HJAR Jul/Aug 2024

CHANGING THE CARE: PCOS 26 JUL / AUG 2024 I  HEALTHCARE JOURNAL OF ARKANSAS   patterns of hair growth driven by excess an- drogens (like testosterone) — is also essential. While it is not uncommon for many women to experience some degree of hirsutism from fa- cial hair, asking about coarse hairs on the chest, lower abdomen, inner thighs, and upper arms is important because these locations would be highly characteristic of the increased andro- gens of PCOS. Other signs of hyperandrogen- ism include hair loss. In men, it is our testoster- one that is responsible for our bald spots and male pattern hair loss. When women are mak- ing too much testosterone relative to estrogen, the same fate can befall them, except in a much less culturally acceptable manner. Severe acne can also be due to an excess of androgens. Asking about insulin resistance, which can manifest as difficulty losing weight despite extraordinary effort to do so, is also highly characteristic of PCOS. Skin tags are more common in PCOS and should be identified by performing a comprehensive physical exam. Other evidence of insulin resistance can include abnormally elevated fasting blood sugar or even overt prediabetes as evidenced by a hemoglobin A1C between 5.7 and 6.4. Lab testing should explore reasons for the abnormal menstrual cycles, including a pregnancy test, prolactin levels, and level of thyroid-stimulating hormone (the latter two hormones being pituitary gland hormones). LH and FSH can also be checked but may not be overly useful if all other evidence is pointing solidly toward a diagnosis of PCOS. Under appropriate circumstances, one should consider checking anti-Mullerian hormone to evaluate for premature ovarian insufficiency. Hyperandrogenism should be evaluated by checking testosterone levels +/- DHEA sulfate levels. Lastly, a rare entity known as non-classical congenital adrenal hyperplasia can look very similar to PCOS and could prompt a lab test known as 17-alphahydroxy progesterone. A transvaginal pelvic ultrasound to look for ovarian cysts is not necessary if the other two Rotterdam criteria of hyperandrogenism and insulin resistance are identified. The mainstay of treating PCOS should begin with what will hopefully one day become the normative standard for all healthcare — iden- tifying the individual goals of each patient. If acne, hirsutism, and hair loss are their biggest concerns, then oral contraceptive pills are first- line therapy, but preferably with a standard estrogen dose and a low androgen progester- one. Examples of low androgen progesterone options include norgestimate (Ortho-Cyclen) or drospirenone (Yaz) because they do not have any androgenic properties and therefore will not worsen the hirsutism. When oral con- traceptives fail to adequately control acne, hirsutism, or hair loss, then spironolactone can be used to directly block the androgens responsible for these undesired complica- tions of PCOS. Troublesome hair loss may also respond to minoxidil (Rogaine). While only topical minoxidil has been approved for the treatment of hair loss, some experts find off- label use of oral minoxidil to be more effective. For treatment of insulin resistance, metfor- min can and should indeed be prescribed routinely because in addition to improving insulin resistance, it also improves ovula- tion, regulates menses, and boosts fertil- ity (if desired). The role of GLP-1 agonists (like Ozempic) has shown some promising signals in recent trials as well. And if fertility is the desired goal, then treating fertility typically will involve a fertility specialist and might in- clude treatment with clomiphene or letrozole. Learning from the past to create the future Reflecting on my own medical career, I know in my heart that I am now more up to date than ever. Why? Because I am fortunate enough to no longer be on the “hamster wheel” of tra- ditional health systems where incentives are built primarily around the volume of patients seen rather than the value of outcomes cre- ated. I have time to read medicine, and I de- vote at least the first two hours of every morn- ing to do so. Finding joy in medicine has never been more palpable for me; and instead of feeling morally injured and burned out, I am more excited than ever about life in health- care. I only hope that my own health stays intact so that I can continue this path for at least another 20 or more working years. And, who knows, maybe one day I will even return to private practice. But only if it is in a system that I have helped to shape and create; only if it is part of a multi-disciplinary care team that is financially rewarded not by the volume of patients seen, but rather by the outcomes that we co-produce together with patients. Creating the future is about getting it right much more often and getting it wrong as in- frequently as possible. But getting it right can only happen if we are measuring our outcomes while holding ourselves rigidly accountable for those outcomes. Reducing the frequency of getting it wrong involves continuously learning from those outcomes to drive longitudinal per- formance improvement. Getting the bare mini- mum of Continuing Medical Education (CME) credits to maintain licensure requirements is woefully inadequate. Most importantly, the future is about helping patients achieve the health-related goals that matter most to them, while using a team-based approach to help overcome the barriers and challenges that stand in the way of progress. And again, the hard part is not how to design such care to be delivered effectively. The hard part is the cultural change necessary to achieve change on a grand scale; but although hard, it is not impossible, and, at least for the systems that deliver health, those changes are already well underway. n “Diagnosing PCOS begins with the single most important interaction in healthcare, albeit one that is not at all highly valued by traditional transaction- based healthcare financing mechanisms — listening to and talking with patients.”