Reproductive disorders are very common.
In fact, hormonal disorders are the third most diagnosed condition in the United States, and infertility affects roughly 1 in 6 couples. This is important because our reproductive wellness affects our overall health, and infertility is often the first sign of an underlying health condition. For these reasons, early detection of reproductive disorders is vital for preventing chronic issues. One of our most important missions at Pelex is focusing on early detection of reproductive disorders.
Research has shown that infertility is associated with early death in both men and women. In fact, one study followed over 100,000 women from 25-42 years of age and found that infertility was associated with an increased risk for premature death, particularly due to cancer. This risk was higher in women with infertility at a younger age or for those who were never able to conceive, and the highest risk was associated with diagnoses of ovulatory disorders and endometriosis. Male infertility is also associated with morbidity and mortality, including the risks of cancer, as well as cardiovascular, metabolic, and autoimmune diseases. These associations may arise from a genetic predisposition, developmental influences, or lifestyle-based origin, but the exact nature remains unclear. Research has found that semen quality may be a fundamental biomarker of a male’s overall health.
If women have irregular menstrual cycles, they could have a wide range of underlying issues. For this reason, it is important for women to know when their last menstrual cycle began and if their menstrual cycles are occurring regularly. In a sense, the menstrual cycle should be considered the sixth vital sign. A common example of these underlying issues is polycystic ovary syndrome, or PCOS.
Polycystic Ovary Syndrome (PCOS)
PCOS is diagnosed if at least two of the following are present:
Excess levels of androgens can increase the free testosterone levels in your blood. This can cause a few events to occur:
The main focus for treating PCOS is improving insulin resistance. This can be done by:
For the population of patients trying to conceive, there are a few options available:
For the population of patients not trying to conceive, the primary treatment option is birth control pills. These work to:
For PCOS, early diagnosis and intervention are important for quality of life and well-being, yet 50% of women see 3+ health professionals prior to diagnosis. Further, for ⅓ of these women, it takes >2 years to receive a diagnosis, and only 16% of women were satisfied with the health information and educational materials that they received about their condition.
Relative Energy Deficiency in Sports (RED-S)
Women who play sports may be at risk for relative energy deficiency in sports (previously known as the female athlete triad syndrome). Common conditions associated with RED-S are:
Estrogen is the link between stress fractures and energy deficiency
Birth control: the Imposter
Many women are put on birth control pills in their teens. While taking birth control, a monthly placebo week can cause vaginal withdrawal bleeding to occur, which many women mistake for a period. This can create a false reassurance of regular periods when there is actually an underlying issue present. Birth control pills provide steady levels of estrogen and progesterone each month, but this is different from the fluctuations observed in a normal menstrual cycle. Since the estrogen levels remain low, it can cause sustained or worsening fracture risks.
Reproductive endocrinology can help with RED-S
Reproductive endocrinology is important because it:
The ultimate goal is to optimize overall health and performance of the female athlete to prevent initial or recurrent injury.
Menopause refers to the absence of a period for one year, so it takes one year to diagnose it. Menopause can be treated with hormonal therapy. Women only taking estrogen had less breast and colorectal cancer, while women taking both estrogen and progesterone had lower all-cause mortality rates.
Pelex believes in preventative care for reproductive health
Sadly, infertility and reproductive disorders are one of the only areas of medicine where prevention isn’t standard of care. At Pelex, we believe that:
Most importantly, reproductive wellness is important for overall health, even if you are not trying to conceive. Optimizing health early prevents costly treatment later on, so it’s important to screen for, diagnose, and treat reproductive and endocrine conditions early to improve overall health and decrease overall healthcare spending. This also prevents the need for time-intensive and costly treatments down the road.
We know that women with PCOS are at a higher risk for pregnancy complications (e.g. miscarriage, gestational diabetes, pregnancy-induced hypertension, preeclampsia, and preterm birth). We also know that PCOS is associated with other comorbidities, including obesity, pre-diabetes/diabetes, metabolism syndrome (hypertension, high cholesterol, obesity), anxiety and depression, fatty liver disease, and obstructive sleep apnea.
We counseled the patient to do the following:
At her next appointment, the patient reported:
2. A 34 year old woman struggling to get pregnant for the past 14 months comes to Pelex for treatment. Her Pelex doctor ordered blood tests and diagnostic imaging. The results indicated that she has an underactive thyroid, which is causing luteal phase insufficiency.
Luteal phase insufficiency is a hormonal imbalance that can be a result of thyroid or prolactin abnormalities, being overweight or underweight, excessive exercise, or experiencing excessive stress. It makes embryo implantation difficult because the period controls too early.
We prescribed the patient oral medications to help with her thyroid function and ovulation, along with timed intercourse. As a result, the patient successfully became pregnant and was able to avoid expensive and invasive treatment such as IVF.
3. A 49 year old woman struggling with poor sleep, anxiety, hot flashes, night sweats, brain fog, and joint pain comes to Pelex for treatment. We prescribed her a bioidentical, transdermal, low-dose estrogen patch with cyclic biochemical progesterone. The patch is important because it allows the hormones to not get absorbed by liver before they enter the rest of the body.
Our plan is to start with a very low dose and gradually increase her dosage to optimal level. Pelex meets with patient 3 times to gradually titrate the dose to the lowest dose possible that is effective for the patient, which resolves her symptoms and quality of life.
4. A 22 year old woman, who has not had a period for a year, recently noticed worsening energy and endurance at her exercise class. Her PelexSports provider orders blood work and a bone density scan at a local testing center. The results reveal low:
1. Pituitary hormone levels (FSH/LH)
2. Estrogen levels
3. Bone density for her age
As a result, the patient meets with a Pelex Sports Dietician, who helps her with a weekly meal plan with adequate calories that will meet her energy requirements. A few months later, the patient reports that her energy has improved and her period has returned. A follow up scan shows improvement in her bone mineral density.
Dr. Wolff: I would encourage your friend to start a birth control pill in order to control the levels of androgens in her system. That way, she will not need to continue doing the laser hair removal as often. New diabetic drugs are also revolutionizing how we treat PCOS because it helps correct a lot of molecular aspects associated with PCOS. This, in turn, can help prevent the hair growth and other physical characteristics associated with PCOS.
Dr. Wolff: An IUD, implants, or injections usually only contain progesterone, which can decrease endometrial hyperplasia and the endometrial cancer risk. However, if they do not include an estrogen component, then your body will not raise the sex hormone binding globulins (SHBGs), which can cause an increased level of androgens (testosterone) in the body. Options such as a patch or Nuvaring would help improve PCOS.
Dr. Wolff: We do a recurrent pregnancy loss workup, which includes any or all of the following:
Rarely, recurrent miscarriage can be due to recurrent aneuploidy. As we get older, we have a higher chance of having a pregnancy where the chromosomes have abnormalities. In some cases, even younger patients have genetically abnormal embryos. For these patients, we recommend doing IVF and testing the embryos through preimplantation genetic testing (PGT). This can help determine which embryos have the correct number of chromosomes, which can increase the risk of a successful pregnancy. This is a popular option because the most common cause of miscarriages is having an embryo that has genetic abnormalities.
Dr. Wolff: With our basic labs, we do two things: we look at ovarian reserve markers (how many eggs are left in the ovaries) and screen for other things that can be causing infertility. The ovarian reserve markers include:
Dr. Wolff: It depends on if your lifestyle allows you to maintain your health. If you have normal menstrual cycles and no other red flags, then you are likely getting an adequate amount of nutrients. Sometimes, though, women restrict their diets as a control mechanism to decrease their stress levels. In these cases, it becomes increasingly restrictive (disordered eating) and can affect your overall health.
Dr. Wolff: We used to use Metformin to induce ovulation and used it interchangeably with Clomid or Letrozole. A big study found that using Metformin by itself was not as effective as using Clomid, and using Clomid with Metformin is the same as using Clomid alone.
With PCOS, there are subpopulations. When patients with PCOS have insulin resistance, I like to use Metformin. Metformin can cause nausea, stomach upset, and diarrhea, which can cause weight loss, so it also helps to kickstart weight loss so you can change your diet.
Dr. Wolff: I don’t know of any association between citrus fruits and PCOS and fertility.
Dr. Wolff: Birth control pills can help a little bit with fibroids because they lower your levels of FSH and LH, which can decrease the rate of fibroid growth. But birth control pills are not usually very effective at treating fibroids.
Dr. Wolff: Our chances of getting pregnant naturally decrease after 35 years of age. It’s rare for patients to get pregnant on their own after around age 42, and menopause begins around 51 years of age. There are some circumstances when women get pregnant on their own in the mid to late 40s if there is still ovarian activity occurring, but it is rare.
Dr. Wolff: If you look at trends for patients that do IVF, they are at higher risks for pregnancy complications. However, these women are part of an infertile population. Really careful studies have found that infertile women who do IVF have the same risks as infertile women who do not do IVF. So, it is not the IVF that is causing these risks to the mother, but rather the infertility. Infertility is associated with ovarian cancer, endometriosis, PCOS, POI, and other reproductive conditions can cause worse outcomes later in life.
Dr. Wolff: As a field, we have agreed to prescribe patients with suspected endometriosis a medication that induces a medical menopause, and then see how their bodies react. This medication turns off reproductive hormone function in your body to stop the stimulation of endometriosis. If you feel less pain or discomfort, we know the medication is working. This is a presumptive diagnosis.
Outside of that, it’s usually indicative when a patient says that she has heavy, very painful periods and pain with deep penetration during intercourse. These symptoms are highly specific for endometriosis. The most definitive way is to get a sample of the tissue and test it.
An ultrasound can also diagnose higher endometriosis. An endometrioma (chocolate cyst) on the ovary that is full of dark blood can give your provider a definitive diagnosis of endometriosis.
Dr. Wolff: Unfortunately, it’s more of a trial and error process. If one type of birth control does not seem to work, another class of birth control can be tried until one is found that minimizes that side effect.
Dr. Wolff: The most important pro is that it acts as an insurance policy if you need the eggs in the future. The younger you are when you freeze your eggs, the more likely it is that they will be genetically normal, which can increase your chances of a healthy pregnancy if they are utilized in the future. Further, up to ⅓ of all couples with infertility have male factor infertility, so you and your partner may require more eggs in order to achieve fertilization.
The biggest con is the cost. Egg freezing is rarely covered by insurance and is quite expensive. Another con is that you can go through the process of freezing your eggs and may end up not needing them in the future.
Dr. Wolff: To prepare, try to improve your overall health (decrease obesity, treat sleep apnea, moderate alcohol intake, stop marijuana use, etc.). You can also ask your PCP to test your testosterone levels or check for varicoceles, which may be impacting sperm quality. I also recommend having a semen analysis performed to determine if there is any male factor infertility.
Dr. Wolff: It depends on your folate levels since folate deficiencies can cause neural tube defects such as spina bifida in babies. But it’s generally advised to start at least 3 months prior to trying to conceive. But do not double your normal vitamins since some vitamins, such as vitamin A, can be toxic in high levels for pregnancy.
Dr. Wolff: You can book directly online (www.pelexmed.com) using our scheduling tool, or you can call us at 703-215-2467. You can also email us as firstname.lastname@example.org.
Dr. Wolff is the founder of Pelex, a concierge fertility practice where she educates her patients in the complexities of assisted reproduction and serves as their advocate throughout their journeys toward parenthood.