Patient wants to avoid birth control pill

Dear Dr. Roach: What can you tell me about polycystic ovary syndrome? My daughter has just been diagnosed. She is in her mid-20s, exercises regularly and watches what she eats, but still puts on weight. She does not want to go on birth control. Where do we start?

B.M.

Polycystic ovary syndrome is very prevalent, affecting six to eight per cent of women, but it is variable in terms of both the types of symptoms and their severity. The most common symptoms are menstrual irregularities and consequences of high male hormones (such as excess body hair and acne). Being overweight or experiencing weight gain is important, as is the metabolic risk from diabetes and abnormal cholesterol levels. Lesser-known symptoms that are seen regularly in women with PCOS include depression, anxiety and eating disorders. The polycystic appearance of the ovaries themselves is demonstrated in women with PCOS, but also can be seen in normal women and therefore is not needed for diagnosis. Diagnosis is made after a careful history and physical exam, and by laboratory testing (which also is necessary to exclude some other causes, such as a hormone-producing tumor).

Treatment of PCOS is intended to reduce symptoms, to reduce the risk of heart disease and diabetes, to manage fertility (including contraception, if needed, and helping women get pregnant, if desired) and to reduce risk of abnormal growth of the lining of the uterus (the endometrium) associated with abnormal hormone levels. The primary treatment is with lifestyle changes, so I agree with getting regular exercise and a prudent diet. If these are inadequate, it is reasonable to consider medication treatment.

For women with symptoms of high androgen (male hormone) levels, birth-control pills are the most prescribed treatment, and your daughter’s doctors should discuss your daughter’s concerns about taking them. They provide many benefits in women with PCOS, especially by reducing male hormone effects and reducing risk of abnormal endometrial growth (and possibly cancer). Of course, they have side effects, including risk of blood clots.

For women who cannot take birth control pills, metformin, which reduces insulin levels, has some benefits. It helps with weight gain and menstrual irregularities, and it probably reduces diabetes risk. It does not help with the body hair.

PCOS is a large topic that I can’t cover fully. I recommend starting with the American Congress of Obstetricians and Gynecologists’ FAQ page at http://tinyurl.com/z7we7er. Dear Dr. Roach: I had a stroke in July 2015. I have had five months of intense therapy, but I still cannot use my left arm. I walk with a four-pronged metal cane. My question is whether there is a shot to help the blood flow back to my brain?

R.C.

In a stroke, the blood flow to the brain is interrupted, and the three main causes are a blood clot forming in one of the arteries to the brain (analogous to a heart attack); an embolism, in which a chunk of blood clot or other material suddenly blocks an artery to the brain; and hemorrhage, in which a blood vessel bursts. In a stroke, the damage to the brain can be temporary or permanent, but in all cases the brain has an ability to re-train itself, to greater or lesser degrees. Different parts of the brain sometimes can take over for the area where the brain cells have died.

Unfortunately, once the brain cells have died, returning blood flow to the area does not improve function.