By Chris Galletti
September 11, 2018
Editor’s Note: September is designated as Polycystic Ovarian Syndrome (PCOS) Awareness Month. This case report of a woman we will call Rachel to protect her privacy was written by Chris Galletti, a fourth year medical student at Florida State University College of Medicine. He was impressed by the usefulness of charting the menstrual cycle to identify and understand a complex condition like PCOS and with the use of fertility awareness based methods (FABMs) to treat it. Rachel’s story, told as a medical history with details from the patient interview, raises awareness about the practical applications of FABMs for health monitoring beyond their more familiar use in family planning.
Introduction
When people think about FABMs, also known as Natural Family Planning (NFP), most think about it as a natural way to either avoid or achieve pregnancy. While family planning is often the goal when using these methods, there is much more we can learn from the charts of a woman’s menstrual cycle. In fact, FABMs provide key details that can help diagnose, treat, and manage medical conditions.
Meet Rachel
Rachel is a 32 year-old Caucasian woman with no pregnancy history who presented with amenorrhea (an abnormal absence of menstruation). She had not had a period for the previous seven months. Her cycles usually lasted 30-35 days and had heavy flow that included passing clots during menstruation. As a graduate student in a rigorous university, Rachel felt very stressed. She also noted other symptoms including insomnia, headaches, fatigue, weight gain, acne, pelvic pain, breast tenderness that fluctuated with her cycles, and mood disturbances associated with PMS (premenstrual syndrome).
Her past medical history was significant for anxiety, depression, and ADHD, for which she was on medication. She did not have diabetes or thyroid disease, did not drink alcohol or smoke tobacco, and noted no sexual activity.
A Different Approach
Rachel went to her primary care physician for these complaints and was referred to an endocrinologist. The endocrinologist performed an ultrasound of her ovaries, which revealed small cysts. PCOS was diagnosed, and he recommended oral contraceptive pills (OCPs) for treatment. However, Rachel was skeptical that simply taking more hormones was the best solution, so she politely declined. She was frustrated yet highly motivated to find a solution. After some research, she found a local family physician familiar with FABMs. Under his care, she underwent daily hormonal testing to provide more insight into her menstrual cycle. She also attended a Creighton Model NFP class to learn how to make observations of her cervical mucus and how to chart her cycles.
This evaluation revealed a low progesterone level during her luteal phase, the phase that begins after ovulation. Progesterone supplementation was given during this time period, beginning three days after her peak day for 10 days after which she had her menstruation. With this treatment, Rachel felt less PMS-like symptoms. Her cycles resumed but were not completely regular. With the addition of Metformin, commonly used to improve insulin sensitivity in diabetes,[i] her cycles stabilized, and she noticed less clotting.
Pathophysiology of PCOS
PCOS is a complex medical condition with an unclear etiology. It is the most common endocrine disorder of reproductive age women, affecting about 1 in 10 women. The diagnosis is made by having at least 2 of the following 3 criteria: androgen excess, irregular menses, and polycystic ovaries. An excess of androgens (male sex hormones such as testosterone) leads to a condition in women called hirsutism, which is excess hair in a male pattern distribution, such as facial hair. Acne is also increased with androgens. Women tend not to have periods for greater than 6 months.
PCOS is associated with various conditions, including obesity, diabetes, anxiety, and depression. When patients like Rachel present with signs and symptoms suggesting PCOS, an ultrasound to look for ovarian cysts and labs to assess hormone levels are part of the evaluation. Enlarged cystic ovarian follicles are often seen on ultrasound and result from hormonal patterns common in PCOS. Although FSH and LH make the follicles grow, ovulation does not occur because the LH surge is absent. By adding charting to the evaluation, Rachel’s physician and Rachel were able to identify and appreciate in greater detail how PCOS was affecting her.
In a 2009 study, researchers found that women with PCOS have varying types of cervical mucus compared to the norm.[ii] The cervical mucus, which becomes more porous under the influence of estradiol, can even vary between women with ovulatory or anovulatory cycles. Rachel did not experience this chronic cervical discharge; instead, her cycles were fairly dry, except for one day of slippery type mucus.
Targeted Treatment with FABMs
As for treating her PCOS, targeted progesterone supplementation stabilized Rachel’s endometrial lining, leading to improved cycle regulation. Her androgenic symptoms improved with Metformin,[iii] which restores regular menstrual cycles in up to 50-70% of women with PCOS.[iv] While OCPs are recommended by medical society guidelines, they do not identify the underlying hormonal anomalies and simply suppress the body’s natural cycle.
In general, since FABMs are not yet integrated into medical training, many physicians are unaware of FABMs or discount their effectiveness. In fact, a 2010 study surveyed physicians regarding the use of NFP.[v] Half of the physicians would not recommend NFP, and less than 6% of physicians knew the perfect use effectiveness of the various methods. Rachel felt lucky to have learned about FABMs because she may have otherwise started OCPs without getting to the root cause of her symptoms.
With our culture’s desire for more natural ways of living, public awareness about FABMs is increasing, but our understanding is still behind in its utility. FABMs can be used as the “5th vital sign” for women to understand their overall health better. Rachel hopes that all young girls are taught how to chart their menstrual cycles so they can be empowered to know their bodies better. In sharing this story, my goal is to help people recognize the usefulness of FABMs not only for family planning but also for a woman’s overall health.
Editor’s Note: The Rotterdam criteria have been the basis for diagnosing PCOS for decades. Two of the following three criteria must be present: oligo/anovulation, hyperandrogenism, and/or polycystic ovaries on ultrasound. In addition, other diagnoses must be excluded, such as thyroid dysfunction and Cushing syndrome, among others. Interestingly, although the Rotterdam criteria have been useful clinically over the years, they remain consensus-based rather than evidence-based. For a historical review of their evolution as well as a compelling appeal for a scholarly assessment of the Rotterdam criteria, read the 2017 article HERE. Learn more about polycystic ovarian syndrome HERE.
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Author Bio: Chris Galletti is a fourth year medical student at FSU College of Medicine in Tallahassee, FL. He is pursuing a career as a family medicine physician. Chris recently completed the FACTS medical student elective and will serve as a FACTS ambassador this year.
References
[i] Moghetti P, Castello R, Negri C, et al. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin Endocrinol Metab. 2000;85(1):139–146.
[ii] Pilar Vigil, Manuel E. Cortés, Ana Zúñiga, Jessica Riquelme, Francisco Ceric; Scanning electron and light microscopy study of the cervical mucus in women with polycystic ovary syndrome, Journal of Electron Microscopy, Volume 58, Issue 1, 1 January 2009, Pages 21–27, https://doi.org/10.1093/jmicro/dfn032.
[iii] Romualdi D, De Cicco S, Tagliaferri V, Proto C, Lanzone A, Guido M. The metabolic status modulates the effect of metformin on the antimullerian hormone-androgens-insulin interplay in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2011;96(5):E821–E824.
[iv] Williams, Tracy, et al. “Diagnosis and Treatment of Polycystic Ovary Syndrome.” American Family Physician, 15 July 2016, www.aafp.org/afp/2016/0715/p106.html.
[v] Choi, J, et al. “Natural Family Planning: Physicians’ Knowledge, Attitudes, and Practice.” J Obstet Gynaecol Can., U.S. National Library of Medicine, July 2010, www.ncbi.nlm.nih.gov/pubmed/20707956.
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MEDICAL STUDENTS & RESIDENTS!
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I had never even heard of the concepts this course covered despite being a 4th year medical student in my last semester at a prestigious medical school. This information about cervical mucus and the impact hormones have on it should be taught routinely in the pre-clinical years.
— M.B.P.
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