Polycystic Ovary Syndrome – PediaCast 451

Show Notes 


  • Dr Kate McCracken visits the PediaCast Studio as we consider polycystic ovary syndrome. This common condition is associated with obesity, infertility, type 2 diabetes, high blood pressure and heart disease. Early diagnosis and treatment can make a big difference for teenagers and young women with this disease. We hope you can join us!


  • Polycystic Ovary Syndrome (PCOS)




Announcer 1: This is PediaCast.


Announcer 1: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio. 

It's Episode 451 for February 6th, 2020. We're calling this one "Polycystic Ovary Syndrome". I want to welcome you all to the program. 

So we are covering another disease this week, one that is fairly common. In fact, it affects about 10% of all adult women in the United States, with symptoms frequently beginning during the teenage years. And it's one that can result in significant and long-term complications, especially when there is a delay in the diagnosis or inadequate treatment. 


So it's another one of those health conditions that really is important to recognize, and yet like rumination syndrome, which we covered a few weeks back, most have either never heard of it. Or if we have heard of it, we likely have a foggy notion of what it entails or how to recognize the conditions and proceed with seeking medical help. 

The condition we're talking about, as I mentioned in the show title, is polycystic ovary syndrome. And yes, it involves cysts in the ovaries, but the cysts are not really the problem. They just happen to be there. 

The real problem relates to associated hormone changes that are accompanied by obesity, insulin resistance, metabolic syndrome, the possibility of Type 2 diabetes and an increased risk of cardiovascular disease including high blood pressure, heart attack and strokes, especially as those impacted by the disease journey into and through adulthood. 


But because the problem begins in adolescence, there is opportunity to intervene early and reduce the chance of significant complications down the road.

Now, I realize I used some medical jargon in that description, insulin resistance, metabolic syndrome. Don't worry, we'll explain what these terms mean as we proceed today. 

And, oh, polycystic ovary syndrome is also associated with an increased risk of infertility. So lots of important things to consider with this topic as we empower parents to be on the lookout for typical signs and symptoms of polycystic ovary syndrome in your teenage daughters.

To help us explore this condition, we have a terrific guest visiting the studio. Dr. Kate McCracken, she is a pediatric and adolescent gynecologist here at Nationwide Children's Hospital. 


Before we get to her, I do have an important public service announcement for both parents and medical providers. It regards antibiotic stewardship. 

Now, what is that? What is antibiotic stewardship? Well, it is the appropriate evidence-based use of antibiotics. I mean, antibiotics are great when they are needed. They reduce disease symptoms and complications, they can save lives that are threatened by significant bacterial infections. Things like pneumonia, meningitis, blood infections. 

But antibiotics also have problems. They contribute to the rise of resistant bacteria, which means that antibiotic we use today may not help us in the future. They contribute to the killing of our gut microbiomes, so the good bacteria that lives in our intestines. And killing those off, we are discovering, is associated with other problems, including in young kids the possible development of allergic conditions. 

And antibiotics can also cause their own side effects and complications. So they are great when we need them, sometimes life-saving, but antibiotics also come with their own risks and pitfalls. 


And so, we want to be good stewards of antibiotics as we prescribe them for our patients in an appropriate and evidence-based way. So that begs the question, what are some practical ways to put antibiotic stewardship into practice? 

And for the providers in the audience, we did show a few months back, it is Episode 31 of PediaCast CME. That's our continuing medical Education podcast, and I'll put a link to it in our show notes, for this episode, 451, over at pediacast.org. And it was called Antibiotic Steward. Dr. Preeti Jaggi, she's a pediatric infectious disease expert now at Children's Healthcare of Atlanta, she was my guest.


And some of the things we covered, of course, only using antibiotics for bacterial infections, not viral colds and coughs. Being intentional about who we test for strep throat, because you may find the carrier state during colds and flu, meaning the strep is there but it's not the thing that's making your patient sick. 

And so, you feel like you have to treat it. And then, oftentimes, that antibiotic is not really good at eradicating the carrier state which there's not really good evidence that we need to eradicate that anyway if it's not causing a problem. And yet because you have this positive strep, you have to treat them. And so, the thought is don't even test the folks who have bad colds and normal looking throats just because they have a sore throat. 

Another thing we mentioned was obtaining urine cultures with your urinalysis and only treating urinary tract infections with significant bacterial growth in the urine. And then, of course, choosing the right antibiotic for the job. And that may mean, starting them on an antibiotic, waiting to see what the culture shows. And if the culture does not have significant growth, and the child's getting better, then maybe try stopping the antibiotics. 


So we go through all this antibiotic, really classic antibiotic stewardship kind of points in that podcast. 

Another important aspect of antibiotic stewardship is prescribing shorter durations of antibiotic therapy for certain infections.  And this presents an opportunity for all of us medical providers and parents, to make a difference. From the medical provider, from our point of view, by incorporating shorter courses of antibiotic therapy when it's clinically appropriate, we can be stewards of antibiotics. 

And parents, by asking about the possibility of shorter duration therapy and then giving your child's provider the opportunity to explain why they're choosing one length of treatment over another. But it's good to ask the question and find out if this is a case where maybe we could get by with a shorter duration of antibiotic. 


Now, one particular disease which provides us with immediate opportunity for making an antibiotic stewardship positive change in our practice is acute otitis media, otherwise known as the middle ear infection.

The American Academy of Pediatrics released a clinical practice guideline in 2013 called the Diagnosis and Management of Acute Otitis Media. And I'll put a link to that in the show notes for this episode, 451, over at pediacast.org. 

That clinical practice guidelines states that the antibiotic of choice is high dose amoxicillin, unless, of course, that's been used in the past 30 days or the patient is allergic to penicillin antibiotics. And recommended duration of therapy for non-severe acute otitis media, so middle ear infections, for kids who are less than two years of age, it's ten days of treatment. 

For those who are two years of age to five years of age, it's seven days of treatment. And for those who are older than five, it's five to seven days. 


So shorter duration, it's not necessarily ten days for everyone like it has been in the past, but we want to say if it's non-severe ear infection, they're less than two years, go ahead and do the ten days. From two to five years of age, cut that back to seven days. And if they're over five years of age, you could do five to seven days. 

So what do we mean by a non-severe ear infection? Well, a severe ear infection will be considered if there's a fever more than a 102 degrees Fahrenheit, so not a 100.2 which is not really a fever, but a 102 degrees Fahrenheit. That would be considered a severe ear infection. Or if the ear pain is really bad, it is severe. So it's not a little discomfort, it's not mild, it's not moderate, it is severe. 

And those kids with the higher fever and severe pain regardless of their age, just go ahead and give them ten days of treatment. But for everyone else with non-severe ear infections, again less than two years of age, ten days of treatment. Two to five years, go down to seven days. And if they're over five, five to seven days. 


So why am I making a big deal about this, especially given that guideline has been around since 2013? Well, many medical providers continue to prescribe amoxicillin for ten days for all comers regardless of the severity of their disease or the age of the patient. And that's usually from either a lack of awareness of these guidelines or simply out of habit. 

And if that describes you as a provider that's listening to this program, no worries. Until recently, it described me, too. And until we had an educational push within our institution, it described many of my colleagues as well. 

But if we want to be good antibiotic stewards and collectively make a difference in reducing bacterial resistance to antibiotics and the excessive killing of our good gut bacteria, along with reducing possible side effects and complications, if we want to lessen all of these things, reduce them, one easy action is to reduce the length of therapy for kids over the age of two who have non-severe symptoms with their ear infection, which ends up being a lot of kids.


Couple other quick notes, you're going to hear this message again because I think it's an important one, not only for providers but also for parents as you advocate for your child's health. I will provide a link to the AAP Clinical Practice Guideline, the diagnosis and management of acute otitis media so you can read it for yourself. 

We also have an excellent blog post on the subject which you can share with patients, families, friends, online, on social media, by email, that sort of thing. It's called Ear Infections: Why Kids May Not Need 10 Days of Antibiotics. 

And for the doctors and other medical providers in the crowd, would you please consider taking our very brief... We're calling it a five-minute survey. Honestly, it will take you less than five minutes, just a handful of questions regarding your preference for treating ear infections, as we explore practice patterns and try to gauge the effectiveness of educational messages like this one in the form of digital content and podcast. 


And I'll put a link to that anonymous survey in the show notes, Episode 451, over at pediacast.org. I'll put a link to the survey, that blog post and then the AAP Clinical Practice Guideline for you. 

You can also find the survey by clicking the Survey tab at the top of any page over at pediacast.org. We'll put it on our Survey page as well. It's called Survey: Length of Treatment for Ear Infections. So please do consider taking that if you are a medical provider. 

All right, let's move on. Before we get to our guests today, I want to remind you that the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.


Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

So, let's take a quick break. We'll get Dr. Kate McCracken settled into the studio and then we will be back to talk about polycystic ovary syndrome. That's coming up right after this.



Dr. Mike Patrick: Dr. Kate McCracken is a pediatric and adolescent gynecologist at Nationwide Children's Hospital and an assistant professor of Obstetrics and Gynecology at the Ohio State University, College of Medicine. Her clinical and research interest include many disorders affecting girls, teenagers, and young adult women, including our topic today, polycystic ovary syndrome. So let's give a warm PediaCast welcome to Dr. Kate McCracken. Thanks so much for stopping by today. 

Dr. Kate McCracken: Thanks for having me. It's great to be here. 

Dr. Mike Patrick: Yeah, really appreciate you taking time out of your busy schedule. So let's start with just a definition. I think it's one of those things I think people sort of heard of but really have no clue what it is.

So what is polycystic ovary syndrome? 

Dr. Kate McCracken: Sure. So PCOS or polycystic ovarian syndrome is a condition that affects many women. And it basically is a hormonal imbalance that can happen in girls and women. And really, the underlying issue is that there's an elevation in testosterone, which is a type of hormone that women make, but in polycystic ovary syndrome, that hormone is higher than normal.


And so, what happens in healthy females, typically, your ovary will release an egg or ovulate approximately once a month. But in women with PCOS, the high testosterone levels basically block ovulation. And so, that can lead to a change in periods and the higher testosterone can also lead to other sort of physical symptoms such as acne or excess hair growth. 

Dr. Mike Patrick: Is that why there are cyst in the ovary? Because normally a cyst gets made sort of as part of ovulation and then the egg is released and then the cyst goes away. So are those just times where the cyst didn't ovulate and that's why the cyst are there? Or is there some other reason?

Dr. Kate McCracken: Exactly. So it's sort of a tricky name, when people hear this name, they think, "Oh my goodness, my ovary is huge and full of cysts." But what happens with typical ovulation, like you said, is that a winner egg is chosen and that egg gets ovulated. And then, the fluid remaining around is a little fluid collection that we call a cyst. So that's a normal ovarian function once a month.


In polycystic ovarian syndrome, the testosterone level sort of stop the development of those eggs. And so, multiple eggs are stuck at the same stage of development and you get multiple little fluid collections within the ovary that make the ovaries look a certain way on ultrasound and are a little bit bigger. But it's not light there's a huge cyst within the ovary. 

Dr. Mike Patrick: So it's not really a problem with the cyst. The cyst just kind of go along with it but it does help with the diagnosis because you would be able to see those on an ultrasound. Although, as I kind of research this, it looked like sometimes, you don't see those. So you can't rule it out if the cyst aren't there. But it's just a feature of it rather than the cause.

Dr. Kate McCracken: Exactly.

Dr. Mike Patrick: Got you. And so, that increased testosterone then is going to cause lots of different issues -- and we're going to talk about those -- but first how common is that disorder and who is affected?

Dr. Kate McCracken: Sure. So PCOS is really common. Five to 10% of women of reproductive age have PCOS. And women of all races and ethnicities are at risks of it. We're not exactly sure what causes PCOS. We think there may be some genetic component, but likely, it's multifactorial. 


Like I mentioned earlier, all women make normal amounts of estrogen and progesterone and testosterone and all different hormone. But in women with PCOS, it really is the elevation and testosterone that causes the condition. 

Dr. Mike Patrick: And for some of the women, it seems like maybe there's a genetic component to it. Do we see this more sometimes running in families? You have more risk if your relatives do have this?

Dr. Kate McCracken: We do. Exactly. So women who I see in my practice, if their mother or their grandmother or an aunt has PCOS, it does raise a red flag that the patient may be at risk for PCOS. 

Dr. Mike Patrick: And then, along with the increased testosterone, we also can see -- and I've mentioned this in the intro -- but things like obesity and insulin resistance, Type 2 diabetes, those kind of things. But are those caused from PCOS? Or do those things make it more likely that you'll... Sort of which came first, the chicken or the egg? 


Dr. Kate McCracken: Right. That's a little bit tricky to answer. So we do know that women who have insulin resistance where their body isn't responding to insulin in a typical way are more likely to have PCOS. Obese women are more likely to have PCOS. But there are many women with PCOS who are abnormal weight and still have the features of PCOS and actually have the diagnosis.

Dr. Mike Patrick: So what causes the increase in testosterone? And I think people would be like, "Women make testosterone? I thought that was a male hormone." But there is usually a small amount that's normally made, right?

Dr. Kate McCracken: Right, yeah. So all women have a small amount of testosterone. We don't know why that switch is flipped in PCOS women that they make higher levels of testosterone, but that is the underlying driving force for all of the features of PCOS. 


Dr. Mike Patrick: Some ideas of why that may happen? 

Dr. Kate McCracken: I think we know that obesity probably plays a role in it. I think we know that women hormone are maybe predisposed for insulin resistance may play a role in the development of that. But I don't think we have an answer, and there's certainly not a genetic test that we can do to say, "Oh, you're likely to get PCOS or you're not." 

Dr. Mike Patrick: And it seems like it could be... And please correct me if I'm wrong because I am not an expert on this at all. But it seems like it's one of those things that there are multiple things that could end up make more testosterone which then would lead to PCOS. 

But from genetics, so you're kind of programmed to make more and maybe there's an environmental hit when the baby's growing in mom's uterus. You know, maybe there's an environmental thing that happened. And so lots of different things could kind of lead down that same path, which makes it then harder to understand what the inciting event is because they're different ones. 


Dr. Kate McCracken: Exactly, exactly. Yeah, exactly. And thanks for bringing up the enterouterine environment. So we do know that babies who are larger for gestational age when they're born are maybe more at risk later for obesity and for PCOS. And so, all of those things, there's probably some complex mechanisms that we don't yet completely understand but leads to the possibility of PCOS.

Dr. Mike Patrick: And then, some folks especially if you... Because I'd start with a Google search so I'm seeing what parents are seeing when they look this up. And one of the things is BPA and plastics and is that a hormone disruptor? And could that somehow play a role? But the answer is really, "We don't know," right? 

Dr. Kate McCracken: We don't know, right. Certainly, there is a genetic component and certainly there is an environmental component. But I don't think we've teased out exactly what those things are yet. 

Dr. Mike Patrick: So let's move on then to signs and symptoms. What are the things that we see with polycystic ovary syndrome that would make a parent as they think about their teenage daughter like, "Hmm, maybe we should think about this?" What are some of those symptoms that would make you think about this?


Dr. Kate McCracken: So the hallmark of PCOS is menstrual irregularity, in combination with signs of high testosterone. So when you have that higher testosterone level and you're not ovulating or letting that egg out of your ovary regularly, you're not getting the downstream signal to have a regular predictable shed of the uterine lining. 

And so, you often have this sort of dysfunctional period pattern when you may have months without periods. You may have months where you have two periods in a month. Sometimes, people have frequent bleeding or heavier bleeding. So it's a disruption in the normal menstrual cycle pattern. 

And then, along with that, the other things that testosterone drives such as development of acne on the face or the chest or the back. And then, sometimes too much hair in places that we think of more of a male hair pattern. So hair on the upper lip, or the side burns or the chin.


We also think about obesity. But certainly, that doesn't rule out PCOS if your daughter, if the patient is thin. And then, there can be some darkening of skin creases. And we call that acanthosis nigricans. And that's where it's a hallmark that your body is working harder to process insulin. And so, as to the response to insulin, so it's an insulin resistance marker. And that's where you can have sort of a discoloration or darkening of the skin on the back of the neck or in the groin or under the breast. 

Dr. Mike Patrick: The periods are going to be, I think for a lot of families, sort of the first thing I would think that kind of brings this to attention. And the other things maybe a little bit more subtle where you kind of just say, "Well, that's going to get better. Your acne is bad now but a lot of people have bad acne." 

What I find interesting though is sometimes it can be heavy, more frequent bleeding, but it can also be infrequent periods.

Dr. Kate McCracken: Exactly.


Dr. Mike Patrick: And so, really anything that you feel could possibly be abnormal with periods, you're going to want to bring that to someone's attention. 

Dr. Kate McCracken: Right. So as a reproductive health care provider, we really use the menstrual cycle as a vital sign. And so, that tells us that your daughter is healthy enough to have a period, first of all. And then, once she's having periods, that she's consistently having a regular cycle. 

And so, if your daughter hasn't started her period and it's been more than three years from the onset of breast development, or if she has started her period but then all of a sudden, she has months and months without periods, that's a red flag. Or if periods are happening too frequently, that can be a red flag. 

So really, as you're having a healthcare encounter with your primary care provider or a reproductive healthcare provider such as a gynecology, really being attentive to what is the period pattern your daughter's having, which is sort of tricky in adolescence because...

Dr. Mike Patrick: Yeah, that was going to be my next question. 


Dr. Kate McCracken: Right.

Dr. Mike Patrick: What's normal?

Dr. Kate McCracken: So the first couple of years after the onset of menstruation can be more irregular. And so, we tolerate that a little bit. And in fact, we don't technically diagnose someone with PCOS if they're still within those two years after starting periods.

We can be highly suspicious that they may have PCOS or beyond that pathway, but to formally diagnose someone, you have to be over two years from the onset of periods. 

Dr. Mike Patrick: So in terms of normal, once you are two or three years out, we think 28 days. But there's still wiggle room there, right? 

Dr. Kate McCracken: There is wiggle room, right. So we specifically think anywhere from three to five weeks from the onset of one period to the next. And if you're more frequent than that or further apart than that, that would be a red flag.

Dr. Mike Patrick: So a week early, a week late, we're okay. And it's also going to be if a one-time off, you're not as concerned. But if it's something that's happening routinely, that's very unpredictable that someone know about that. 


So that's sort of the menstrual findings, but then there are skin findings. We talked about abnormal hair growth, excess of acne. And also, as you think about testosterone, increased muscle bulk or maybe deepening voice. But those aren't as common.

Dr. Kate McCracken: Those aren't as common and those would sort of be also red flags for is there some other cause for high testosterone levels? So when we're evaluating someone for possibility of PCOS, we certainly want to rule out other causes for high testosterone, such as a tumor that secretes high testosterone levels or other conditions that may be present. 

Dr. Mike Patrick: Yeah, absolutely, that makes sense. And then, there's the metabolic features that we talked about. So obesity, insulin resistance. Metabolic syndrome, what is that?

Dr. Kate McCracken: So metabolic syndrome is a constellation of findings. So it's obesity, it's insulin resistance. There can be some abnormal lipid levels or cholesterol levels. So it's sort of an overall term to look at some of these sort of global health. 


Dr. Mike Patrick: And so, just for the parents listening who maybe aren't medically savvy and you've heard of these things, insulin remember is a chemical that our pancreas makes that helps to get sugar into cells. And our cells use sugar glucose for energy. And so if we have insulin resistance, you're still making insulin, it's just not working as well at the cell level. 

So then glucose starts to back up and you get higher glucose levels, so your blood sugar would go up. If you don't have insulin, then that would be type 1 diabetes. We're talking about insulin resistance, so you're making insulin but the glucose can't get into the cells because insulin's not working right.

And so we can have then Type 2 diabetes. And then that can be associated with problems with cholesterol and your triglycerides and lipids, which over time that can all lead then into cardiovascular problems and high blood pressure and increased risk of strokes and heart disease and heart attacks, mostly in adulthood. 


But if this whole process starts during the teenage years, it's nice to kind of get a handle of it to help prevent some of those things later on. I hope I didn't oversimplify that. 

Dr. Kate McCracken: No, I think that was perfect. Spot on. 

Dr. Mike Patrick: And then, in addition to the metabolic stuff, I also had read that sleep disorder breathing, so like obstructive sleep apnea can go along with this as well. 

Dr. Kate McCracken: It can, and I think that's typically a function of obesity or being overweight. We see that more common in obese patients. So it's not a diagnostic criteria for PCOS, but certainly something that we do screen for.  

Dr. Mike Patrick: I also wanted to mention -- before we move on to our differential diagnosis and how we'd come up with the diagnosis here compared to other things that compose these problems -- the cysts in the ovaries, do those cause any discomfort?

Dr. Kate McCracken: No.

Dr. Mike Patrick: So abdominal pain is not a part of this. 

Dr. Kate McCracken: Abdominal pain is not a part of this, nope. 

Dr. Mike Patrick: Okay. 


Dr. Kate McCracken: There are many different causes for ovarian cysts and so I think that PCOS is a little bit of a silly name really for this condition. You might be more descriptive if you call that excess testosterone syndrome.

Dr. Mike Patrick: Yeah, no, that makes sense. And just historically, that's what we call it. 

Dr. Kate McCracken: Exactly, that's historically. 

Dr. Mike Patrick: But when we think about someone who has abdominal pain and discomfort around the time of their period. And then, maybe you go into an emergency room and they do an ultrasound and they say, "Oh, you have an ovarian cyst." That's not what we're talking about here. 

Dr. Kate McCracken: That's not what we're talking about. 

Dr. Mike Patrick: Those are much larger cysts.

Dr. Kate McCracken: So there are different types of cysts. They can be larger. And that would be a different condition altogether. 

Dr. Mike Patrick: Yeah, okay, that makes sense. 

And then, those can then lead to ovarian torsion where the ovary twist. And we did an episode with Dr. Jerry Hewitt, another one of our gynecologist here. That was one of our Continuing Medical Education episodes, 27. So those who are interested in polycystic ovary syndrome may also be interested in hearing about pediatric ovarian torsion. So I'll put a link to that in the show notes for this episode over at pediacast.org. 


But ovarian torsion is not a risk with PCOS?

Dr. Kate McCracken: No. 

Dr. Mike Patrick: Okay. So in terms of this constellation of symptoms, there must be other conditions that could sort of mimic this. What are some of those? 

Dr. Kate McCracken: Sure. As I mentioned, when we're thinking about PCOS, we're thinking about this high testosterone level. And we really want to make sure that we're not overlooking another condition that could actually be causing the high testosterone level. So there are certain types of tumors or masses that may cause excess testosterone production.

There are certain conditions such as congenital adrenal hyperplasia, which is an endocrine condition were there can be hormone imbalance and we'd want to rule that out. That's typically diagnosed in patients who are young, diagnosed in infancy. 

It would be sort of a non-classic presentation, to congenital adrenal hyperplasia to diagnose in adolescence, but it is part of our evaluation when we're working someone up or diagnose anything. 


Dr. Mike Patrick: Yeah, to make sure they don't a have tumor that's leading to this.

Dr. Kate McCracken: Exactly.

Dr. Mike Patrick: The thyroid gland, what about that one? 

Dr. Kate McCracken: So the thyroid gland is a gland that's in your neck and it produces hormones and that can make menstrual irregularities. So again, when we're screening for this, checking your thyroid function which is checked by a blood test, doing an exam where we feel the thyroid, that is part of our evaluation. 

Dr. Mike Patrick: And then, I had come across that those with seizure disorders, there are certain seizure medication that could also possibly be related to this.

Dr. Kate McCracken: Right. 

Dr. Mike Patrick: So when we think about menstrual changes or menstrual pattern changes, there's a wide variety of conditions that we think about and that we want to systematically be thoughtful to rule in or out. And seizure medications can cause a change in menstrual regularity. And also, they can, in some patients, cause weight gain which can lead to obesity, which can then lead to menstrual changes. 


Dr. Mike Patrick: And the biggest culprit in this is valporic acid or Depakote.

Dr. Kate McCracken: Correct.

Dr. Mike Patrick: And I only mentioned that because there are a lot of kids, you know, on Keppra and their parents are wondering, "Wait, is this one of them?" But really, it's the valporic acid, that's the big one. 

And, of course, anabolic steroids can also sort of mimic to what testosterone is doing. So if your child is using a supplement or getting a hold of some steroid kind of medicine, you could potentially see these same sorts of changes. 

Dr. Kate McCracken: Exactly, and it all comes back to that high testosterone level and different reasons why that may happen.

Dr. Mike Patrick: So with so many different things that could cause menstrual irregularity and obesity and possibly acne, I mean these are all pretty common things. How do you arrive at the diagnosis of polycystic ovary syndrome? 

Dr. Kate McCracken: So what we do is we first take a really thorough history and do a physical exam. And we're asking about how old were you when you started your period? What is your period pattern looks like? Are you having frequent periods or infrequent periods? Are you having heavy bleeding or daily bleeding? All of those things to get a really thorough menstrual history. 


And like I mentioned earlier, you really do, to make the PCOS diagnosis, if you're being really academic about it, you have to be two years from your first period. Because of that normal sort of irregularities that can happen within those first two years.

So we talk about periods a lot. We look at people's skin. So we look at acne. We look for hirsutism, which is that excess male type hair pattern, so upper lip hair, side burn, chin. Sometimes, on the chest or the abdomen. 

And then, we typically do a lab panel which is a blood draw, where we're looking at different hormone levels. Sometimes we do do an ultrasound to look at the ovaries and the uterus. That type of ultrasound is just on a lower abdomen and it really is not uncomfortable for a patient. It's just over the lower abdomen. 


And it looks at the uterus, it looks at the size and shape. It looks how thick that lining is within the uterus. And then, it takes a look at the ovaries to make sure that there's not a mass there that could be producing testosterone or to sort of look what the follicles look like. 

And then, you use all of those data points to say, "Oh, this looks like the pattern of PCOS," before we make that diagnosis. 

Dr. Kate McCracken: Absolutely.

Dr. Mike Patrick: And then, once you do arrive at this diagnosis, how do you go about treating this disease?

Dr. Kate McCracken: It's a great question. So really the goal of treatment I like to break down when I'm talking to families, is we want to address the menstrual side of things. 

And that really is to protect the uterus, because what we don't want to have happen is we don't want that lining with the uterus to get overthickened. That could lead to really heavy periods, really long periods. And that, over decades, so not during adolescence but over decades, if you have this irregular menstrual pattern, that does increase the risk of cancer within the uterus. 


So I don't want anyone to feel nervous that that would happen during the teenage years, but we're being thoughtful about protecting the uterus and preventing that lining from getting overthickened. 

Dr. Mike Patrick: Because this is one of those life-long issues. 

Dr. Kate McCracken: It's one of those life-long conditions, right. And so, that's one thing. And then, we want to address the other high testosterone features, such as helping the patient have acne treatment or reducing the amount of unwanted hair growth and really, really focusing on maintaining a healthy weight and a healthy lifestyle and diet. 

So when I talk to patients, I sort of break it into those categories, getting regular exercise, trying to maintain a healthy body weight, following a healthy diet. That's the mainstay of any sort of PCOS management. 

Dr. Mike Patrick: You know, when you're talking to families about that, if we think that PCOS leads to those things, and then we're going to treat those to help it, so there's kind of those circle or symbiosis of this whole thing going on. 

Dr. Kate McCracken: It is, exactly. 


Dr. Mike Patrick: But from a lot of teenagers' standpoints, they may look at themselves as a failure that they're obese in the first place. And so, you do have to kind of tie this into this is part of the diseases, it's not your fault.

Dr. Kate McCracken: It's not your fault. There are certain things that you could help modify, but no, it's not your fault. If  you have high testosterone levels, it's harder to lose weight and you have to work harder. So really working with a multidisciplinary team to say, "Let's make sure that you're making healthy food choices. Let's sort of help you figure out an exercise plan that works in your life."

Life is busy, it's hard to prioritize diet and exercise, but certainly having those conversations. So sometimes we're pulling our nutritionist and we, certainly at Nationwide Children's Hospital, have the Center for Healthy Weight and Nutrition, which is a really great partner that can help our families. 

Dr. Mike Patrick: Yeah, and as we mentioned then, I did an episode of PediaCast CME again for providers on the management of childhood and teenage obesity with Dr. Eneli, who's a director of our Center for Healthy Weight and Nutrition and Dr. Marc Michalsky of our Bariatric Surgery Program. They were both here and that was an interesting episode. So if you have an interest in that, I'll also put a link to that episode in the show notes for 451. 


In terms of the menstrual irregularities and sort of getting the hormones back into balance, what do you do for that?

Dr. Kate McCracken: Right. So what we typically do is talk about hormonal medication which when you say that, people instantly think about a birth control pill. And that is something that we frequently use. 

And so, that's a pill that contains estrogen and progesterone. And that combination of hormones essentially forces the uterus to shed a lining at a predictable time. And so, you're preventing that lining from getting overthickened. 

And the estrogen also in the pill can help increase this molecule in the blood that soaks up testosterone. And so then your body will see less testosterone and that will help with the acne and can sometimes help with the hair growth. 


Dr. Mike Patrick: And I would think if we think that insulin resistance and obesity and metabolic syndrome and Type 2 diabetes is kind of also tied in to that increase in testosterone, does that help then, the hormonal therapy help with those things, too? 

Dr. Kate McCracken: Yeah, so it can. And there's also another medication called Metformin that often people with PCOS will take. And that's a pill that you take that help of sort maintain your normal blood sugar levels. So that is helpful with insulin resistance and obesity.

Dr. Mike Patrick: I don't know, and I did not come across this as I was researching this material, but is earlier treatment of PCOS tied to better outcomes from a cardiovascular metabolic standpoint in adulthood?

Dr. Kate McCracken: It definitely is. So the earlier and the more aggressive you are with treating PCOS and maintaining that healthy body weight and making healthy lifestyle choices around diet, certainly, has long-standing impact for your future. 

Dr. Mike Patrick: So this really is an important thing... 

Dr. Kate McCracken: It is.

Dr. Mike Patrick: To diagnose in the teenage years. 

Dr. Kate McCracken: Absolutely.

Dr. Mike Patrick: And get a handle on earlier. Earlier is better. 


Dr. Kate McCracken: And we know that just from general information on obesity treatment and management. I'm sure Dr. Eneli and Michalsky talked about that. But the earlier that you treat teenage or childhood obesity, the better the long-term lifestyle outcomes are in cardiovascular outcome.  

Dr. Mike Patrick: I think we covered, I'm sorry I interrupt you so many times. 

Dr. Kate McCracken: It's okay.

Dr. Mike Patrick: Did we cover all of the treatment stuff? 

Dr. Kate McCracken: No, not yet. 	

Dr. Mike Patrick: Okay, yeah. I thought maybe we shouldn't move on yet.

Dr. Kate McCracken: The other part of the treatment is acne treatment. And so, sometimes we treat acne with topical medications, so creams that you can place on your face. The birth control pill can be helpful with acne, and then there's also...

Dr. Mike Patrick: And we should minimize that, right? 

Dr. Kate McCracken: Right, right. No, no, acne treatment is a big deal because that definitely can impact someone's self-esteem and their confidence during the teenage years. So we're really treating PCOS from multiple standpoint. I'm a gynecologist so I care a lot about obviously the uterus and the ovaries, but I certainly care about skin and hair. And those things can be really challenging for patients with PCOS. 


So when we think about acne and hair treatment, one medication that sort of affects both and can be helpful is something called Aldactone or spironolactone. That's a pill that you can take that blocks the testosterone receptor. And so, your body again is not seeing as much testosterone and so your acne and your hair can improve. 

Dr. Mike Patrick: Yeah, they're very good to know.

For folks, maybe that's actually how it comes to mind from a parent standpoint because I'm sure in some families, we're not talking about our periods, whether they're irregular or not. And so, if your daughter is having a significant acne problem, obviously, have them see your medical provider for that. But, definitely, be asking them about their period if you're noticing that, too. 

Dr. Kate McCracken: Absolutely. And there are different genetic and ethnic variation in hair. So that's something that some people have just more facial hair than others. 


And so, not everybody with facial hair has PCOS, but it's sort of the constellation of symptoms, the period irregularity, the acne, plus the excess hair that really does make us think, "Oh, could this be PCOS?" 

Dr. Mike Patrick: So some primary care providers are going to be more in tuned and have more awareness about this disorder. If you find yourself with a provider who's not taking these things seriously or is not providing a referral, can parents get their daughters in to see a gynecologist? At what age would you think about doing that? 

Dr. Kate McCracken: Oh, absolutely. So we are happy to see anybody for gynecology care at Nationwide Children's Hospital. And we see patients from birth through early 20s with our practice, which is really, really great. And so, you can just call to make an appointment.

Dr. Mike Patrick: You don't need a referral. 


Dr. Kate McCracken: It really depends on your insurance. So if your insurance requires that you need a referral, you may need one from your primary care provider. But no, there is no barrier to just you calling as a parent and asking to make an appointment with gynecology. 

Dr. Mike Patrick: Okay, good to know. In terms of the hormonal treatment, I'm sure that some parents are going to be concerned about putting their daughters on oral contraceptive medication. What are the risks associated with that and how do you navigate like risk-benefit kind of stuff?

Dr. Kate McCracken: Yeah, obviously, before we put anybody on a hormonal medication, we'd want to make sure that that was appropriate. There are some health conditions in which you can't take medication with estrogen. So as a provider, we would do part of our history is really screening for things that would be contraindications to using hormonal medication. But hormonal medication is really overall very safe. 

And so, there's really low risk for long-terms issues with hormonal medication use. It doesn't affect your future fertility so your ability to go on to have a healthy pregnancy is not impacted by using hormonal medication. We don't think there's an increased cancer risk with using hormonal medication. And so, in the majority of women, it's very well tolerated and very safe. 


Dr. Mike Patrick: One of the biggest things we think about is blood clots. And so, if your did have a condition in the family where there may be blood clots are common or blood clots in the legs or pulmonary embolism or something like that.

Dr. Kate McCracken: Yes, if the patient themselves has had a history of the blood clot in the leg or the lung, we would not want to use an estrogen containing hormonal medication if there is a known clotting disorder in the family. Again, we would not use estrogen containing methods if the patients have uncontrolled high blood pressure, if they have migraines with aura. We often say you really shouldn't use an estrogen containing methods. 

So there are some medical conditions that we'd want to avoid. But that doesn't take the option of hormonal medication off the table because there are progesterone only method that also are really helpful in PCOS. They just work differently. 


Dr. Mike Patrick: We're seeing a lot of kids vaping and that can be a high nicotine exposure. And we know nicotine can also, because it causes vasoconstriction, and so the blood vessels have a narrow diameter. So then if you have more risk of clots, that could be an issue. And I only mentioned that because in the past, you know, you think, "Well, my kid's not smoking cigarettes," but these vaping products have really high levels of nicotine in them. 

Dr. Kate McCracken: It's totally true and so I think it's part of our job as the provider is really making sure that we understand what our patient's doing. And in teenagers, sometimes, talking confidentially to the patients themselves about what are you doing so we can understand, "Are you vaping, are you smoking cigarettes?" This is a real deal and this is why it's important that we know that information.

As a reproductive healthcare provider for adolescents, confidentiality is a big part of what I do. And so, we're very used and very comfortable to having those conversations. 


Dr. Mike Patrick: And then, sometimes you see some side effects that folks will think, "Oh, these are going to last a long time," and they may not have compliance, may not take their medicine. But a lot of the side effects like nausea and headaches and mood swings are usually short-lived, right?

Dr. Kate McCracken: They're usually minimal and short-lived. And most women who are on hormonal medication don't have those side effects at all. I think it's really the infrequent case. 

Dr. Mike Patrick: Yeah, and then from the teenager's standpoint, "Oh, I'm on a birth control pill." We still have to think about sexually transmitted infections and let them know that it's not going to protect them from that. And so, barrier is still important.

Dr. Kate McCracken: Yeah, so making safe decisions about sexuality is super important. And we always talk about that, "Just because we're starting you on a hormonal that it is a birth control medication, it's not necessarily saying that you should go become sexually active if you are not. And we still, if you are sexually active, want you to use barrier method such as condoms or dental dams to reduce the risk of sexually transmitted infection acquisition or getting an STD." 


And so, we have those safe sex talks all the time.

Dr. Mike Patrick: Great.

Dr. Kate McCracken: And we also talk about how well hormonal medication works to prevent pregnancy, right? Because there are certain methods like the intrauterine device, so the contraceptive implant, the Depo shot that are more effective to reduce the risk of an unplanned pregnancy compared to the birth control pills. So that's part of our counseling whenever we start somebody on a hormonal medication. 

Dr. Mike Patrick: And are those other ways that you mentioned also useful for the treatment of PCOS?

Dr. Kate McCracken: They are, so progesterone-only methods like the levonorgestrel IUD or the etonogestrel contraceptive implant, those are helpful because they reduce the thickness of the uterine lining. And so, really, we get back to the root of preventing that lining from getting overthickened. And so, it is helpful in treatment of PCOS. 

Dr. Mike Patrick: We had, and I didn't prepare this as I was getting this material together, but it's coming to mind that Dr. Berlan, one of our pediatric adolescent physicians. She was on the program and we did show on contraceptive choices in all of these things. 


And so, I'll find that and put a link to that in the show notes as well. So I think parents would find that particular episode pretty interesting as well. 

So we've talked about a lot of the complications that can arise if there's a delay in diagnosis or inadequate treatment, obviously, all these things, the weight gain, metabolic syndrome. We've talked about obstructive sleep apnea, which if you from the obesity have that and you're not sleeping well, that can affect school performance and mood disorders. So all of this is really tied into a lot of different complications. 

One of them that we haven't mentioned though is infertility. So is there a high risk of infertility in folks who have this?

Dr. Kate McCracken: Yes, so with PCOS and the high testosterone levels, it does prevent regular ovulation. So not everybody with PCOS will struggle with getting pregnant. But certainly those with PCOS do have a higher risk of needing help getting pregnant because they're not ovulating per se at a predictable time or regularly. 


And so, while there are many, many different causes of infertility, PCOS can be one of them and it's one of the most common. 

Dr. Mike Patrick: And once you get them on hormonal therapy, does that automatically improve fertility or is there some other underlying thing that even when it's treated you could still have infertility problems. 

Dr. Kate McCracken: So even when it's treated, you can still have infertility issues and that all comes back to are you ovulating regularly and at the right time to conceive a pregnancy, to become pregnant? But that being said, many women with PCOS do get pregnant without any difficulty.

So if you have PCOS, don't think of it as a contraception or a birth control option. If you're sexually active and you're not wanting to be pregnant at that point, you still do need to use a birth control method. 


Dr. Mike Patrick: And maybe that this is purely speculation on my part, but we talked at the beginning that there are different things that lead to PCOS. And so, maybe the difference between women who have more fertility problems than others, maybe because it's because there's some other initiating things that would be more likely to result in infertility. But again, we don't know anything.

Dr. Kate McCracken: We don't know. It's certainly possible. 

Dr. Mike Patrick: This is my scientist mind thinking, I don't know how you test that.

Dr. Kate McCracken: Sure.

Dr. Mike Patrick: And then in terms of long-term outlook for those affected by this, we mentioned you're going to have this issue probably your whole life. But then, at some point, is it not a problem anymore? 

Dr. Kate McCracken: Right, so long term, we think that once you're diagnosed with PCOS, you do have that. And really, we're focusing on managing it. And so, long term, the biggest thing that you can do as a patient to reduce your long-term risk associated are maintaining a healthy weight and choosing a healthy diet. 

And then, this really is a condition of the reproductive years. So once you're post-menopausal, things are a little bit different. 


Dr. Mike Patrick: And then, in terms of here at Nationwide Children's Hospital, kind of walk of us through what treatment for PCOS looks like in terms of the different resources that you have at your disposal. I mean, one of them you mentioned was the Center for Healthy Weight and Nutrition. But your really do take a multidisciplinary approach, right? 

Dr. Kate McCracken: We definitely do. So we, as the Gynecology team, work with the Endocrinology team. We work with Adolescent Medicine. We work with the Center for Healthy Weight and Nutrition. We work with Individual Nutrition Services. 

So once we see a patient and we make that diagnosis of PCOS, we treat as multidisciplinary. And we focus on "Let's look at those periods. Let's treat acne." We may need to loop in our dermatology friends to help with acne treatment. Sometimes we refer patients for hair removal with laser therapy or electrolysis, and looking at the hair standpoint. 


But we are very open to working with other disciplines and what we really want  is for the patient be completely treated for their PCOS.

And everybody is different, so we really individualize that therapy. Someone's who's maybe earlier with PCOS isn't necessarily as worried about the contraceptive efficacy or how well a birth control method works when they're making a decision on what hormonal method is that they want to use for their PCOS ovary syndrome treatment.

People who are older may take that into consideration. As we're transitioning some of our patients on to adult providers, we link them with infertility specialist if they are thinking that they may want to get pregnant or if they're already been trying to get pregnant and they're struggling. So I think we really do individualize the therapy here. 

Dr. Mike Patrick: And it's so great to have all the different disciplines that you really can tap into and utilize just right here on campus. 

Dr. Kate McCracken: Absolutely. 

Dr. Mike Patrick: So great. What are some of the other disorders that Pediatric and Adolescent Gynecology takes care of here at Children's?


Dr. Kate McCracken: Yeah, so as you mentioned there are two gynecologists here, so Dr. Geri Hewitt and myself. And we have a wonderful nurse practitioner, Dana Lenobel. And we all see patients and we all treat a wide spectrum of gynecologic conditions. So we take care of kids from birth to mid-20s and we see patients at main campus and the other satellite locations. 

And commonly, we treat heavy periods. We treat painful periods. We treat endometriosis which is a condition that can cause pelvic pain. We surgically manage ovarian masses or cysts or tumors. We deal with uterine anomalies or maybe a different shaped uterus or any sort of vaginal issue. 

We often commonly treat vaginal discharge, little girls with discharge and itchy bottoms or skin conditions that affect the vulva. We also provide reproductive care for girls with developmental delay or special needs and help them manage their periods. We do a lot around menstrual management, birth control, safe sexuality.


And some of the other multidisciplinary teams that we work with, we work with the THRIVE team here which is a team that works with individuals with gender concerns or differences in sexual differentiation. We work with the Fertility Team at Nationwide Children's and we also work with the Center for Colorectal and Pelvic Reconstruction. 

Dr. Mike Patrick: We are really happy that the two of you are here at our hospital.


Dr. Mike Patrick: And I'm sure that you keep very busy, too, as well. 

Dr. Kate McCracken: We do. It's great, we're happy to be here.

Dr. Mike Patrick: I will put a link to Pediatric and Adolescent Gynecology at Nationwide Children's Hospital so folks can read more about your program. I'll also have a link to more information about polycystic ovary syndrome. I had mentioned several podcasts that sort of relate to this area. I'll put links to all of those things in the show notes for this episode, 451, over at pediacast.org. 


So Dr. Kate McCracken, pediatric and adolescent gynecologist here at Nationwide Children's Hospital, once again, thanks so much for spending some time with us. 

Dr. Kate McCracken: Thanks for having me. 


Dr. Mike Patrick:  We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. 

Also, thanks to our guests, Dr. Kate McCracken, pediatric and adolescent gynecologist here at Nationwide Children's Hospital. 

Don't forget, you can find PediaCast in all sorts of places, really, wherever podcasts are found. We are in the Apple Podcasts app, Google Play, iHeart Radio, Spotify, SoundCloud and most mobile podcast app for iOS and Android.

We're also a proud member of the Parents on Demand Network, which you can find at parentsondemand.com.

We also have that landing site, pediacast.org. You'll find our entire archive of past programs, also our show notes for each one of those episodes, transcripts for many of them if you like to read through the content, and our handy Contact page, and of course, that Terms of Use Agreement which is very important.

The Contact page, if you do have an idea for the program, you have a question for me, you want to point me in the direction of a news article or something's that's in the news you're hearing about -- like corona virus for instance, no one's asked about that -- if you do have a question, please use the Contact page and let me know what it is. 

Reviews are helpful wherever you listen to PediaCast. We always appreciate when you take a moment to share your thoughts about the program.

And, of course, we love connecting with you on social media. You will find us on Facebook, Twitter, LinkedIn and Instagram. Simply search for PediaCast.


And, then the other things that's really helpful in terms of sharing this program with friends and family is really just word of mouth. Just tell them, when you get together face to face, let them know, "Hey, you have young kids or you're expecting a child, or you take care of kids?" maybe a babysitter, let them know we do have this program that can help them understand child health and perhaps take care of the kids in their lives a little bit better. 

Also, please let your child's medical provider know, their pediatrician, their family doc, nurse practitioner, whoever it is that's taking care of your child's health, please let them know about the programs. They can share it and listen themselves and share it with their other patients and families. 

And while you have their ear, let them know we have a podcast specifically for them as well. It's called PediaCast CME. That stands for Continuing Medical Education. It's similar to this program. We turned up the science up a couple notches and offer free Category I Continuing Medical Education Credit for those who listen. 


Shows and details for that program are available at the landing site for that one, pediacastcme.org. And that program is also in Apple Podcasts, iTunes, Google Play, iHeart Radio, Spotify, and most mobile podcast apps. Simply search for PediaCast CME.

Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.


Announcer 1: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

Leave a Reply

Your email address will not be published. Required fields are marked *