Secondary Amenorrhea: A Description, Not A Diagnosis

Question:

Hello Dr. Ramirez,

I'm 20 and 293 pounds. I have had  Secondary Amenorrhea for close to 4 years now. It is apparently being caused by my weight. I'm not planning to TTC for at least another 12 or 13 years. I don't hate babies but it's not just a good time on the emotional or financial level to have them. If I'm able to get down to a decent weight and get rid of this disease,  What are my chances of getting pregnant when it's time for me to TTC???

There's a history of Diabetes in my family and I haven't had a asthma attack since I was 8.My mom had thyroid disease before I was born but I don't think that's genetic. But I don't have any other diseases than the SA at the current moment and my hormone levels were just fine at my last doctor appt which was last October. I've been on progesterone more than I count and it gets me a period but I want to have it without the help of drugs. Is there some kind of natural cure to SA??

I know that it seems a bit silly to ask about this NOW but I'm not getting any real answers about this disease from my OB. Everytime I asked my OB about this, she would tell me not to worry about it or brings a therapist in the room to basically tell me that I'm crazy.

She's since moved her practice out of state and I have a new OB that I'll start seeing very soon. But how in the hell am I crazy for wanting to be proactive about my own health?? I'm sorry for the language but I'm just so fed up about this and at my wits end.

I know that I'm not producing eggs right now but what else could this be doing to my body?? Do I have a reason to be concerned about it besides the obvious infertility scare?? If I do get rid of this disease,  Is there some kind of leftover side effect that could cause me to get Ovarian Cancer in the future??

I don't have these answers and I need to know what's going on. Please help me clear at least some of this up.

Thank You. D. R. from Michigan.

Answer:

Hello D. R. from the U.S. (Michigan),

Good riddance to your previous Ob doctor!  "Secondary Amenorrhea" is a description of a problem and NOT a diagnosis.  It just means that you used to have periods and now you don't.  It doesn't explain the cause.  The most common reason for old women to have secondary amenorrhea is menopause.  The most common reason for young women to have secondary amenorrhea is pregnancy.  However, a close second is an ovarian disorder called "Polycystic ovarian disease."  This diagnosis is manifested by irregular or rare natural menstrual cycles and at least one of the following findings: ovaries that look like PCO ovaries on ultrasound, inverted FSH/LH ratio, obesity, hirsuitism (increased facial hair), elevated testosterone levels, diabetes, elevate insulin levels signifying insulin resistance.  I think that you have PCOD but without a thorough endocrine evaluation, I cannot say for sure. 

With this disorder, you have a hormonal imbalance and that needs to be corrected.  The most simple way to do that is to use a low androgen birth control pill such as Yaz.  Once you are ready for pregnancy, then you will have to use fertility medications, which actually do not increase your fertility but induce your ovaries to ovulate, so that you can give off an egg to get pregnant.  You need to see a COMPETENT gynecologist or a reproductive endocrinologist to be evaluated and treated correctly!

You may want to see a more detailed explanation of Polycystic Ovarian Disease on my website.

Glad you wrote! Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

Young Woman With Endometriosis & PCOS Fails Five Clomid Cycles: Next Step?

Question:

Dear Doctor,

Hi, I'm from Minnesota. My husband and I have been trying to conceive since August of 2011. I have endometriosis and PCOS (polycystic ovarian syndrome) since finding out when I was around 17 years old, I'm 25 now. I have had five cycles of Clomid that didn't work. I had laparoscopy surgery for this post December, blocked tubes, suck ovaries, scar tissue, cysts and endometriosis. I'm on metformin because that's supposed to help with infertility and PCOS.

I started femara this month. Had 4 follicle on left and 1 on right from ultrasound. I usually ovulated on the 15th day, this time I didn't ovulate so I took the ovidrel shot and had a positive test. Started estrogen and progesterone day 3po. Currently on day 10po. I have cramps on and off.  I was just wondering what my chances of conceiving are and what is the next step if this didn't work this cycle. Any information or insight would be great! K. from Minnesota

Answer:

Hello K. from the U.S. (Minnesota),

Your statistical chances of pregnancy with Stage Four Endometriosis (endometriosis with extensive adhesive disease) and PCOD is probably less than 1% using any natural treatment method (Clomid, Femara or Injectables with intercourse or IUI).  That is because you have an abnormal pelvis and this location is critical for passage of the egg from the ovary to the tube.  Scar tissue, which is like spider webs, can block the egg from entering or reaching the tube.  Endometriosis causes a chronic inflammation of the pelvis which leads to the inflammatory cells attacking and destroying the egg as it exits the ovary to reach the tube. Polycystic ovarian disease is an ovarian dysfunction where the ovaries don't function properly and so there is a resultant hormone imbalance and lack of ovulation.  All of these put together significantly reduces your chances.

See my website for more extensive information and explanation of the options available for both Endometriosis and PCOS. I am convinced that with the proper information patients become empowered to make the right decision about their healthcare and can ascertain if they are receiving the best care.

It is my humble opinion that you are probably not seeing an infertility specialist because a good infertility subspecialist would have told you all this and not done all the treatments you have done.  The treatment of choice is to proceed to IVF so that you can bypass the pelvis completely.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com 

Monterey, California, U.S.A.

New 2011 Study Questions Routine Metformin Use In All PCO Patients

Dear Readers,

A recent study published in the medical journal "Clinical Endocrinology" Frans S., Clinical Endocrinology. [Oxf], 2011; 74:148-151, brings into question the routine use of Metformin in PCO (polycystic ovary) patients. The study showed a small improvement for ovulation but not clearly better than weight loss. It also showed no improvement in pregnancy outcomes, except in patients with diabetes. It showed no benefit or improvement in hirsuitism, acne or hair loss resulting from PCO (polycystic ovary). Alone, it showed no improvement in pregnancy rates but did show some improvement in combination with Clomiphene (Clomid), yet there was no increase in the live birth rate. The authors therefore concluded that there was no real evidence to draw any conclusions regarding Metformin’s treatment in PCO, and that its only benefits may be in patients with diabetes or impaired glucose tolerance.

As you have seen through reading my blog, PCO (polycystic ovaries) is a very common problem among infertility patients. I have participated in numerous posts, have had several on-line, television and radio discussions regarding this problem, and I have given my opinion regarding the diagnosis, management and treatment options associated with this problem. One of the main problems that I face, almost on a daily basis within the medical community, is the mistreatment of PCO patients with Metformin. I see this commonly done by second tier providers such as Nurse practitioners and Physician Assistants, as well as, Physician providers such as Family Medicine practitioners and general Ob/Gyns. Many of these providers have mistakenly latched onto Metformin as the ultimate drug for the treatment of PCO, much the same as they have latched unto Clomid is the ultimate treatment for infertility. As a result, they automatically treat all suspected PCO patients with Metformin. This practice is unfounded and this recent study shows that treating all PCO patients with Metformin may be misguided. In fact, it brings into question whether there is any benefit at all.

I would not say or conclude that there is no benefit, but there is selective benefit. There are certainly studies that show benefit in a sub-population of PCO patients, just as this study shows benefit in patients with impaired glucose tolerance. These are patients that have been found to have an elevated insulin level or diabetes from insulin resistance. Not diabetics who do not produce insulin. Decreasing this level, either through weight loss or Metformin, will often return the ovary to normal function in these patients, or make their ovaries more responsive to fertility medications.

But clearly, it does not benefit all PCO patients and therefore should be selectively used, not, as many of these aforementioned providers do, used for all PCO patients. There is not a good way to know exactly which patients will respond or not respond to this medication, but here are three requirements that I abide by.\:

*First, a fasting insulin level should be taken to see if it is elevated. If not, then skip the Metformin.

*Secondly, if Metformin is going to work, it can take several months, some authors state 6-8 months, to see if there is any effect. The effect should be noticed by resumption of normal ovarian function i.e. regular menstrual cycles or decrease of the fasting insulin levels.

*Thirdly, a minimum dosage of 1500 mg per day is required. I have seen some patients taking only 500 mg. That is a total waste. If you are going to use this medication then you have to use it in the clinically effective dose.

The exact cause of PCOS is not understood. Some thought it was elevated insulin, but that clearly is not the case in all patients. Some thought it was increased weight, but that also is not the cause. It is clearly some inherent pathway within the ovary that is dyfunctioning, and it is clear that there are many forms of this disorder. It may be a multi-factorial condition where there is not one presentation or one treatment. In is imperative that patients and Physicians understand this and not latch onto one treatment modality for all. Treatments have to be specific to the patient.

Which brings me to my final point regarding the patient-doctor relationship:

This is exactly why Medicine can never be dictated by a cookbook method. People are all different, present differently and must be treated differently. We call that the art of medicine, and this is what makes some doctors better or worse than others, makes some doctors decide to specialize, an option which, unfortunately, is quickly disappearing from medicine as we look to less trained and less costly practitioners.

Edward J. Ramirez, MD, FACOG
Medical Director
The Fertility & Gynecology Center
Monterey Bay IVF
http://www.montereybayivf.com/

Clomid Protocol In Depth: Dosage, Specific Indications & Period Of Use

Hello Doctor,

Your willingness to answer fertility questions is admirable. Let me say, "Thank you!"

I've been trying to find specific information on your blog regarding clomid protocol and I simply cannot find what I'm looking for. I do find questions and answers regarding clomid, but not specific information on how and when to use it, for how many months etc. Do you have a specific link perhaps? Thank you again, J. in the USA

Answer:

Hello J. from California,

Actually the answers to those questions are in the blog but are within the body of the answers. I don't think I have one entire blog post that goes over the specific indications or period of use. You can look at my website for more information as well: "Ovulation Induction".

I will endeavour to explain as much as I can here:

Clomid is one of many medications that are used to induce ovulation. In most cases it is used for patients that have an ovulation disorder, i.e. don't ovulate spontaneously or have a hormonal imbalance leading due to an ovulation disorder. Clomid is an estrogen that blocks the estrogen receptor and induces the brain to increase the FSh output thereby stimulating the ovaries harder. Some doctors will also use Clomid, and other fertility medications, to "superovulate" the ovaries. That is to increase the number of eggs that the ovaries give off so that the chances that an egg with reach, enter and get fertilized will be increased. Unfortunately, many doctors use this as their "magic pill approach" to infertility and will prescribe it without doing an infertility evaluation or determining whether or not it is indicated.

In my blog, I go over how the Clomid is given and how I recommend doing a Clomid ovulation induction. But as a basic method, Clomid can be given in doses ranging from 50mg per day to 250mg per day (1-5 tablets). It is taken orally once per day for a five day period. Most Physicians will give it between cycle day #3-7, 4-8 or 5-9, with cycle day #1 being the first day of the period. It should be taken at approximately the same time of day each day but the specific time is not critical. Most textbooks will state that you should start with the lowest dose of Clomid and increase the dosage in 50mg increments per month if the patient does not respond to that dose. Many doctors blunder by increasing the dosage anyway if the patient does not get pregnant in that month, thinking that a higher dose increases the chances of fertility. That is not true! It only risks increasing the number of eggs that the patient ovulates and therefore the higher chances of a multiple pregnancy.

In essence the lowest ovulatory dosage should be used, so that if a patient responds to 50 mg with ovulation, then you stay at that dose. If ovulation does not occur, then it is increased by 50 mg. I don't quite follow this method because as you can see, if the patient does not respond to dosages less than 250mg, then you have wasted four months finding that out. Instead, my experience has shown me that it is better to be more aggressive and quicker in finding the dose that the patient responds to or to know whether she will respond at all. For example, the most common patients that require ovulation induction are PCO patients. I don't start at 50 mg. Rather, I start at 150mg then proceed to 250 mg if they don't respond. If they don't respond to 250mg, then I know that we have to move to stronger meds. This is because most PCO patients will require high dose Clomid or will not respond to Clomid so I want to find out as soon as possible. In a patient being superovulated, you have to use doses lower than 150mg because these patients are already ovulating. I use superovulation mainly in older ovulatory patients (over 35 years old) because I know that one problem they are facing is an egg quality issue and increasing the number of eggs does in fact increase their chances. I will often strive to get them to ovulate up to 5 eggs per cycle. Finally, I don't recommend more than 6 ovulatory cycles of Clomid. If you have not achieved pregnancy by then, then there is something else going on and so you have to move to a more aggressive treatment plan.

I hope that this answers your questions.

Good luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Can Progesterone Be Given With Clomid Induction? PCO Patient With 3 Failed Cycles Wants To Know...

Question:
I'm 31, never pregnant. Dx PCOS, receiving metformin 1500 mg a day. Three cycles with clomid with no ovulation. HSG normal, husband semen analysis OK. Now going through second cycle of IUI (intra uterine insemination), ovulation stimulated with Gonal F and triggered with ovidrel.

First cycle progesterone level on day 3 after second IUI was low (2.3), so I asked the doctors why they can not prescribe progesterone to improve luteal phase and make implantation more possible, and they told me they do it only with IVF. Is this Ok? What I mean is, why don't give progesterone if the level is low, and it is know than low progesterone impairs implantation and also increases risk of miscarriage in first trimester? Please give me some advice, or some reference articles where to read about this (scientific articles to support my request) Thank you! S. from Arkansas

Answer:

Hello S. from the U.S.,

You have a very valid question and you should ask your doctor why they don't give progesterone after intra-uterine insemination. I'm sure there are many articles on the web that you could find that advise this technique. There is absolutely no reason not to give progesterone after IUI or even after simple ovulation induction.

However, I think that your thinking may be incorrect, however. If the ovulation induction were proceeding correctly, and ovulation occurs, then the hormones should be corrected and there should be a normal luteal phase. Usually a mid-luteal progesterone is not to see if there is adequate progesterone for implantation, but to see if ovulation in fact took place because if it did not, the progesterone would be low. So you see, rising progesterone levels occur from ovulation. If the progesterone is low, that is an indication that ovulation did not take place and replacing progesterone would not have anything to help i.e. no implantation would occur any way.

I have to wonder about the protocol that your doctor is using, and I would suggest that you look at my blog under how I do clomid induction cycles. One specific technique that I use is to follow the follicle(s) with the ultrasound to determine when ovulation is going to occur. That way, I can better time the insemination. I also give an HCG trigger. Then I start progesterone the day after the second IUI (I do two IUI's per cycle) for luteal phase support. This is mainly because progesterone is an easy medication to use, is not expensive and has no adverse reactions/side effects/harm to the pregnancy. It can only help and increased progesterone is one of the main stays for the treatment of implantation failure due to inadequate b-integrin levels.

Maybe you should ask your doctor why he uses it for IVF and not for IUI? The reason to use it should be the same.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Polycystic Ovarian Disease In Young Woman

I have had many, many questions regarding Polycystic Ovarian Syndrome or Polycystic Ovarian Disease. As an infertility specialist, I see women every week that suffer from either the syndrome or the disease. If not treated, it can lead to serious health problems such as diabetes and heart disease. It can also cause infertility. PCOS or PCOD is common and affects as many as 1 in 15 women. Often the symptoms will begin in a woman's teen years, like the following questioner from Texas.

Question:

Hi Dr. Ramirez,

I am a 19 year old black female in Texas looking for answers. I started having periods at 12, but I have never had a normal, monthly cycle. I generally skip 3-6 months, after which I have a period lasting anywhere from 2 weeks to 3 months. At first, because I am hirsute and I was overweight, it was thought that I had polycystic ovarian syndrome, but I have been tested numerous times for such and I don't have that. During my long periods it was thought that I had uterine fibroids, for which I was also tested negative more than once.

I've lost 35 lbs. but I still have the same issue. Now I have a "bloodless period", with a brownish or clear fluid. I have been to 4 different ob/gyn's, non with a conclusive answer. The reason I post this in the infertility section is because I don't believe I am fertile, but I want to know what is causing my infertility so maybe I can go and get help to resolve the issue.

Thank you so much!

Answer:

You have PCOD. The is NO specific test for this disorder. It is a clinical diagnosis, which means that it is based on the signs and symptoms. If you have hirsutism, increased weight and very irregular periods, that is enough to make the diagnosis. PCOD has a wide variety of presentations. Some will have an FSH/LH imbalance on blood testing, but not all. Some will have irregular periods, but not all. Some will have increased hair growth, but not all. Some will have elevated insulin levels, but not all. The point is, your doctors are wrong. You have PCOD.

Therefore, you should be on the birth control pill to control your cycles. The problem with PCOD is that the ovary is dysfunctional and not processing FSH and LH correctly. Because of the dysfunction, it does not lead to ovulation and estrogen and progesterone are not produced. Instead, the precursors, the chemicals that usually are made into estrogen and progesterone, proceed to making testosterone, a male hormone. That leads to the increased hair growth, hair loss, obesity etc. By using the birth control pill, the ovaries are shut down, so that no testosterone is formed, and the estrogen and progesterone replace the hormone that you are not producing. The best pill for this purpose is Yasmin because the progesterone type, Drospirenone, blocks the testosterone receptors as well.

There are fertility issues with PCOD patients because they are not ovulating, which means, they are not giving off an egg each cycle. Those patients need to use fertility medication to get the ovaries to ovulate. Once ovulation is resumed, they have a normal chance of getting pregnant.

I hope this clarifies things for you. You might want to see a Reproductive Endocrinologist because this kind of doctor specializes in women's hormonal disorders and understands PCOD.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

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