fixed Dose Combination
FRS = Framingham Risk Score
GlycoMark = monitors intermediate glycemic control by measuring the levels of the monosaccharide 1,5-anhydroglucitol (1,5- AG) in blood
HDLc = High Density Lipoprotein Cholesterol
HgbA1c = Glycosylated Hemoglobin A1c, (also A1c) for diagnosing diabetes and managing glucose levels post diagnosis.
HTN = Hypertension (high blood pressure)
IDLc = Intermediate Density Lipoprotein Cholesterol
LICA = Left Internal Carotid Artery
LDLc = Low Density Lipoprotein Cholesterol
Lp-PLA₂ = Lipoprotein-associated phospholipase A2, The PLAC Test.
Met Syn = Metabolic Syndrome, or The Cardiometabolic Syndrome
MI = Myocardioal Infarction (Heart Attack)
NCEP = National Cholesterol Education Program
NHDLc = Non-HDL Cholesterol
NTproBNP = N-terminal Prohormone BNP
OGTT = Oral Glucose Tolerance Test
PPG = Postprandial Glucose
Qd = Daily
RLP = Remnant Lipoprotein
TC = Total Cholesterol
TG = Triglycerides
TSH = Thyroid Stimulating Hormone
VAP = Vertical Auto Profile (VAP) Lipid Panel
VAP UC = VAP Ultracentrifugation = VAP Lipid Panel
VLDLc = Very Low Density Lipoprotein Cholesterol