Nancy Onyett, FNP-C

Insulin Resistance and Polycystic Ovarian Syndrome

Over the past few weeks I have posted blogs related to obesity and insulin resistance with the signs/symptoms, pathology, and laboratory findings. I want to discuss the impact of insulin resistance and obesity on polycystic ovarian syndrome. The signs/symptoms are generally the same with the most common complaint "I can't lose weight", weight gain, no energy, headaches, fatigue, no satiety with foods. However, there are other symptoms leading to a hormone imbalance such as irregular periods, inability to conceive, chin hair, lip hair, persistant skin rash, acne, oily skin, and a darkened neck ring. These symptoms are the most common and can be varied dependent upon the phenotype from person to person.

Usually these women are in their 20's to 30's and present to the office with a caveat of the above symptoms. There is a difference here with people who have insulin resistance and those who have insulin resistance with polycystic ovarian syndrome. The hormonal imbalances are triggered from the high insulin levels causing the ovaries to secrete more estrogen, testosterone and less progesterone. This is what interrupts the menstrual cycles called anovolutary cycles meaning no ovulation and a deficit of progesterone to shed the lining of the uterus monthly.

I went into great detail in the first blog about laboratory values that are indicative of this syndrome. I will review the highlights. The FSH/LH ratio is flipped or is at a 1:1 ratio along with values high for free testosterone, estradiol and low for progesterone. The insulin levels are usually greater than or equal to 15. At times there may be findings of impaired thyroid function and elevated cholesterol panels. The fasting sugars may be elevated for impaired fasting glucose or the 2 hour postpriandial blood sugar is elevated out of the normal range, but not in the diabetic range.

Treatment must start early as complications of infertility, male balding pattern,  diabetes, unopposed estrogen, and miscarriage are more prone to these individuals. The unopposed estrogen can lead to endometrial thickening and complications with numerous ovarian cysts; which are pearl-like strings. The obesity can lead to metabolic syndrome with altered lipid panel and hypertension.

The first goal in treatment is lifestyle change to a structured regimen of calculated macronutrients, and exercise routines involving both cardio and strength training. The weight must be lost to help reverse this syndrome and restore normal ovulatory and menstrual cycles. Here, it is the patient's accountability to commit to making this change that will be lifelong to prevent the weight gain.  Pharmacological treatment consists of metformin, spirolactone, natural progesterone, and armour thyroid if T3 value is  low. The medications added help with  unwanted hair growth, energy,  metabolism,  insulin lowering, and balancing estrogen. Once approximately 5-10% of the weight is lost and progesterone is consistently taken the menstrual cycles resume and insulin levels lower.

Patients with this syndrome are seen biweekly for weigh in and to adjust exercise and dietary regimens. The successful patients lose up to 2 pounds per week which is the good range to prevent regaining the weight. The challenge is exercise routines when there is lethargy. To counteract this I offer lipotrophic B injections and daily supplement of B50. It may take up to one year for the severely obese or shorter dependent upon the amount of weight needing to be lost.

Obesity the Disease with Insulin Resistance

When I tell a young female that she has insulin resistance which can lead to diabetes, I have been asked" how did I get like this"? I discuss the disease of obesity as a multisystem paradigm with weight gain, low energy, a BMI (Body Mass Index) in the obese range, and sluggish metabolism  It is a disease of the person's lifestyle and 30% genetics. What does this mean to you? By eating the wrong foods, smoking and  
sedentary lifestyle, your body starts a oxidative stress response. This response increases free radicals that activate the aging genes. These activated genes  lead to cellular disruption allowing disease states to manifest. The result is obesity from high insulin levels that become resistant to sugar metabolism in the tissues.  This is why I always recommend antioxidants to my patients to counterract the production of free radicals and disease processes

 What are the signs and symptoms patients experience? Headaches, weight gain, fatigue, irregular periods, the sensation of constant hunger, frequent infections and lethargy. Some patients with more advanced insulin resistance complain of unwanted hair growth on their chest,and face which can be accompanied with acne. Slowly, a  dark skin ring surrounds their neck and in very advanced cases the skin has the appearances of a velvety type rash appearing on their neck, chest or axillas.

The most important intervention is to diagnose the disease state through blood work, history and physical exam. A normal fasting insulin level is 2-4 and a normal fasting blood sugar is below 100. The American Association of Clinical Endocrinologists (AACE) guidelines indicate that a fasting blood sugar 100-125 is impaired fasting glucose and a 2 hour blood sugar after a 75gm glucose load less than 140 is within range; however, a blood sugar between 140-199 is impaired glucose tolerance. The mid-range fasting insulin level of 15 is a marker for treatment. A top range for fasting insulin level is 25 by most labs.  Other diagnostic criteria include the range of BMI, waist size, blood pressure, and lipid panel. Metabolic syndrome must be ruled out to determine the appropriate treatment. There may be other endocrine abnormalities from the irregular periods but I will address Polycystic Ovarian Syndrome in the next blog.

What is the most important intervention for insulin resistance with obesity? I can't emphasize enough to all my patients they are in control of their life and  prevention of disease management. It starts with lifestyle change, dietary weight loss and consistent daily exercise 30 minutes cardiovascular and 20 minute strength training. Why strength training??? When fat starts burning strength training is the longest fat burner up to 24 hours after the weight lifting session and secondly, when weight is lost, skin sags loosely leaving a jelly bag appearance. We know that cardiovascular training only gives 4 hours of fat burning after the training session is completed but the combination of the two increases metabolism.

Several studies have demonstrated favorable results with lifestyle intervention compared to Metformin. The pharmacotherapy treatment is secondary to lifestyle intervention but is still used to maximize insulin lowering and weight loss. The treatment includes Metformin and Armour Thyroid . Newer therapy includes the use of Byetta and Sylmlin that has shown effective weight loss and insulin level lowering in patients.  A customized  weight loss program is designed for the individual with weekly nutrition and exercise guidelines. Patients are supplemented with long acting B12 lipotrophic injections and oral B50. 

Most importantly, I educate women in the importance of lifestyle change to correct the underlying metabolic disruptions that will be life long and deleterious if the weight is regained.

Obesity the Disease with Insulin Resistance

When I tell a young female that she has insulin resistance which can lead to diabetes, I have been asked" how did I get like this"? I discuss the disease of obesity as a multisystem paradigm with weight gain, low energy, a BMI (Body Mass Index) in the obese range, and sluggish metabolism  It is a disease of the person's lifestyle and 30% genetics. Actually, it is oxidative stress with an increase of free radicals that activates the aging genes and disease entities develop from the chemical interraction and disruption at the cellular level. This is why I always recommend antioxidants to my patients to counterract the production of free radicals and disease processes.

It is a very difficult concept for the majority of people to grasp since they cannot see their body from the inside and the chemical processes taking place. Overeating, sedentary lifestyle, smoking is the way to gain the diagnosis of obesity. When  blood work is checked there is more diagnoses such as insulin resistance and maybe diabetes type 2.  What next with this multisystem paradigm?

So what are some of the symptoms patients experience? Headaches, weight gain, fatigue, irregular periods, the sensation of feeling hungry all the time, frequent infections and no energy. Some patients with more advanced insulin resistance complain of unwanted hair growth on chest,and face with or without acne. The classic dark skin ring surrounds their neck and in very advanced cases the skin has appearances of a velvety type rash.

Most of these patients have  Polycystic Ovarian Syndrome (PCOS). This syndrome is a result of the insulin resistance  which causes chemical changes within the ovaries to secrete more estrogen and testosterone leaving progesterone behind. This is what interrupts the cycles and promotes acne with unwanted hair growth with darkened skin. So when we talk about PCOS, it is the disease of insulin resistance originating in the pancreas. The pancreas works harder to promote enough insulin to cover the blood sugars resulting in elevated fasting insulin levels. A normal fasting insulin level if 2-6, when it gets to 15 and above it needs to be treated. The analysis of blood work for PCOS includes a equalizing FSH=LH or the LH flip LH >FSH. The higher the LH goes the person is becoming more advanced in their insulin resistance and may even have impaired glucose tolerance as the beginning of diabetes. The free testosterone and estradiol  is elevated on blood work and the progesterone is usually low. On ultrasound not all patients have the classical pearl string of cysts within their ovaries as there are many phenotypes to this syndrome. The most important point with the establishment of obesity, insulin resistance, and PCOS is the intervention needed to correct the underlying metabolic processes. If PCOS and insulin resistance is not reversed it can lead to infertility, diabetes type 2, and metabolic syndrome with low HDL, hypertension.

What is the most important intervention for this syndrome? I can't emphasize enough to all my patients they are in control of their life and their prevention of disease management. It starts with lifestyle change, dietary weight loss and consistent daily exercise 30 minutes cardiovascular and 20 minute strength training. Why strength training??? When fat starts burning strength training is the longest fat burner up to 24 hours after the weight lifting session and secondly when weight is lost skin sags loosely and nothing is toned leaving a jelly bag appearance. Cardiovascular training only gives 4 hours of fat burning after the training session is completed. My motivated patients want to do what it takes to succeed in reversing this syndrome and fat loss. Sadly, there are less motivated ones that go on to develop metabolic syndrome, obesity, hypertension, dyslipidemia, and diabetes type 2 which we see around the time of menopause.

Next week:  Treatment of Obesity the Disease with Insulin Resistance