Friday, November 2, 2018

The High Price of Multiple Cesareans


A recent study once again reinforces the message that the more cesareans are done, the higher the risk for complications.

In previous posts, we have mostly discussed cesarean risks in terms of future pregnancies. We have written about Placenta Accreta Spectrum several times here already. This is where the placenta implants too deeply into the uterus. This is a life-threatening potential complication of pregnancies after cesareans, and the risk goes up with the number of prior cesareans. 

However, the risks with multiple cesareans aren't limited only to future pregnancies.

This new study highlights that the risk for other problems occurring during and after surgery also rises with the number of prior cesareans. The study found that: 
  • After 2 cesareans, the risk for organ injury and hysterectomy increased
  • After 3 cesareans, the risk for hemorrhage (massive bleeding) and surgical site complications increased
Injuries to organs around the area are serious because they usually involve the bladder or intestines. The more abdominal surgery someone has, the greater the risk for adhesions, scar tissue that can cause internal organs to stick together. This can make it difficult to operate in the area without causing collateral damage to organs nearby. If organ injury occurs, it can have lifelong consequences for the mother's urinary and/or G.I. system. Even if organ injury does not occur, adhesions alone can cause significant pain. For some people, it causes life-long severe pain. 

Obviously, the risk for major bleeding increases with surgery. Each successive surgery takes longer because of the scar tissue, and that increases the risk of hemorrhage even more. Some women need blood transfusions during or after the surgery. Many suffer problems with anemia, which can affect milk supply. Those with very severe hemorrhages may even experience Sheehan's Syndrome, life-long endocrinological problems because severe bleeding affected the pituitary gland. 

The risk for completely losing your uterus (hysterectomy) also increases with more cesareans. This is usually due to cases of accreta or in response to severe bleeding. The placenta cannot detach properly with accreta, or the uterus doesn't clamp down properly during surgery and the bleeding can't be stopped. Often the only way to keep the mother alive may be to take her uterus out, forever altering her fertility. . 

In addition, surgical site complications increase with each surgery. These can include infections, which can go septic and spread to the entire body. Although rare, some women die due to infections after cesareans. Others lose their uterus. Other surgical complications include seromas and hematomas (pockets of fluid or blood around the wound), and the surgical wound not healing (dehiscence). While these can be treated, they often cause long-term wounds and a painful recovery. They complicate recovery and make mothering difficult.

The Take Away Message

Sometimes when cesareans are questioned, people get all defensive. Mothers who had their babies by cesarean may feel like they are being judged or that some may think them less of a mother because of their cesarean. Doctors may feel defensive and point out the many times that cesareans have saved lives.

That's not what this is about. This is not about any one person's cesarean or a judgment about whether that cesarean was necessary or lifesaving. This is a public health issue about the overuse of cesareans and the potential consequences of that. The take away message here is:
All of the potential complications of cesareans need to be taken more seriously and cesareans used only when truly necessary. 
Cesareans are not evil. They can be a wonderful, life-saving intervention, and no one should feel like less of a mother because they had a cesarean. However, cesareans do carry risk. When overused or done without need, they can cause severe problems and even death, especially when multiple repeat cesareans are being done. 

National Public Radio has been running an excellent series on maternal mortality in pregnancy, as well as on near-misses (where the mother almost dies during or just after pregnancy), that highlights many of these complications: 
...according to the CDC, the rate at which women are suffering nearly fatal experiences in childbirth has risen faster than the rate at which they're dying. Based on the rate per 10,000 deliveries, serious complications more than doubled from 1993 to 2014, driven largely by a fivefold rise in blood transfusions. That also includes a nearly 60 percent rise in emergency hysterectomies — removal of the uterus and sometimes other reproductive organs, often to stem massive bleeding or infection. In 2014 alone, more than 4,000 women had emergency hysterectomies, rendering them permanently unable to carry a child. The rate of new mothers requiring breathing tubes increased by 75 percent, as did the rate of those treated for sepsis, a life-threatening inflammatory response to infection that can damage tissues and organs. 
"These numbers are really high, and far too many of them are preventable," said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative and a national leader in efforts to reduce maternal deaths and injuries...
...more than 135 expectant and new mothers a day — or roughly 50,000 a year, according to the Centers for Disease Control and Prevention — endure dangerous and even life-threatening complications that often leave them wounded, weakened, traumatized, financially devastated, unable to bear more children, or searching in vain for answers about what went wrong.
Although certainly not the only factor in the rising rate of complications, many of these near-death and fatal experiences begin with cesareans. The same NPR article noted:
Only about one-third of U.S. C-sections are medically justified, according to [Eugene]  DeClercq, the Boston University maternal health expert. A web of factors explains the rest, including hospital culture (C-section rates vary widely from one institution to the next); efforts to make childbirth more convenient (C-sections can be scheduled); and indirect financial incentives. Because C-sections normally take much less time than vaginal deliveries, they are more cost-effective for hospitals and providers. Additionally, several studies point to the influence of "defensive medicine," a term for doctors' fears of being blamed by their patients for not having done everything possible to avoid medical problems.
The culture of cesareans is strong in many hospitals, and as a result many unnecessary cesareans are being done. And once a woman has had a cesarean, she is often pressured into further cesareans by doctors who say Vaginal Birth After Cesarean (VBAC) is "too risky." But the fact is that multiple repeat cesareans are not risk-free either. Both VBAC and Repeat Cesarean have risks to mother and baby that must be carefully weighed. It should be up to the mother to decide which choice to pursue.

Research is clear that taken as a group, cesareans are not risk-free and should not be taken lightly or done routinely. 



References

Am J Perinatol. 2018 Oct 29. doi: 10.1055/s-0038-1673653. [Epub ahead of print] Risk of Maternal Morbidity with Increasing Number of Cesareans. Sondgeroth KE, Wan L, Rampersad RM, Stout MJ, Macones GA, Cahill AG, Tuuli MG. PMID: 30372778
OBJECTIVE: To estimate the risk of perioperative morbidity with increasing number of cesareans. STUDY DESIGN: We conducted a retrospective cohort study from 2004 to 2010. Patients delivered by cesarean were included. Outcome measures were a composite organ injury (bowel or bladder), hysterectomy, hemorrhage requiring transfusion, severe morbidity, or surgical site complications... RESULTS: Of the 15,872 women in the cohort, 5,144 had cesarean delivery: 3,113 primary, 1,310 one prior, 510 two prior, and 211 three or more prior cesareans. There was a significant increase in organ injury, hysterectomy, and surgical site complications with increasing number of cesareans. In multivariable analysis, the risk of organ injury and hysterectomy was increased compared with primary cesarean after two prior cesareans, and after three or more cesareans for hemorrhage requiring transfusion and surgical site complications. CONCLUSION: The risks of organ injury and hysterectomy are increased after two or more prior cesareans, and risks of hemorrhage and surgical site complications are increased after three or more cesareans.
Arch Gynecol Obstet. 2017 Feb;295(2):303-311. doi: 10.1007/s00404-016-4221-8. Epub 2016 Oct 21. Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section. Arlier S, Seyfettinoğlu S, Yilmaz E, Nazik H, Adıgüzel C, Eskimez E, Hürriyetoğlu Ş, Yücel O. PMID: 27770246
PURPOSE OF INVESTIGATION: We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity. MATERIALS AND METHODS: We  analyzed intra-abdominal adhesions of 672 patients. RESULTS: Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively. CONCLUSIONS: Emergency operations and adhesions increased complications.

Thursday, October 25, 2018

Remaking Jam That Didn't Gel


I've been preserving and canning food for a while now. I'm no expert but I've had pretty good luck so far with applesauce, chutney, jellies, and all kinds of jams.

Until now.

Yep, I just had a couple of large batches of jam fail spectacularly.

The Backstory

This summer we had a HUGE crop of plums in our yard from just two plum trees. Stupendously big crop. SO. MANY. PLUMS.

We gave plums away, we dried plums, we made plum chutney, we made plum sauce, we made plum pies. And still we had plums coming out our ears.

So we decided to try to make plum jam. This is not a jam I'd ever made before. A friend made me plum jam from a different type of plum a few years ago and I didn't like it at all. Thus, we'd never tried plum jam with our plums...but we were ready to try anything to get rid of all these plums!

So we made a few successful batches of plum jam, and I tried a little on toast one day. WOW. I was so surprised. I loved this plum jam. I think the difference was ours was made with Italian plums which makes a delicious, thick, extremely flavorful jam. I immediately knew I'd be making more.

We finished picking all the rest of the plums...we got like 3-4 big buckets more. So we decided to make several batches of jam, using up the last of the regular pectin (Sure-Jell) in my cupboard. The first batches went well, no problems. The last batch, though, was a full-sugar recipe (which I rarely use because I find it too sweet). But I was out of my preferred pectin, and I'm loathe to waste food. So we winced and made full-sugar plum jam. We thought we followed all the directions correctly, but in the end it never gelled.

So now I had a whole bunch of jars full of plum syrup. This is not something I am likely to use. I have some raspberry syrup from a batch of raspberry jelly that didn't set up a couple of years ago and we are still trying to use it up. Mostly we add it to lemonade to make Raspberry Lemonade, but it doesn't take much so it takes forever to use up. All those jars of Plum Syrup were never going to get used.

So I thought, let's see if we can remake that jam and get it to set up properly.  I'd never done this before so I did a little research and found some articles online.

Keep in mind, the information below is pertinent only to jams with an added pectin like Sure-Jell (either the pink box or the yellow box).

Cooked jam without any added pectin is another story entirely and not covered here; Food in Jars is a good website for that type of jam. Directions for remaking jams with Pomona Pectin can be found on the Pomona Pectin website.

General information about different types of pectins and the pros and cons of each can be found in my article on pectins. This article gets a lot of online traffic so hopefully people are finding it useful.

Why Gelling May Fail



When it comes right down to it, making jams and jellies is really a chemistry experiment. Certain reactions are needed in order to make gelling action happen. Basically you cook up mashed fruit, then add a certain amount of sugar, acid, and pectin in order to make those reactions happen. Get the balance right and you get lovely jam or jelly. Get the percentage wrong and you get a runny mess.

Fruits naturally have some pectin in their cell structures, especially in the skins and seeds. The goal of cooking the fruit is to break down the pectin in the individual fruit so it can then build a mesh with the pectin from other fruits. This makes a gel where fruit bits are suspended in a latticework of pectin.

The problem is that pectin molecules repel each other. Acidity is needed to overcome this and let pectin molecules bond with each other to make the lattice structure. Sugar is needed to bond with the water so the water doesn't overwhelm the pectin. So all of these, heat, sugar, acid, and pectin, are needed in just the right amounts and timing to make jam or jelly.

Here is a quote about the process from a science blog:
The whole chemistry of jam making is all about making this pectin that's in the fruit break down and become water soluble. That then recombines, and all of those hydrogen bonds that are holding it together recombine in a chemical reaction with the fruit acid and with the sugar, and that makes a lovely network that forms a gel, and that's the kind of jelly-like substance of jams. 
So you need to get that chemical reaction right, the pectin amount right, the fruit acid right, and the amount of sugar right so that you make the right consistency of that network that will hold your jelly together, your jam together, so you don't get fruit sauce.
Fruits that are naturally high in pectin and acidity like quince, underripe apples, red currants, cranberries, and gooseberries are an exception. They often don't need anything except cooking in a little water to set up and gel.

Here are a few reasons why an added-pectin jam of most other fruit may fail to set up/gel:
  • Not enough acidity - Some fruits have enough acidity on their own to gel without adding lemon juice, but most fruits need added acidity via lemon juice, lime juice, vinegar, or other acids. If you didn't add enough acid, the fruit won't gel
  • Not enough sugar - Box pectin jam recipes should not be altered. If you use less than the full amount of sugar, the jam will not set up. Therefore, follow the recipe on the box and measure exactly; don't try to make it "healthier" by using less sugar. The recipe depends on that exact amount of sugar. The exception is Pomona Pectin, which uses a type of pectin that doesn't need sugar to activate it; it uses calcium instead. If you want to reduce sugar in jams, use Pomona Pectin, but remember that most jams need at least some sweetener for the sake of taste 
  • Too much water added - Using too much water to cook the fruit can throw off the balance of pectin, acid, and fruit. Use only enough to keep the fruit from burning 
  • Doubling a batch or making too large a batch - Jam batches need to be made one at a time, no more than 4-6 cups of fruit at a time. You can't double a batch and expect it to set up properly. One of the annoying things in jamming is having to make and clean up each batch separately. But that's better than having to throw it all away!
  • You didn't get a hard enough boil - Added pectin needs a hard boil of about a minute in order to activate properly. If you didn't boil the pectin long enough, the gel may fail. If the pan boiling the fruit plus pectin was too deep, then the heating may be uneven, affecting the gel
  • Cooked too long - Some jams turn out runny because they were boiled too long. Overcooking can destroy the ability of the pectin to sustain its structure
  • Using over-ripe fruit - The riper the fruit, the less acid and pectin it contains, and the runnier the resulting jam. If you use very ripe fruit, either add more pectin and acid or add some under-ripe fruit to balance the batch. Another choice can be to add in fruit naturally rich in pectin and acid like the ones listed above if you don't mind the extra flavors in your jam 
  • Pectin too old - Some types of pectin lose their effectiveness if not used within the first year. Pomona Pectin does not have this issue but it's the only one that is reliably long-lasting
  • Leaving the jars in hot water too long - If you put the jars into the canning pot too soon, before the water has boiled, the total exposure to heat may become too much and break down the pectin structure. Likewise, if you leave the jars in the hot water too long afterwards, that can also break down the pectin. After the 10 minute canning time and the 5 minute rest time afterwards in the canning pot, take the jars out immediately and place on a towel on the counter
  • Tipping the jars - Some resources say that tipping the jars to the side as you take them out of the canning pot (or while they are cooling on the counter) can destroy the pectin bonds that are trying to form. Pick jars straight up out of the canner and leave them on the counter. Resist the temptation to tip them and check the set until at least 24 hours have passed 
  • Not waiting long enough - Some jams with some pectins don't set up for a long time, even a week or two. You can always just let them set on the counter and see if the gel improves
Bottom line, if your jam didn't set up, the most likely cause is that you were out of balance with your sugar/acid/pectin, or you didn't cook it for the right amount of time. However, there are a few other nitpicky mistakes that even experienced jammers can make. If you have a significant jam failure, review the list and see if any apply.

Remaking Syrupy Jam



Whatever caused your syrupy jam, don't throw it away. Even very experienced jammers have had batches fail, so they have certain techniques for fixing a failed gel. They don't always work but they are worth a try. The following is the most commonly recommended technique for remaking jam.

First, be sure you have everything you need ready to go ahead of time. This includes a canner full of hot water; funnels, jar-lifters, and ladles clean and ready to go; extra new lids for the jars; and enough extra sugar, pectin, and lemon juice to remake the jam.

Open the lids of the runny jam (these lids cannot be reused for canning). Pour the jam out into a glass measuring cup until it makes a total of 4 cups. Clean the old jars in soapy water and rinse, or use new clean, sterilized jars. 

Mix 1/4 cup sugar, 1/2 cup water, 2 tablespoons bottled lemon juice, and 4 teaspoons powdered pectin. Heat up until it has been brought to a rolling boil. 

Add the 4 cups of syrupy jam. Stir continuously until the whole thing has been brought to a rolling boil. Keep boiling for at least 30 seconds more, but don't overboil. 

Remove from heat, ladle into jars, put on NEW lids, add screwtops, then can in a waterbath canner for 10-15 minutes, depending on the size of the jars. Turn off heat and let jars sit in water for 5 more minutes, then immediately remove jars straight up out of the canner without tipping them. Put them on a towel on your counter overnight.  Don't check or tip them until 24 hours have passed. 

Some people report that chia seeds can be used to thicken up a runny jam, if you are open to that. Personally, I dislike chia seeds so I have never tried this but if you like them it may be worth a try.

Remain Philosophical About Results


Sometimes you can seemingly do everything right and a jam will simply not set up. Who knows what went wrong? All you can do is give it your best shot at redoing it. About half to two-thirds of the time, you can fix a runny jam. Sometimes you never do. Don't be afraid to just give up and call it Syrup at some point. Feel free to pretend that's what you wanted all along. Plenty of cooks before you have done the same!

Don't throw away your results. People use syrupy jam as toppings for pancakes, waffles, ice cream, yogurt, or desserts like poke cake. Our family sometimes adds it to lemonade to make a special drink during the summer. It can also be dehydrated into fruit leather, like above. Or you can add a little corn starch and use it as a glaze for roasted meats. It's surprisingly tasty as a glaze with pork in particular. (If that sounds weird, think about cranberry sauce with turkey at Thanksgiving. Same principle of fruit with savory.)

My first try at remaking syrupy plum jam was a mixed success. Some of it came out perfectly; no problem with the set the second time around.

However, about half of it didn't set again. Oh well. Considering how many batches of plum jam we made, that still left me with a lot more Plum Syrup than I wanted. On the other hand, we saved half the batch. I consider that a win.

I'm not quite sure why some batches failed in the original jam. My guess is we got sloppy in our measuring because of how much fruit there was and used too much fruit at once. I also think the last batch of pectin was from an older box. Also, my daughter helped, so she may have cooked it too long; I'm not sure. But at least we were able to rescue about half of the runny batches and remake them properly.

The rest of the syrupy jam we just made into Plum Fruit Leather, using both the oven and a dehydrator. Same great flavor, and at least we didn't waste it!


Resources and References

Tuesday, October 16, 2018

We Remember: Pregnancy and Infant Loss


October is Pregnancy and Infant Loss Awareness Month. I have a number of friends who have lost babies to miscarriage, stillbirth, or early death. It's more common than you might think. My heart always is heavy when I think of the babies missing in their lives, of who these babies might have become.

If you know someone who has lost a baby to miscarriage, stillbirth, or early infant death, please give them sympathy and a listening ear. Don't tell them how to feel or second-guess their situation, but just listen. If the time seems right, ask them how they are doing or offer to just hold them. They may not want to grieve in front of others, so a card or a message of love and support can be helpful yet still allow them to grieve in private. Take your cue from the mother as to what kind of support she needs. Don't assume she'll be "over it" in a month or two. That loss will likely live on in her heart forever.

We remember:
the babies born sleepingthose we carried,
but never held,
those we held,but could not take home.those who came home,
but could not stay.



Tuesday, October 9, 2018

Women Are Dying From This: Taking Cesareans Seriously


When women have cesareans, they are rarely warned that a possible complication can be placental problems in future pregnancies.

Many women (and especially higher weight women) are pressured into cesareans in their first pregnancy. Many of these same women are counseled away from Vaginal Birth After Cesarean (VBAC) and into repeat cesareans in subsequent pregnancies.

Few of these women have been told that cesareans raise the risk for Placenta Accreta, a very serious complication, and that every cesarean increases the risk for it. I know *I* wasn't told this. This is a tremendous disservice to parents and to the importance of informed consent.

About Accreta

In Placenta Accreta, the fertilized egg implants near or on scar tissue in the uterus. This scar tissue is usually from a prior cesarean, but can also be from a D&C procedure, fibroid removals, a perforation from an IUD, or any uterine surgery or instrumentation. The placenta then grows into the uterine wall in this scar tissue. After the baby is born (often prematurely), the placenta can't separate properly and bleeding can become prolific. If the bleeding is not resolved, the mother can die.

There are degrees of Placenta Accreta. When the placenta grows into the uterine wall, that's Placenta Accreta. 

When the placenta invades the muscles of the uterus, that's known as Placenta Increta.

When the placenta grows through the uterine wall and into nearby organs like the bladder, that's called Placenta Percreta. All are extremely serious conditions, but percreta is the most serious of all.

The accreta rate has risen over the years as the cesarean rate has increased. Doctors are seeing more and more cases these days of what used to be a very rare complication. Some data indicate that the accreta rate has risen from about 1 in 4000 in the 1970s to about 1 in 533 now.

You can read more about this in my blog series on Placenta Accreta.
  • Part One - What Is Placenta Accreta?
  • Part Two - Life-Threatening Complication of Prior Cesarean 
  • Part Three - Risks to Mother and Baby
  • Part Four - Diagnosis, Treatment, and a Cautionary Story
The absolute numerical risk of accreta occurring in any one person is low, even with prior cesareans. Most women who have had cesareans will not experience an accreta. However, it is such a life-threatening condition that even a relatively small incidence carries a tremendous burden of complications, cost, and potential loss of life.

The more cesareans you have had, the greater the risk for accreta. In one very large study (Silver 2006), accreta was present in:
  • 0.24% of women undergoing their first cesarean (previously unscarred)
  • 0.31% of women undergoing their second cesarean (one prior cesarean)
  • 0.57% of women undergoing their third cesarean (two prior cesareans)
  • 2.13% of women undergoing their fourth cesarean (three prior cesareans)
  • 2.33% of women undergoing their fifth cesarean (four prior cesareans)
  • 6.74% of women undergoing their sixth or more cesarean (five or more prior cesareans)
This is why it is important to avoid automatic repeat cesareans and to keep VBAC a viable choice. Multiple repeat cesareans are the single most preventable factor for accretas. 

Accreta does sometimes occur after only one cesarean, like the woman in the video below, and that's why it's important to prevent a first cesarean whenever possible as well.

One Mother's Accreta Story

This mother had only had ONE prior cesarean, but still developed accreta with baby #2. Her first cesarean was a planned cesarean, urged by her OB. She was never warned that her cesarean meant accreta was a potential risk for the future.

THIS is why the high cesarean rate matters. On a case-by-case basis, a cesarean can be a good thing. But the public health implication of a high cesarean rate is that more women will develop life-threatening complications like placenta accreta, more babies will be born prematurely, and more women will die or experience permanent damage. Sometimes even after only one cesarean.

If we want to decrease maternal mortality rates and prevent complications from accreta, we MUST decrease cesarean rates. As the mother in the video below states:
A cesarean can be a life-saving intervention. The goal is not to eliminate cesareans. The goal is to make decisions regarding cesareans appropriately, and to recognize that even an uncomplicated cesarean and recovery can still put the mother at significant future risk....


She continues:
"There are too many cesareans now, 1 in 3 births, and researchers estimate that as many as 50% of those are unnecessary. 
And since a prior cesarean is a significant risk factor for developing a future accreta, that means that there are women developing accreta when it could have been prevented. So the easiest way to reduce the amount of accretas is to reduce cesarean levels... 
Women are dying from this, and mothers are dying from this. We need to take the risks of a cesarean seriously."


Sunday, September 30, 2018

Exercise Reduces the Risk for Gestational Diabetes in Higher Weight Women

The Padded Lilies
Here is a recent research review that found that physical exercise reduced the risk for gestational diabetes (GD) in "obese" and "overweight" women during pregnancy.

Here is a summary of the research review, and also a discussion of how to use exercise and food timing and choices to keep your  blood sugar as normal as possible during pregnancy.

Quick View of Study Details

The authors reviewed 13 studies with a total of 1,439 participants. On the up side, they found that physical exercise reduced gestational weight gain and the risk of gestational diabetes (GD). This is good news.

On the other hand, exercise made no difference in the risk for blood pressure issues, macrosomia (big babies), cesarean rates, or premature births. This isn't bad news, but it does point out that exercise is not the panacea that some doctors hope it would be.

How significant are these findings? Well, it depends on the finding.

The weight gain finding is negligible. The difference in weight gain between groups was extremely small, about 1.14 kg. That's about two and a half pounds total. Not exactly a lot, and not enough to really make a difference in outcomes between groups. But doctors being doctors, you know they are doing cartwheels over even that. (Like 2 or 3 pounds makes a big difference in complication rates.)

However, the difference in risk for GD was more substantial. The relative risk of getting diagnosed with GD was 0.71 in the groups that had more exercise. That's nearly a 30% cut in risk for getting GD, which is significant. That should be paid attention to by people of size and their medical professionals.

The strength of this review was that it didn't just rely on results from one or two studies. They reviewed thirteen studies, which makes for stronger conclusions because the results are less likely to be from chance.

One weakness of the review is that 1,439 participants is a bit small for 13 studies. That means a lot of the individual studies were on the small side, and small studies run the risk of biasing the results. The review also noted that there was little information on newborn outcomes and that future studies should account for these concerns in their study design.

These are all important points. Better studies with more participants and tracking of neonatal outcome are needed. But what we have so far suggests that exercise is helpful in larger women.

Pregnancy Exercise for Plus-Sized Women

Women of size vary in their utilization of exercise. It's a myth that fat people never exercise. Some do lots of exercise, some don't do any, while most are somewhere in the middle. Here are some practical suggestions for increasing exercise in pregnant women who recognize the importance of exercise.

Exercise doesn't have to mean running marathons or even running at all. Forget the little skinny doctors who tell you that the only "real" exercise is running. Walking is one of the best exercises for pregnant folks, and it's much easier on the knees and hips. All you need are comfortable clothes and supportive shoes. Just go outside and take a walk around your neighborhood.

If your neighborhood is unsafe or not conducive to walking, walk around your yard or inside your house. Or get a second-hand treadmill or exercise bike for cheap off of eBay and use that inside.

Swimming or water aerobics is another exercise that works particularly well for women of size. While it's a pain to get in and out of a swimsuit when extremely pregnant, the buoyancy in the water is incredibly soothing to larger bodies. And water immersion has a strong beneficial effect on reducing swelling near the end of pregnancy, which can be quite helpful. Plus it just feels great! 

Water immersion can be particularly important for women with lipedema. The hormone changes of pregnancy can sometimes cause lipedema to get worse. But the pressure of having your legs underwater forces fluid back into your lymph system and helps it flow more freely. Remember, the lymph system doesn't have a pump like the heart directing it; it relies on exercise to improve lymph flow. If you have any degree of lipedema, it's especially important to be in water as much as you can. Even if you don't swim, just walking around in the pool is helpful.

Prenatal yoga can be another excellent choice. It's not as aerobic as other forms of exercise but the stretching and strengthening can be very helpful. The relaxation poses at the end of most classes are great for helping blood pressure and stress levels. And prenatal yoga classes tend to be more size-accepting and tolerant of different fitness levels than regular yoga classes.

If the weather outside keeps you from getting your usual exercise in, try walking or dancing around your house, going up and down the stairs, or some vigorous vacuuming. Even just using some cans to do a set of arm curls can help. [Don't laugh! I did all of those things during icy weather in my pregnancies, and even just vacuuming showed a difference in my blood sugar readings. These things helped me keep my blood sugar normal.]

If you haven't exercised much recently or are out of shape, start with what you can do and don't judge yourself about it. Start slowly, then increase the amount and frequency of what you are doing. Building a regular time for exercise in your daily routine is helpful. If you miss a workout, don't stress over it; just get back into it as soon as you can. Remember, any exercise is better than no exercise.

If you already exercise regularly, good for you! Give yourself props for what you are doing. Consider intensifying your routine by adding more sessions or changing up the kind of exercise you do. Keeping it fun helps keep it a part of your life.

Sometimes people sabotage their exercise by focusing on the wrong things. They compare themselves to others as they exercise, they feel self-conscious in front of others, or the peanut gallery in the brain keeps a running commentary of negative remarks. Put aside the negativity. Do what you can and don't beat yourself up about your fitness level, your looks, your shape, or whatever your personal demons are. Don't indulge in negative self-talk but instead focus on your improvement. Think or say body affirmations or pregnancy affirmations during your workouts. The repetition of positive affirmations during exercise can be powerful.

Exercise and Food for Managing Blood Sugar


As the study review shows, exercise can be an important part of managing blood sugar in pregnancy for women of size. However, there are ways to increase the effectiveness of exercise even more.

These are suggestions taken from the experiences in my own four pregnancies and from helpful advice from medical professionals to me and others. In my first pregnancy, I had a marginal glucose test result and was diagnosed with GD. I was put into a program to learn how to manage my blood sugar and given a glucometer. My pregnancy went fine and my baby was healthy, but that diagnosis made me subject to many more interventions than I truly needed. So I became determined to be as proactive as possible for any future pregnancies.

In my next three pregnancies, I never had GD again, despite being about the same size each time and getting older. I didn't change my weight or what I ate, but I did change how much I exercised and the food combination and timings of what I ate. Just doing that helped me avoid GD again, but I never took it for granted. I always considered myself borderline to be cautious, and I used my glucometer regularly every day to help make sure my blood sugar was staying normal.

If your family history (strong history of diabetes), prior medical history (prediabetes or prior GD), or medical condition (PCOS or reactive hypoglycemia) put you at extra risk for GD, then you should probably consider buying a glucometer and measuring your blood sugar regularly. That will give you information to guide you in what your "danger times" are, how you respond to various foods, and when adding exercise would be most beneficial. Glucometers are pretty affordable and can be bought at your local pharmacy. However, if money is an issue, your care provider may have one that you can borrow for free, leaving you just the cost of testing strips.

If you have a glucometer, you can see how your particular body responds to the blood sugar challenges of pregnancy. For example, some pregnant women have the most trouble after meals, while others have the most trouble with their fasting numbers first thing in the morning. The way you manage each is different.

Generally speaking, exercise intensity is less important than exercise frequency from a blood sugar point of view. It's not how hard you work out that matters most, but the regularity with which you do it.  In other words, walking even just a little every day is better for your blood sugar than a more intense workout once or twice a week. You are trying to lessen insulin resistance and make the insulin you have work more efficiently, and regular daily exercise works the best at this. Intensity is important for improving aerobic response, but frequency is the most important factor for blood sugar regulation. Try to exercise every day if possible, or at least five days a week.

Timing of exercise and smart food combinations are also important. Pregnant women tend to have several problem spots, like early mornings or after meals or certain foods. Placental hormones increase insulin resistance in order to increase the energy available to the baby. That means a meal that might not make your blood sugar high when not pregnant can result in a high reading during pregnancy. Or you get high readings from certain foods that don't normally raise your blood sugar when not pregnant.

If you find that your blood sugar is most volatile in the morning after breakfast, rest assured that this is a common problem for pregnant women. Many people do not eat protein with breakfast but consume very carb-intense breakfast meals like cereal with milk, a glass of juice and a muffin, or similar meals. Protein slows down the energy spike from a carb-heavy meal and keeps it from crashing later. So adding a protein food to your breakfast is one of the best things you can do to reduce morning blood sugar spikes. Taking a quick walk after breakfast is also great at smoothing out blood sugar spikes. Doing both (adding protein and going for a walk after breakfast) works best for blunting the post-breakfast spike common in many pregnant women.

Some women are intensely sensitive to certain foods at breakfast and can get blood sugar spikes from them in the morning, but no spikes from the same food later in the day. It has to do with the surge of placental hormones that often happens in the mornings. Some women who are especially sensitive simply cannot drink milk or juice at breakfast or even have fruit, but later in the day those foods are okay. The glucometer can help you discover whether you have problems with certain foods or at certain times.

If your blood sugar is running a little high routinely after all your meals, a couple of short walks each day after meals is helpful. Remember, shorter walks done more often is better than a longer walk every few days. If meals are your vulnerable time, then schedule your exercise times to happen after meals. Just work on getting your heart rate up for a sustained amount of time.

Avoiding heavy intake of carbs is helpful to improving blood sugar after meals. There's no need to eliminate all carbs, but avoid or minimize carb-intense foods like breakfast cereal, juice, muffins, pizza, bagels, and other obvious foods. Try to keep your carb intake to around 60g or less with each meal (a piece of bread is usually around 15g of carb). If you are not sure of the carb content of a food, look at the label. If there is no label, google it to get a general idea. If you do decide to have a carb-intense meal or snack for a special occasion, taking protein with your carbs or getting in some exercise afterwards can often improve blood sugar markedly, but don't do this often because it is easy to overdo.

Some people don't have much trouble with high blood sugar after meals, but instead have problems first thing in the morning after the overnight fast. If you have a tendency to high fasting blood sugars first thing in the morning, you need to investigate further because your approach to managing it will be different depending on its cause.

If your morning fastings are running just a bit high and you don't know why, try a substantial protein snack late in the evening and then take a short walk or workout before bed. Sometimes a little snack and exercise before bedtime is all you need to help the blood sugar normalize overnight.

Some women have high fasting blood sugar because they experience a "bounce." In other words, their blood sugar goes too low in the night so the body compensates by burning fat for energy, thus raising the blood sugar sharply to create enough energy for the baby. A side effect of going too low at night is spilling ketones, which is a by-product of burning fat for energy. A small amount of ketones on occasion is not a reason for concern, but a large amount of ketones on a regular basis is potentially risky for the baby. You can buy ketone sticks over the counter at local pharmacies if you want to keep track of that.

The best way to treat a "bounce" is to prevent it in the first place. Going too long without eating is a classic cause of a bounce. If you eat dinner at 6 the night before and then don't eat breakfast until 8 the following morning, that's a 14 hour fast. While that might be fine in a non-pregnant person, it's too long for many pregnant people. The body will respond by burning fat for energy and causing the morning blood sugar to go high. Keep your overnight fasts to 8-10 hours if you are having trouble with high fasting numbers in the morning.

Another common cause of a morning "bounce" is exercising before breakfast. You would think that this would be helpful in preventing high blood sugar, but again, it may cause you to go too low after an overnight fast. The liver produces glucagon and the body burns fat in order to give you the energy you need for the workout, but the price is that your blood sugar becomes elevated. Eating first and then exercising can solve that problem quite easily.

If you suspect you are experiencing an overnight bounce, the solution is to add a good snack before bedtime. However, the snack must be considered carefully. Adding a high-carb bedtime snack with no accompanying protein will spike the blood sugar and then make it crash in the middle of the night, setting up a bounce when the body compensates. A better bedtime snack is a protein-heavy snack with a whole-grain carb, which should give longer-lasting, more even energy that can regulate overnight blood sugar and prevent a bounce.

Some people find that they have "trigger foods" that cause high readings. For example, when I was pregnant I found that corn tended to make my blood sugar spike. I also found I could not consume cereal without a spike. If I ate protein with my cereal, it blunted the spike, but not enough for my satisfaction, so I just eliminated cereal from my intake. It was just a food I found I could not consume during pregnancy.

If you have reactive hypoglycemia (a tendency towards very uneven blood sugar), then eating protein every 2-3 hours is helpful. It keeps your blood sugar much more even and less prone to spikes and crashes. Eating protein every 2-3 hours is also great for people who are having a lot of pregnancy nausea, which is often related to unstable blood sugar. That doesn't mean it will prevent all vomiting; it won't. But it might well lessen it. Even if you throw up, go rinse your mouth, rest for a few moments, and then eat a small amount of protein. The secret is to avoid large amounts of food at once, but to graze frequently during the day, emphasizing protein foods with any carbs. That will help blunt the spike/crash cycle that can be so hard on the body and the baby. People with hypoglycemia also should eat well before their exercise routines and carry some quick energy foods with them in case they go low during exercise.

If you have tried all of these ideas and you are still getting high blood sugar numbers, you may need additional help to normalize your blood sugar. Your medical professional will help you decide whether to use medications like metformin or insulin. If you do end up needing insulin, it doesn't mean that you have failed, just that your pancreas cannot create enough insulin anymore to compensate for the insulin resistance from the increasing hormones of late pregnancy. Progesterone in particular peaks in the third trimester a month or more after the usual GD tests, so you may start out fine with dietary control and still end up needing insulin. Either way, don't feel guilty; it's just the way your body copes with pregnancy hormones.

These are just a few ideas that many women have found helpful in managing blood sugar during pregnancy. However, it's important to emphasize that not all GD can be prevented. Sometimes people still get GD no matter how hard they work at healthy eating and regular exercise. And while most people can manage their blood sugar with diet alone, some may also need medications or insulin to keep their blood sugar normal. If you get GD, don't view it as a personal failure. Just remember that with good care, most women with GD have good outcomes. Dealing with GD is just what you need to do to help give your baby the best possible start.

Take Home Message

The most important message from this review of studies is that exercise in pregnancy may be very helpful in people of size in lowering the risk for GD. 

If GD does occur, exercise plays an important role in managing the GD and minimizing its risks. So does careful consideration of food intake and timing. Getting a glucometer so you can monitor your results at home helps you manage things based on your own needs and responses. Although it's a pain to test, it really does allow you more control over the whole process and outcome.

Since doctors tend to get all uptight about gestational diabetes in higher weight women and a GD diagnosis is the beginning of many interventions, anything women can do to lower their risk for GD is potentially very helpful. Exercise is one of the most powerful interventions women can make on their own behalf.



References

Birth. 2018 Sep 21. doi: 10.1111/birt.12396. [Epub ahead of print] Effects of physical exercise during pregnancy on maternal and infant outcomes in overweight and obese pregnant women: A meta-analysis. Du MC, Ouyang YQ, Nie XF, Huang Y, Redding SR. PMID: 30240042
...The purpose of this meta-analysis was to assess the effect of physical exercise on maternal and infant outcomes in overweight and obese pregnant women... RESULTS: Thirteen studies involving 1439 participants were included. Physical exercise reduced gestational weight gain (mean difference = -1.14 kg, 95% CI = [-1.67 to -0.62], P < 0.0001) and the risk of gestational diabetes (RR = 0.71, 95% CI = [0.57-0.89], P = 0.004) in overweight and obese pregnant women. There were no significant differences in other outcomes such as gestational hypertension, preeclampsia, cesarean delivery, birthweight, large for gestational age, small for gestational age, macrosomia, and preterm birth. CONCLUSIONS: Prenatal exercise interventions reduced gestational weight gain and the risk of gestational diabetes for overweight and obese pregnant women, which reinforced the benefits of exercise during pregnancy. However, no evidence was found with respect to benefits and/or harm for infants. Consideration should be taken when interpreting these findings as a result of the relative small sample size in this meta-analysis. Further larger well-designed randomized trials may be helpful to assess the short-term and long-term effects of prenatal exercise on maternal and infant outcomes.
*For more information on troubleshooting  high blood sugar numbers with GD, read my article on it. Be aware it's from my old website (which I can no longer update), so some information is outdated, but most of it is still valid. 

Thursday, September 20, 2018

Weight-Neutral PCOS Series: A Quick Guide


This blog has an ongoing series on Polycystic Ovarian Syndrome (PCOS). Because so much information has been gathered about it, I am putting up this Quick Guide to the PCOS Series so the information is more searchable and easier to use. Keep checking back periodically. More posts will be added as they are finished.

This PCOS series is unique on the internet because it is weight-neutral. 

There are many other sites with information on PCOS, but most emphasize weight loss or strict dietary restrictions as cornerstones of treatment. (More on that below.) This series does not push weight loss or a particular diet as a treatment, but rather discusses approaches that are not weight-centric. Weight loss as an approach is mentioned on occasion because doctors recommend it so often, but it is not promoted, and its pros and cons are critically examined. No one is shamed because they do or do not choose weight loss as a treatment.

I encourage you to review many different sites on PCOS and to think critically about the information you find from them. Ultimately your treatment choices are up to you.

In this PCOS series so far you will find an introduction to PCOS as a health concern:
Many people with PCOS have high levels of insulin, so one of the mainstays of treatment is to lower insulin levels. You will find a mini-series on insulin-sensitizing medications here, including:
Other hallmarks of PCOS include high levels of androgens (male hormones) and irregular periods. Therefore I also have information on medications for these things, including:
In addition, there are articles that discuss specific conditions associated with PCOS and the treatments available for them. This includes:
  • The risk for endometrial cancer with PCOS and the weight loss dilemma
  • Hirsutism (facial and body hair in PCOS women in typically "male" patterns) 
One of the least-discussed conditions associated with PCOS is Alopecia Androgenetica (AGA, also called female-pattern hair loss or FPHL). I did a 3-part mini-series on it:
The blog also has an occasional post reviewing recent research studies on PCOS, like one on inositols for ovulation, inositols in general, or inositols for preventing gestational diabetes. Sometimes I publish an opinion piece/rant about weight bias and fertility treatment discrimination and how it impacts people with PCOS.

As more posts are added to the series, this list will be updated. Please feel free to share a link to this series on your social media platforms or on PCOS forums. As always, you may read this information for free. However, if you quote an article or use its information elsewhere, you must give credit to me and link back to the original article. I do not give permission for these articles to be reposted elsewhere. Just give a brief comment and link back to the original article with proper citation.

PCOS Sites: Caution Needed

Polycystic Ovarian Syndrome (PCOS) affects many higher weight women, but sadly many don't know they have it. Among those who do know about PCOS, there are many gaps in knowledge. Even among medical professionals who treat people with PCOS, there is a great deal of misinformation and mismanagement due to ignorance and weight stigma. There is a pressing need for good, research-based information about treating PCOS.

There are now many resources online about PCOS but unfortunately, not all of them are very evidence-based. Some do quote research but only selectively, without giving a full picture of the pros and cons of a particular treatment. Others promote all kinds of alternative treatments as if they are proven, but with only anecdotal evidence to support it.

This PCOS series is designed to take an evidence-based look at PCOS and its various treatments, both traditional and alternative. Links to research are placed in each blog post, and the most important studies are summarized at the bottom of most posts. Anecdotal stories are not immaterial so they are considered too, but they are not seen as proof.

Financial conflicts of interest contaminate many PCOS resources. Remember that the weight loss and diet business is highly lucrative, and many scientific researchers and doctors are biased by grants and ties to obesity treatment programs and drug companies. They are often not even aware of their own biases and conflicts of interest. Even consumer-run PCOS resources often promote and make money off a particular dietary approach, supplement, or personal health coaching business. Therefore, when researching PCOS, look for conflicts of interest and question conclusions.

Every source of information is subject to bias, even when no financial incentive exists. Be aware of the bias of the sites you read. That includes this resource. Its weight-neutral approach makes it unique among PCOS resources, but some would charge it might be biased against weight loss. On the other hand, unlike many PCOS resources, this series has no financial incentive towards any particular treatment. I make no money from the blog and do not benefit from people choosing non-weight loss treatments. I consider evidence for weight loss and try to be as fair as I can in its evaluation, but I won't pull punches about when it doesn't measure up. It's up to you to decide if I'm writing about it fairly and what the right course is for yourself.

If you are new to this site, I strongly suggest reading the Terminology Page and the Health At Every Size® information to understand the language and philosophy of a weight-neutral approach.

A Weight-Neutral Emphasis

As noted, most PCOS websites have a tremendous weight-loss emphasis. Some are run by people who are selling "lifestyle coaching" or various supplements for PCOS and are profiting from their PCOS connections. In essence, they have monetized their diagnosis. There is nothing necessarily wrong with this, but it does inherently bias the information they have available and the treatments they promote.

The strong weight loss emphasis on many sites also alienates people who have moved beyond dieting and embrace a size acceptance point of view. People like this often avoid typical PCOS sites because of the weight emphasis and so miss important information about treating the condition. There is a strong need for good, in-depth information without pushing weight loss as the cornerstone of all treatment, something that is very missing in most PCOS resources.

Of course, the weight-centric paradigm is very strong in PCOS circles, both among consumers and medical professionals. Even the mere suggestion that dieting could be counter-productive is heresy to some. The idea of a PCOS resource that does not promote weight loss will immediately discredit this series in some eyes.

But remember, you are your own boss. No one is telling you what to do. It doesn't hurt you to consider an weight-neutral point of view. If you decide it's nonsense, you can certainly pursue weight loss as a treatment for your PCOS. No one is going to stop you. Certainly, there is some research that weight loss can be helpful for some things in PCOS, though I would point out it's usually temporary. If you want to pursue that, go ahead. There are plenty of PCOS resources friendly to that approach and no shortage of weight loss advice online.

The problem is that PCOS and weight loss research, like most research on weight loss, is short in duration (usually less than 24 months), has very poor long-term success, and completely ignores the risks that can be associated with weight loss/weight cycling. Does a 5-10% (or larger) weight loss really benefit your health if you end up heavier afterwards and with more eating-disordered behaviors? Or if you end up with gallstones, kidney cancer, or endometrial cancer from weight cycling?

Given the overwhelming evidence of poor long-term success with weight loss and the significant harms that can come from yo-yo dieting, it's important to know that there is an alternative. You can treat your PCOS without having to go on yet another diet that is likely to fail. That doesn't mean that lifestyle is irrelevant to treating PCOS, but simply that an emphasis on weight loss is not required. This blog examines lifestyle as an intervention for PCOS, but without an emphasis on guilt or pressure for any particular approach. Nor do we measure success by the scale.

This series does not ignore the possibility of weight loss as treatment, but promoting weight loss is not its focus, unlike most other PCOS resources. The decision on whether or not to lose weight is left up to the individual.

As with any medical situation, readers will have to carefully consider the pros and cons of all their choices and decide what is right for themselves. That might involve intentional weight loss, but it might mean choosing a Health At Every Size® paradigm instead, which emphasizes healthy habits guided by lab results and symptoms instead of the scale. Whatever you decide on the weight loss question for you is fine; just make that decision from an informed place.

Please remember that this blog is meant to be a safe space. If you decide on weight loss, that's fine, but respect other people's right to have a diet-free space. Do not promote diets, weight loss surgery, eating-disordered behaviors, or body-shaming on this site, and treat everyone politely. You are allowed to disagree with my point of view if it's done respectfully. I can and do restrict comments when necessary. No fat hate is allowed.

This series exists because it's important that people know that there are evidence-based treatment approaches that can help mitigate the risks of PCOS without adding in the risks and emotional roller-coaster of weight loss. The decision about how to approach your weight, however, is entirely up to you.

Remember, you can have a good life, even with health challenges like PCOS. But it pays to be proactive and learn as much as you can about the condition and your treatment choices.


Friday, September 14, 2018

PCOS and Hirsutism: Treatment Options


Every September, we discuss Polycystic Ovarian Syndrome (PCOS) in honor of PCOS Awareness Month. Today we discuss PCOS and abnormal facial and body hair (hirsutism).

To review, in our PCOS series so far you will find an introduction to PCOS as a health concern:
You will also find a mini-series on insulin-sensitizing medications, including:
There is a mini-series on other medications for PCOS, including:
In addition, we discuss specific conditions associated with PCOS and have an occasional post reviewing recent research studies on PCOS:
We also have a mini-series on the least-discussed symptom associated with PCOS, Alopecia Androgenetica (AGA, also called female-pattern hair loss or FPHL):
Now it's time to address the topic of hirsutism (excess facial and body hair) and various medical and cosmetic treatment options for it.

What is Hirsutism?

Images from Karen Figgett, 2014
originally posted at hairyfairyweymouth.com
Hisutism is excess facial or body hair growth in women that occurs in a so-called male pattern. In other words, it occurs on parts of women's bodies where terminal hair growth (long, dark, thick hairs) is not expected or is normally very minimal.

If the hair growth is all over everywhere, it is called hypertrichosis. This is very rare and quite different from hirsutism, which is hairiness limited to "male" areas (like the upper lip, the chin, the chest).

Many women with PCOS have hair above their lips, like a mustache, as well as fine hair growing on their chin, cheeks, or neck. Some have just a few hairs sprouting on the face, while others can have quite a bit. Excess hair can also grow on the abdomen, chests, back, upper legs, and arms of women with PCOS. 

Women with PCOS tend to have high rates of hirsutism. Although not all women with PCOS experience hirsutism, it is considered one of the most classic symptoms of PCOS.

Possible Causes and Diagnosis

Hirsutism from PCOS is usually caused by an endocrine (hormonal) imbalance involving the over production of male hormones (androgens). It may also result from an increased sensitivity of the hair follicles to these hormones. Most of the time the source of the increased male hormones is from the ovaries, the adrenal glands, or the brain.

Hirsutism most commonly results from:
  • Polycystic ovary syndrome (PCOS) (cysts on the ovaries giving off androgens)
  • Insulin resistance, which increases testosterone production
  • Congenital adrenal hyperplasia, mostly caused by 21-α hydroxylase deficiency
  • Adrenal problems like Cushing's Syndrome, adrenal gland cancer, non-classical adrenal hyperplasia
  • Hyperprolactinemia
  • Thyroid dysfunction
  • Growth hormone excess (acromegaly, gigantism) from benign tumors near the pituitary gland
  • Ovarian tumors
  • Menopause, which decreases female hormones but continues to produce male hormones
Every woman with significant hirsuitism should seek out a medical evaluation to determine the cause. At their appointment, they should undergo a complete physical exam and have some blood labs run. These may include DHEA-S, testosterone, androstenedione, various thyroid levels, blood sugar, insulin, prolactin, and 17α-hydroxyprogesterone.

A medical history should also be taken, including menstrual regularity and development of hirsutism. A critical question is how fast the hirsutism developed. If it is sudden and marked, it's more likely to be related to adrenal problems such as a tumor on the adrenal gland. If this is the cause, it needs immediate follow-up.

If the hirsutism has been slow to develop, it's more likely due to high androgen levels from PCOS or insulin resistance. If it's associated with irregular menstrual cycles, it is most likely tied to PCOS. Most cases of hirsutism are caused by PCOS or are idiopathic (cause unknown) and are not alarming, just annoying.

A full discussion of hirsutism in all its forms is beyond the scope of this blog. This blog post discusses only PCOS and hirsutism.

Ferriman-Gallwey Score

Doctors use the Ferriman-Gallwey score to evaluate and quantify body hair growth. Although other measures are available, this remains the standard of care in most practices for evaluating hirsutism in women.

In the original method, 11 body areas were assessed for hair growth, including upper lip, chin, chest (especially along the midline), upper back, lower back, upper abdomen, lower abdomen, thighs, forearms (not used anymore), and legs (not used anymore).

According to Wikipedia, forearms and legs were deleted in the modified version of this scale. Some medical professionals use a further modification of the scale to consider 19 total locations, including spots like sideburns, neck, buttocks, feet, and fingers. However, most seem to still use the 9-location scale.

Hair growth is graded on a scale from 0 (no excessive growth of terminal hair) to 4 (extensive terminal hair growth). If the 9-location version of the scale is used, that means that there is a maximum score of 36 points.

Ethnicity plays a role in how much hair is expected. Each patient's ethnic background should be considered in the scale evaluation. In Caucasian women, a score of 8 or more is considered hirsutism, although some care providers use 6 as a diagnostic threshold instead.

There is great debate about the proper diagnostic levels for other ethnicities; this discussion is beyond the scope of this blog post but rest assured, hirsutism happens in every ethnic group. If in doubt, look at others of the same group around you. If your symptoms seem worse than theirs, you probably have some degree of hirsutism.

The most common ways to treat hirsutism include:
  • Oral contraceptive pills (OCPs) to regulate androgen production
  • Gonadotrophin Releasing Hormone analogs (GnRHa) to regulate androgens by suppressing ovulation
  • Anti-androgen drugs like spironolactone or flutamide 
  • 5 alpha-reductase suppressants like finasteride
  • Insulin-sensitizing agents like metformin or pioglitazone
  • Epilation (removal of hair by the roots) with cosmetic methods like bleaching or chemical depilation, plucking, waxing, shaving and more permanent methods like laser, electrolysis etc.
  • Topical treatment with medications like Eflornithine 11.5% or 13.9% cream etc.
Let's take a look at each of these and a quick overview of their pros and cons. 

Oral Contraceptive Pills for Hirsutism

Some birth control pills can have a major anti-androgenic effect and lessen many PCOS symptoms, which is why they are the most commonly prescribed medication for PCOS. However, there are some drawbacks.

Not all oral contraceptives have an anti-androgenic effect, and some significantly worsen androgens. Combined oral contraceptives, especially the ones that lessen androgenic effects, also increase the risk for blood clots, and may have lower birth control efficacy in high-BMI women. Some argue that OCPs merely put a band-aid on symptoms while not adequately addressing the underlying causes of PCOS issues.

Combined Oral Contraceptives (Dianette, Yasmin, etc.)

As we have discussed before, certain combination oral contraceptives (using both estrogen and progestin) have strong anti-androgen effects. As a result, they are often the first-line treatment for PCOS and for hirsutism in general. One OB website sums up the mechanism of action:
Oral contraceptives...suppress pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which in turn suppress ovarian androgen production. OCs also may reduce adrenal androgen production, although the mechanism of action is unclear.
The estrogen component in OCs increases hepatic production of sex hormone-binding globulin (SHBG), thereby decreasing free testosterone levels. The progestin component antagonizes 5α-reductase and the androgen receptor; it also may increase hepatic metabolism of testosterone and can increase SHBG when the OC has low androgenic activity. However, the strength of anti-androgenic effect in oral contraceptives varies. Some birth control pills (second generation, especially those involving levonorgestrel) have strong androgenic effects, which can make symptoms worse in some women with PCOS.

Many of the later oral contraceptives (third- and fourth-generation) have a stronger anti-androgenic effect. These can be used on their own or in combination with other anti-androgenic drugs (usually spironolactone) to treat hirsutism and acne.

Unfortunately, the oral contraceptives with the strongest anti-androgenic effects tend to have the strongest risk of blood clots, particularly for women of size and/or women with PCOS. Each woman's unique medical history and risk factors must be considered very carefully before use of these oral contraceptives. You can read more about these risks herehere, and here.

Here are further details of two of the most commonly-prescribed anti-androgenic oral contraceptives, those using droperinone and those using cyproterone acetate.

Drospirenone (brand names: Yasmin, Yaz, Angeliq)

Drospirenone (also known as 1,2-dihydrospirorenone) is a synthetic steroidal progestin which has weak anti-androgenic properties. Structurally, it is similar to spironolactone.

When combined with ethinyl estradiol, it becomes the combination birth control pill called Yasmin, sometimes called a "fourth-generation" oral contraceptive. It has a modest effect against hirsutism and acne. It was marketed as a treatment for acne. (In a slightly different formulation, drosperinone plus estradiol is called Angeliq, and is sometimes used for menopausal symptoms.)

Yasmin is contraindicated in people with a history of liver, kidney, or adrenal insufficiency. Potassium levels must be carefully monitored in anyone on this medication.

People with a history of depression or family depression might want to avoid this OCP because anxiety and depression are possible side effects. Migraine is another possible side effect.

The biggest concern, however, is blood clots. Research suggests that the risk for blood clots is significantly increased in people on Yasmin, both compared to those not on any birth control pills at all, and in those on other types of birth control pills. Certain risk factors (obesity, high blood pressure, family history of blood clots, diabetes, etc.) may raise the risk even more.

Still, doctors point out that the absolute risk remains relatively low, and certainly lower than the risk of blood clots during pregnancy. And it reportedly does a good job of lessening hirsutism.

Cyproterone Acetate (CPA; in oral contraceptives, Dianette or Diane-35)

CPA is another progestin that has anti-androgenic properties and may be used alone or as part of certain birth control pills. It inhibits production of androgens in ovarian theca cells, and also competes with androgens at receptor sites.

From its Wikipedia entry:
Cyproterone Acetate...is a synthetic steroidal antiandrogen drug with additional progestogen and antigonadotropic properties. Its primary action is to suppress the activity of the androgen hormones such as testosterone and its more potent metabolite dihydrotestosterone (DHT) in the body, effects which it mediates via competitive antagonism of the androgen receptor and inhibition of enzymes in the androgen biosynthesis pathway.CPA is most often used as an anti-androgen treatment for men with prostate cancer. In PCOS women, it is an effective treatment for significant hirsutism and acne. It may be even more effective for this when combined with metformin.
In the U.K. and Canada, CPA has been combined into the oral contraceptives known as Dianette and Diane-35. CPA and the Diane birth control pills are not available in the U.S.

The amount of CPA in most birth control pills is fairly small, and has only a modest effect on hirsutism. Higher doses of CPA tend to have more impact on hirsutism. However, it takes quite a while for the CPA in birth control pills to affect hirsutism; a trial of at least 6 months is needed, and often the maximum effect is not attained until 2-3 years later.

CPA can have significant liver toxicity. Liver enzymes, cortisol and electrolyte levels must be monitored when on CPA. A woman's ability to absorb vitamin B12 may also be impaired, while iron-binding abilities may be enhanced. B12 and ferritin levels should be monitored when on this medication long-term.

Nausea, vomiting, headache, depression, weight changes, edema, increased blood pressure, gallstones, and skin spots are potential side effects. Again, birth defects can occur with this drug, so effective birth control is needed, which is why it is usually administered in oral contraceptive form.

Blood clots are also a significant risk; women on birth control pills with CPA have a higher risk for blood clots than women on certain other types of the Pill, but some OB organizations feel that they can be worth the risk. Like Yasmin, the absolute risk of a blood clot is fairly low, but may be increased in women with certain risk factors.

If you consider use of CPA, a CPA oral contraceptive (like Dianette), or a drosperinone oral contraceptive (Yasmin), be sure to consult with your care providers carefully about your health history, risk factors, and the benefit/risk ratio of these medications. Generally speaking, on their own, OCPs are not that effective for hirsutism, but combined with other medications like an anti-androgen they are far more effective. Still, they often involve significant side effects and must be considered carefully.

You can read more about Dianette oral contraceptives here and the newer oral contraceptives in general here.

Gonadotrophin Releasing Hormone analogs (GnRHa) 

GnRHa medications work by suppressing ovulation, which in turn lowers the androgens in the body. According to one source:
Gonadotrophin Releasing Hormone Analogs suppress gonadal hormone synthesis by imitating GnRH and attaching to target pituitary receptors with ‘high affinity’. The commonly used analogs are potent GnRH agonists (GnRHa). A long-term treatment with a GnRHa like leuprolide acetate acts against ovarian steroidogenesis by inhibiting pituitary LH and FSH production. This in turn reduces the concentration of circulating testosterone and androstenedione, but without affecting adrenal androgens.
These medications tend to work better for PCOS hirsutism than oral contraceptives alone. However, long-term use brings lots of side effects, so this medication is typically only used in women who have very serious hirsutism and only minimal success with other hirsutism medications.

This medication needs to be injected. It is done about once a month, and is quite expensive. It is viewed as a short-term solution only and is not generally used long-term. It may provide a short-term clearing of excess hair that then can be sustained with an oral contraceptive but generally speaking most doctors prefer other choices first.

Anti-Androgens for Hirsutism


One of the most effective treatments for hirsutism is an anti-androgen medication, either by itself or combined with an oral contraceptive. Since PCOS results in androgen excess, treatments aim to reduce the levels of androgens ─ or at least to reduce their effects.

An anti-androgen prevents the body from making as many androgens, or it may limit the activities and effects of androgens. Treatment with anti-androgenic medications can help lower androgen levels, reduce hirsutism, reduce acne, and perhaps even minimize hair loss issues.

While anti-androgens can reduce some PCOS symptoms, they can also cause birth defects and must be taken with an extremely reliable form of birth control, even in women with fertility issues. Occasional spontaneous ovulation does happen even in those struggling with infertility, and the chance of birth defects is high in women who take anti-androgen medications. As a result, anti-androgens are usually taken with oral contraceptives in order to make sure pregnancy is prevented. Sometimes the combination works even better on PCOS than alone, giving it an added bonus.

Anti-androgens are not FDA-approved for the treatment of PCOS. Research reviews note the poor quality of research on these drugs, so the best anti-androgen for treating PCOS symptoms is not yet known, nor is the best combination of anti-androgen and oral contraceptive. Women who want to use any of these drugs should discuss all pros and cons thoroughly with their medical professional.

It is important to note that it takes a long trial of treatment (6-18 months) before it is clear whether a particular anti-androgen drug is impacting your symptoms. Because the hair growth cycle is long, improvement is generally slow and gradual. You must be patient before you decide whether or not an anti-androgen drug is helping.

And remember, the drug's benefits last only as long as you are taking the drug, and the risk of side effects with some drugs is substantial. If the drug's benefits are only modest, some people may feel they are not worth the long-term risk of side effects.

Spironolactone  (brand name: Aldactone)

Spironolactone is the most common anti-androgen drug used for women with PCOS. It is a potassium-sparing diuretic, usually prescribed for treating edema (excess fluid) or high blood pressure. It is also an aldosterone antogonist. Its use for PCOS symptoms is off-label but has been going on for years.

Spironolactone is thought to help in the following way:
Spironolactone inhibits the testosterone secreted by the body, and also competes for hormone receptors in the hair follicles. Receptors are sites on cells which allow hormones or chemical to bind to them, creating a reaction. If another chemical is in the receptor site, androgens cannot bind to them and stimulate the reaction causing hair growth.
Spironolactone has been shown to significantly lessen facial hirsutism in women with PCOS. A recent Cochrane meta-analysis suggests that 100 mg daily is quite effective against hirsutism, although it noted that the quality of this evidence was low and more research is needed. Other OB guidelines have suggested that higher doses may be needed in some women, but that it's best to build dosage up slowly over time.

For many women with significant hirsutism, spironolactone is the medication of choice when used with a form of extremely reliable birth control in women who have even the smallest chance of becoming pregnant. This usually means the Oral Contraceptive Pill. The combination of the Pill and spironolactone can be particularly effective for many women with PCOS. However, not all find it helpful.

Because spironolactone is a diuretic, you will need to be monitored to make sure you don't build up too much potassium in the blood. Frequent urination is the most common side effect. Nausea, fatigue, headache, lightheadedness, indigestion, thirst, electrolyte imbalances, and abnormal bleeding or menstrual disturbances are other potential side effects. Heart arrhythmias can occur if potassium levels spike; this is most common in the elderly or those with kidney disease but can occur in younger patients. Liver enzymes must also be monitored regularly for signs of hepatotoxicity.

The good news is that spironolactone is an extremely affordable drug that is generally quite effective for PCOS hirsutism, especially when used in combination with other drugs. If PCOS-related acne is a problem for you, it often works well for both hirsutism and acne, and possibly for alopecia (hair loss on the head) too. You can read more about the uses, side effects, and cautions for spironolactone here and here

Flutamide 

Another medication that works similarly to spironolactone is flutamide. From one website:
Flutamide is a non-steroidal antiandrogen that is devoid of other hormonal activity. It most likely acts after converting to 2-hydroxyflutamide, which is a potent competitive inhibitor of dihydrotestosterone (DHT) binding to the androgen receptor.
A few studies have found that flutamide helps restore regular menstrual cycles and ovulation in women with PCOS, but it is most useful against hirsutism. It is available in the United States, but is usually prescribed for men with prostate cancer, not women with PCOS. As a result, most of the hirsutism research on it is European.

Flutamide can have significant liver toxicity, so some organizations recommend against it use. Flutamide can also result in significant gastrointestinal upset, as well as issues with dry skin. Because of these side effects, flutamide is generally considered unsuitable for the treatment of acne and other skin problems where its benefit is only minimal.

Because it is more effective for hirsutism, the benefit/risk ratio for this is more controversial. A recent Cochrane meta-analysis suggests that flutamide (250 mg, twice daily) is "effective and safe" against hirsutism, although it noted that the quality of this evidence was low. Another recent meta-analysis disagreed, stating:
Due to its risk for hepatotoxicity, flutamide is not considered a first-line therapy. If used, the lowest effective dose should be administered with careful monitoring of liver enzymes.
Some care providers feel that flutamide is relatively safe with careful monitoring of liver function. The chance for birth defects is quite high with Flutamide, so again, a very reliable form of birth control must be used, or it may be prescribed only for women with no childbearing potential.

You can read more about Flutamide here, here, and here.

5 Alpha-Reductase Inhibitors for Hirsutism

Another way to reduce hirsutism is by lessening the effect of androgens on skin cells. 5 alpha-reductase inhibitors are very effective at doing this. [Note: "alpha" may be written out or the greek letter used - "5 α-reductase inhibitor"]

Finasteride  (brand name: Propecia or Proscar)

Finasteride is a 5 alpha-reductase inhibitor. It is FDA-approved for the treatment of baldness and/or Benign Prostatic Hyperplasia (BPH) in men. It has a relatively good safety profile and is well tolerated by most men, but it is quite expensive. It is not approved for use with PCOS or with women.

Finasteride has been shown in some research to be effective against hirsutism, though not for hair loss in women. It works by preventing the androgens from getting into the cells. However, the recent Cochrane meta-analysis notes that the research on finasteride is inconsistent and therefore conclusions cannot be reached. It does not appear to be effective against hair loss in women.

Finasteride can cause headaches and depression. It is associated with a very high risk of birth defects (pregnancy drug category X), so it is not used in women who have even the smallest chance of becoming pregnant. Some doctors consider it an option, however, for women who have no childbearing potential anymore (beyond menopause, tubal ligation, hysterectomy, etc.).

You can read more about finasteride here.

Bicalutamide (brand name: Casodex, Calutide)

A fairly new option for hirsutism is bicalutamide. It is a 5 alpha-reductase inhibitor, like finasteride. It was developed to treat prostate cancer in men. Its mechanism of action is as follows:
Bicalutamide acts as a pure antiandrogen by binding to the androgen receptor and preventing its activation and subsequent upregulation of androgen-responsive genes by androgenic hormones. In addition, bicalutamide accelerates the degradation of the androgen receptor. 
Bicalutamide is considered to be about as effective as finasteride, but with fewer side effects. Although it can impact liver function, bicalutamide is less likely to cause damage than some other anti-androgen drugs, which is a big advantage. Another advantage is its price, as it is a comparatively cheap medication. A generic version is available. 

Like finasteride, it is associated with a high risk of birth defects and is contraindicated in women with any chance of becoming pregnant. However, there is some minimal research on its use in women. A recent study found that an oral contraceptive pill plus bicalutamide was very effective and well-tolerated. 

You can read more about bicalutamide here.

Insulin-Sensitizing Medications for Hirsutism

Another option for treating hirsutism is an insulin-sensitizing medication. Since many women with PCOS have strong insulin resistance and this may result in higher androgen levels, treating the insulin resistance may be helpful in treating mild hirsutism.

Insulin-sensitizing medications may have some anti-androgenic effects and can be somewhat effective against hirsutism or acne. Since they have the distinct advantage of being effective against multiple PCOS symptoms at the same time, some providers will prescribe insulin sensitizers first in women with PCOS. These include TZDs, inositols, and most commonly, metformin.

TZDs like Actos and Avandia may be somewhat effective against hirsutism but because of concerns over their safety, they are not usually used for hirsutism. However, they may be part of an overall PCOS treatment program with some medical professionals. You can read more about TZDs here.

The inositols (myo-inositol and d-chiro-inositol) are insulin-sensitizing supplements that many people with PCOS find more tolerable than metformin or TZDs. They are effective for lessening insulin resistance, but the research on whether they help with symptoms like hirsutism is mixed. More data is needed.

Metformin (brand name Glucophage) is the most commonly used insulin-sensitizing medication in PCOS. It is an old drug that has been in use for a very long time and has an impressive safety record compared to other insulin sensitizers. In diabetics, it has been shown to lower the risk for heart disease and death significantly, a claim few drugs can make. It has also been shown to delay the development of diabetes in those with strong risk factors.

However, metformin is known for its GI side effects in some people. Diarrhea, gas, and bloating are common. Using the extended release formulation can lessen this for many people, but GI side effects can still happen and lead some people to discontinue its use.

Metformin also has been known to impact vitamin B12 levels in some patients so B12 levels should be checked periodically. Rarely, metformin can result in lactic acidosis, a severe complication that can be fatal. To lessen the risk, many doctors recommend temporarily discontinuing metformin during times of significant acute illness or surgery. Liver and kidney labs should be run before starting metformin and periodically during its use. You can read much more about metformin here.

Metformin has been shown in some past research to be as good as or somewhat better than oral contraceptives alone in reducing hirsutism in women with PCOS. A 2009 literature review for the American Academy of Family Physicians notes that past research showed that metformin was as effective for treatment of hirsutism as many oral contraceptives, although later research did not confirm its effectiveness.

Nowadays, metformin alone is not considered to be a first-line drug for use against hirsutism. However, it may increase the effectiveness when used with other hirsutism medications. One recent review said:
Monotherapy with an insulin sensitizer does not significantly improve hirsutism. While insulin sensitizers improve important metabolic and endocrine aberrations in polycystic ovary syndrome, they are not recommended when hirsutism is the sole indication for use. More recent research suggests that metformin modestly increases the effectiveness of other anti-hirsutism medications, particularly oral contraceptives and spironolactone. In other words, while metformin probably shouldn't be prescribed by itself for hirsutism, it may well be prescribed in combination with an anti-androgen medication (probably spironolactone) or an oral contraceptive.
Herbs for Hirsutism

In addition to traditional medicines, there are herbs that are reputed to have anti-androgenic effects.

For example, herbal spearmint tea has long been used as an anti-hirsutism treatment in Middle Eastern cultures. Research suggests that spearmint tea may have mild anti-androgenic effects and may be helpful with hirsutism, but longer studies are needed to evaluate this.

Other possible herbal agents may include red reishi (a mushroom used in Chinese medicine), licorice root, Chinese peony, green tea, black cohosh, and saw palmetto extract. I am not aware of any studies on these herbs for hirsutism; their inclusion is based only on anecdotal evidence from some PCOS sites.

Many women with PCOS use chaste tree/vitex in particular. More information on the (rather sparse) research behind these possibilities can be found here.

Cosmetic Treatments for Hirsutism



There are a number of cosmetic treatments that can help with PCOS symptoms like hirsutism. None are 100% satisfactory, but most women find them preferable to risky drugs, especially during their childbearing years. Over time they develop a routine that works for them, even if it's not as ideal as they'd like.

Mechanical Hair Removal or Disguise

To deal with bothersome facial and body hair, most women employ cosmetic remedies like shaving, plucking, waxing, epilators, and depilatory creams. Bleaching may also help by making the facial hair less noticeable.

If the degree of hirsutism is mild, then shaving is the easiest way to take care of it. Keep in mind that it has to be done often or stubble will show. Shaving does not make the hair grow back darker and thicker; the stubble left over just appears that way. Using an electric shaver may result in less skin irritation than a blade. One woman reports that an electric eyebrow shaver was the best solution for her.
Eyebrow shavers are the best to use for fuzzy face because the blade is much finer and it cuts the hair at an angle that doesn't result in the hair looking darker/thicker as it comes back in.
Lots of people use plucking or tweezing if the hirsutism is mild and just results in a few stray hairs. Waxing is a faster version of plucking. Epilators are small mechanical devices that basically work the same as waxing or tweezing; they pull the hair out by the root. Under ideal conditions this leaves smooth soft skin and lasts several weeks.

However, plucking, tweezing, etc. can permanently damage the hair follicle. Sometimes this is good as the hair follicle might stop producing hair. Sometimes it is bad because the hair follicle may respond by growing a bigger, thicker, and darker hair. You never know which result you are going to get. Also, tweezing, plucking, epilators, and waxing can sometimes lead to major skin irritation and damage. And they hurt!

Bleaching can work well if you are very light-skinned as it reduces the contrast between hair and skin.  However, bleaching can lead to major skin irritation and damage. For many women of color, bleaching is not a good option.

Depilatory (hair removal) creams can be used at times. These creams use very alkaline formulations that weaken the hair shaft so that the hair breaks off below the surface, leading to very smooth skin. One advantage of depilatories is that their results tend to last longer than shaving; however, many women find that depilatory creams cause significant skin irritation and redness. They do fine for a while but eventually many women become too sensitive to use these regularly.

Most women with PCOS use multiple cosmetic measures to deal with visible hirsutism. For example, women may start by waxing off the excess hair, then using an epilator as it grows back. Or they may rotate their approach to lessen the sensitivity of the area.

However, for some women cosmetic measures are not enough. As a result, they may turn to procedures like electrolysis or laser therapy.

Electrolysis

In order to destroy the offending hair follicles and hopefully achieve permanent hair loss, electricity is another tool. Basically, it's an epilator with the addition of a small electrical current to destroy the hair root. Here is a description of the procedure:
Electrolysis is defined as the electrochemical destruction of the hair follicle. In electrolytic epilation a fine, disposable wire needle is inserted into the hair follicle. Through this needle, a regulated electric current, either direct or alternating, is transmitted from a highly state-of-the art instrument known as an epilator to destroy the germinative hair bulb. It can be correctly performed only by expert professionals. 
The frequency of the electric current (as regulated by the FDA) is generally 13.56 MHz. The current may be either low power and administered for 3 to 20 seconds, or high power and given for less than a second (the commonly known flash technique).
There are several types of electrolysis available, including galvanic electrolysis, thermolysis, and the blend method. Descriptions of these can be found here and here.

Some people have very good results with electrolysis but it is a long process. Even when seen once a week, treatment for significant PCOS hirsutism may take months or even years. Redness and swelling often result after a session. Infections and scarring may occur. Treatments are expensive and painful and may not result in permanent removal of hair.

Therefore, electrolysis seems most useful for women with small localized patches of hirsutism.

Laser Therapy

Some women with hirsutism choose to try laser therapy:
Laser treatment employs a method called selective photothermolysis in order to destroy the hair follicle selectively. The laser is passed through the skin and specifically targets a chromophore called melanin, a natural pigment present in the hair follicle. Melanin absorbs the laser light at a specific wavelength and converts the laser into heat energy for destroying the hair tissue. Since melanin is located in the hair follicle but not the adjoining dermis, targeting it ensures selective damage of the follicle without harming neighboring tissues. However, melanin is present in the epidermis. Hence, laser methods must ensure that the skin is cooled off to prevent thermal damage of the epidermis.
Laser therapy can be used on larger areas of the body, unlike electrolysis. Treatment does not result in permanent hair loss, but the results do last much longer than other forms of treatment, usually several months. Treatment is often done in threes; one initial dose, another dose when hair regrowth appears several months later, and then a final dose when hair regrowth appears again. A lot depends on the type of laser used; see the article linked above for more specifics.

Laser treatment can be somewhat painful and side effects like swelling and redness are quite common. Less common are more serious side effects like scarring and dyspigmentation. Although longer wave lengths can be used for people of color, laser therapy may cause scarring and damage in people with darker skin.

Other Medications

Besides the anti-androgens listed above, another medication that may help with hirsutism is Vaniqa (Eflornithinepronounced EE-floor-nih-theen). This cream is used to slow growth of unwanted hair, especially on the face. It's not a depilatory cream but rather an enzyme blocker.

The drug works by blocking an enzyme (putrescine) needed for hair to grow. If the patient stops using the cream, the hair will grow back, so a long-term management plan is needed. Eflornithine is FDA-approved for the treatment of facial hirsutism and is considered safe to use during pregnancy.

Like other medications and treatments, it can cause redness and irritation in the area being treated. It must be used for at least 8 weeks to be effective. Discontinuing it for substantial lengths of time would stop its effect.

Although it is known to work successfully in women with facial hirsutism, its specific effectiveness at treating women with PCOS is currently unknown.

To Treat or Not to Treat


Of course, it is also a choice not to treat your cosmetic PCOS symptoms. Just because society says that women should look a certain way doesn't mean that we have to do so. After all, facial hair and thinning hair on the head is accepted in men, so why is it considered so unacceptable in women? It results from sexist double-standards, the idea that it is our main duty as women to be as sexually attractive as possible, and that this sexual attractiveness is measured by extremely narrow standards that very few women actually meet.

Some women struggle for years to deal with cosmetic symptoms, find few treatments that work well for them, and in the end decide to opt out of even trying to treat these cosmetic symptoms. For some women, it can be a tremendously freeing to finally get off the merry-go-round of cosmetic treatments and trying to hide what is happening to them, just to meet some sexist standard of what women "should" look like. There is NO obligation to treat cosmetic symptoms if you don't want to do so.

On the other hand, societal pressure causes most women to want to treat distressing cosmetic symptoms, and that's fine too. Although it is not fair that women are subjected to appearance double-standards, it is a fact of life that social judgment can have significant impacts on self-esteem, dating, and work opportunities. If a woman wants to treat her androgenic symptoms, this is also normal and understandable.

The point is that each woman gets to decide on her own what she will and won't treat. There is no symptom that you have to treat. There is nothing wrong if you want to treat certain symptoms, and there is nothing wrong with opting out of treating those symptoms either. It's your choice.

Conclusion

Hirsutism is one of the more difficult and disheartening PCOS symptoms to deal with. There is no magical cure for it, only ways to manage it, each with its own trade off.

Most women choose a variety of methods to deal with it. They  may use medications to decrease the amount of hirsutism, while also using cosmetic removal methods. A lot depends on the degree of hirsutism and whether the woman is planning on having children anytime soon.

If you are in your childbearing years, sexually active, and have any chance of conceiving, your best choice is probably cosmetic treatments, with the possible addition of metformin. Used carefully, this is pretty effective, especially in those with mild to moderate hirsutism.

If you are not interested in or not ready to conceive and you have moderate to significant hirsutism, one of the most effective treatments is an Oral Contraceptive Pill plus spironolactone. Recent research shows that this is highly effective for many women with PCOS. Another choice is metformin plus an Oral Contraceptive Pill, which can be effective for mild to moderate cases.

For those women who do not have childbearing capacity anymore (due to hysterectomy, tubal ligation, menopause, etc.), treatment can include metformin plus spironolactone, or an alpha-reductase inhibitor for very significant cases of hirsutism.

Most women with mild hirsutism find all they need is cosmetic treatments. Those with significant hirsutism find they have to combine some form of medication with some form of cosmetic treatment in order to get the appearance they want.

Whatever treatment you choose, there's no doubt that dealing with excess facial and body hair is hard. It strikes right at the heart of a woman's perceptions of her own femininity, and it affects how others view her as well.

But you are not alone. There are many PCOS support groups available. These can provide invaluable emotional support when dealing with the emotional angst or social stigma of some of the cosmetic and medical side effects of PCOS.

Remember, your symptoms do not define you.

Cosmetic symptoms are distressing and you have every right to be upset and angry about them, but in the end, they do not define who you are or what kind of life you can have. Only YOU can do that.

Women can have symptomatic PCOS and still have good, happy lives, regardless of what they do about their hirsutism. Half the battle is being determined to have a good life, regardless of whatever challenges you are handed.

This is the only life you get; make the most of it! Don't let PCOS or its symptoms keep you from happiness.



References

General Information about Hirsutism
Information about Ferriman Gallwey Score
Study Reviews

Am J Clin Dermatol. 2014 Jul;15(3):247-66. doi: 10.1007/s40257-014-0078-4. Hirsutism: an evidence-based treatment update. Somani N, Turvy D. PMID: 24889738
...Four recently published RCTs met criteria for inclusion in our review. In addition, one meta-analysis and one systematic review/treatment guideline were identified in the recent literature. Physical modalities and oral contraceptive pills (OCPs) remain first-line treatments. Evidence supports the use of electrolysis for permanent hair removal in localized areas and lasers (particularly alexandrite and diode lasers) for permanent hair reduction. Topical eflornithine can be used as monotherapy for mild hirsutism and as an adjunct therapy with lasers or pharmacotherapy in more severe cases. Combined OCPs as a class are superior to placebo; however, antiandrogenic and low-dose neutral OCPs may be slightly more efficacious in improving hirsutism compared with other types of OCPs. Antiandrogens are indicated for moderate to severe hirsutism, with spironolactone being the first-line antiandrogen and finasteride and cyproterone acetate being second-line antiandrogens. Due to its risk for hepatotoxicity, flutamide is not considered a first-line therapy. If used, the lowest effective dose should be administered with careful monitoring of liver enzymes. Monotherapy with an insulin sensitizer does not significantly improve hirsutism. While insulin sensitizers improve important metabolic and endocrine aberrations in polycystic ovary syndrome, they are not recommended when hirsutism is the sole indication for use. Lifestyle modification counseling is recommended. Gonadotropin-releasing hormone analogs and glucocorticoids are only recommended in specific circumstances. Additional therapies without sufficient supportive evidence of efficacy are ovarian surgery, statins (HMG-CoA reductase inhibitors), and vitamin D supplementation...CONCLUSIONS: Risks and benefits of treatment must be carefully considered and discussed with the patient. Expectations for efficacy should be appropriately set. A minimum of 6 months is required to see benefit from pharmacotherapy and lifelong treatment is often necessary for sustained benefit.
Cochrane Database Syst Rev. 2015 Apr 28;(4):CD010334. doi: 10.1002/14651858.CD010334.pub2. Interventions for hirsutism (excluding laser and photoepilation therapy alone). van Zuuren EJ, Fedorowicz Z, Carter B, Pandis N. PMID: 25918921
Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective... AUTHORS' CONCLUSIONS: Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision-making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects.Further research should consist of well-designed, rigorously reported, head-to-head trials examining OCPs combined with antiandrogens or 5α-reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α-reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment.
Treatment of Hirsutism