Happy Holidays

Image by Viggo Johanson,Wikimedia Commons

I'm taking some much-needed time off to spend with my family during the holiday, so the blog will be taking a brief break.

I hope you have a wonderful Christmas (or whatever holiday you celebrate). Many blessings to you and yours!

Honey for Cesarean Wound Healing?

We've discussed honey for wound healing before, and specifically for cesarean wound healing.

We talked about the mechanics of how honey (medical grade honey, not supermarket honey) might help healing and what studies there were on the topic.

As one review notes:

Honey has anti-oxidant, anti-bacterial and anti-inflammatory properties. It can be used as a wound dressing to promote rapid and improved healing. These effects are due to honey's anti-bacterial action, secondary to its high acidity, osmotic effect, anti-oxidant content and hydrogen peroxide content. The use of honey leads to improved wound healing in acute cases, pain relief in burn patients and decreased inflammatory response in such patients...There is biological plausibility.

Mixed Results

While honey has "biological plausibility" as a healing agent, results from use of medical grade honey have been encouraging in some situations and discouraging in others. Results were not very good for venous ulcers, for example, but on some wounds there are better results.

A recent Cochrane review found decidedly mixed results, depending on what type of wound was being studied, and cautioned against its routine use until more data is available. So it's hard to know just how useful medical grade honey really is, and how much is just hype.

The problem is that much of the honey-based research is sponsored by the companies that make medical-grade honey, so the results are at high risk for bias.

Bottom line.....better data is needed. But given the positive results in some studies and its relatively low cost, why haven't there been more well-controlled studies done by independent groups by now?

Medical-Grade Honey for Cesarean Healing

Sadly, there's not a lot of data on using honey for cesarean wound healing. There are a couple of older studies done in third-world countries, but they had small data sets and uncontrolled conditions. As a result, using medical honey on a cesarean wound has not been been embraced in Western countries.

Now there's a new study on the use of honey for abdominal wound healing after cesarean. The data set is still very small and still from a third-world country, but at least the study design is randomized and blinded. The results from this study were encouraging.

This doesn't prove honey is a healing agent of choice for cesarean wounds, but it certainly points to the need for bigger and better studies to further examine the question. 

I would particularly like to see medical-grade honey investigated in the treatment of cesarean wound infections of "obese" women (who are substantially more at-risk for wound infection than other women).

About 15-30% of high-BMI women will experience a wound infection after a cesarean, and sometimes these infections last for months. Wound infections like this can be devastating to a new mother, can interfere with breastfeeding, and are costly to treat.

Many cesarean wound infections in obese women can likely be lowered by using more appropriate dosages of antibiotics, but medical grade honey might give another weapon in the arsenal against infections in this group of women.

Of course, the best treatment is prevention of the cesareans in the first place whenever possible, which is why the 40-80% cesarean rate in "morbidly" and "super obese" women is so completely unacceptable.

But sometimes cesareans truly are necessary. When cesareans do occur in this group of women, more tools are needed to help prevent or treat the wound infections that will result in some of them.

Medical-grade honey might be yet another tool in the toolbox for this situation. And it's past time for Western medicine to investigate this possibility more thoroughly.


Reference

Oman Med J. 2014 Jul;29(4):255-9. doi: 10.5001/omj.2014.68. The effect of honey gel on abdominal wound healing in cesarean section: a triple blind randomized clinical trial. Nikpour M1, Shirvani MA2, Azadbakht M3, Zanjani R4, Mousavi E5. PMID: 25170405

OBJECTIVE: To assess whether honey can accelerate the wound healing in women undergoing cesarean section. METHODS: This was a triple blinded randomized prospective clinical trial. Women with cesarean section were randomly designated as drug (37 cases) and placebo (38 cases) groups. The drug group received local honey gel 25% while the placebo group received similar free-honey gel on abdominal cesarean incision twice a day for 14 days. REEDA scale (Redness, Edema, Ecchymosis, Discharge and Approximation of wound edges) was used to assess wound healing. RESULTS: The mean REEDA was 2.27 ± 2.46 and 3.91 ± 2.74 (p=0.008) on the 7(th) day and 0.47 ± 0.84 and 1.59± 1.95 (p=0.002) on the 14(th) day for the drug and placebo groups, respectively. Redness, edema and hematoma in the drug group were significantly lower on the 7(th) and 14(th) days. CONCLUSION: Honey was effective in healing the cesarean section incision. Using topical honey is suggested as a natural product with rare side effects in order to reduce the complications of cesarean wounds.

Widespread Misconceptions About Obesity

I recently stumbled across an article by pure coincidence. It's called "Widespread Misconceptions About Obesity."

It was written by several doctors and researchers, and it was published last month in the journal, Canadian Family Physician. You can read the full text of the article here.

In the meantime, here are some good quotes from the article (my emphasis):

• Although obesity can be a serious health threat, we lack effective strategies to address this condition on an individual and a societal level. Myths and misconceptions about obesity are pervasive in the media, popular culture, and scientific literature
• It is very common to hear that obese people are lazy and should get off the couch. This discriminatory bias against those with excess weight is not only widespread among the lay public but also among health professionals, even those in regular contact with patients with obesity
• Physicians should remember that obesity is not a choice
• Obesity management should focus on promoting healthier behaviour rather than simply reducing numbers on the scale
• It might be time to shift the focus away from body weight to health and wellness in public health interventions

Here is their list of 7 common misconceptions about obesity:

1. Obesity is primarily caused by a lack of physical activity or by unhealthy dietary habits
2. Obese individuals are less active than their normal-weight counterparts
3. Diets work in the long term
4. Weight loss does not have significant adverse effects
5. Exercising is better than dieting to lose weight
6. Everyone can lose weight with enough willpower
7. A successful obesity management program is measured by the amount of weight lost

The article is not perfect, of course, and I have some nitpicks here and there.

But I was especially pleased to hear them mention shifting the focus from numbers on a scale to health habits. We may not all be able to become a "normal" BMI, but we can all improve our health behaviors, and that will help health, regardless of where your BMI is.

This is right in line with the Health At Every Size® philosophy (even if they don't mention that concept by name), which is starting to gain more traction in mainstream research. Hopefully these authors would support eliminating obesity stigma in public health campaigns as well.

On the whole, this article is a welcome change to the dialogue about obesity. How heartening that at least some family doctors are starting to "get it."

Now if we could only get the word out to medical schools and obesity researchers, where weight stigma runs rampant and largely unchecked.

For example, did you see the recent blog post about professional obesity researchers making fun of fat people and cracking fat jokes during their conference? No less a major journal than The Lancet published a piece about it, which concluded:

In line with guidelines for publishing in obesity and journals of other disciplines that adhere to the standards of the Committee on Publication Ethics, authors should avoid bias and stereotypical language, which should apply to all dissemination activity including academic conferences. Hence, obesity researchers should adhere to these standards.

Amen to that! Hard to believe how unprofessional these researchers were. But frankly, that kind of behavior goes hand in hand with the utter contempt that so many in the obesity field have towards their study population. Kudos to authors Stuart W. Flint and Sophie Reale for having the professional courage to shine a light on this disgusting behavior.

So, on the whole, it was a week of encouragement and discouragement in some ways. It was encouraging to see the Canadian Family Physician article addressing common misconceptions about obesity, but it was frustrating to hear about professional academics resorting to fat jokes and put-downs about the very people they study and are supposed to be "helping." At least The Lancet published a letter calling them on the carpet for it, I guess.

One step forward, two steps back. Sigh.

References

Chaput, J. P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician, 60(11), 973-975. PMID: 25392431 Full text available here. 

Flint, S. W., & Reale, S. (2014). Obesity stigmatisation from obesity researchers. The Lancet, 384(9958), 1925-1926. Full text available here.

Labor Length in "Obese" Women: Dig Deeper

Here's the abstract of an interesting study suggesting that the first stage of labor (dilation) is longer in "obese" women and that this ought to be taken into account when diagnosing labor arrest needing a cesarean in this group.

This is not the first study to find a longer length of labor in higher-BMI women. As a result of these differences, one study concluded:

It is critical to consider differences in labor progression by maternal prepregnancy BMI before additional interventions are performed.

I agree that a possible longer labor length ought to be taken into account before resorting to a cesarean. As we've discussed before, many cesareans are done for "Failure to Wait" rather than for a true emergency, and many cesareans in women of all sizes could probably be avoided if care providers were a little more patient during labor.

In fact, a recent joint statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine suggested that women be allowed a longer time in early ("latent") labor, that women not be considered to be in "active labor" until 6 cm (instead of 4 cm), and that they be given more time both in active labor and in the pushing stage before the doctor starts thinking cesarean.

This may be especially meaningful for high BMI women, as there tends to be a lower surgical threshold for women of size. In one study, labor in obese women was terminated by cesarean an hour earlier on average than in other women. This shows that some doctors are nervous in the labors of obese women and jump to a surgical solution far too quickly.

On the one hand, it is understandable that doctors are nervous about doing a truly emergent cesarean in obese women, since accessing the baby takes longer and the surgery is more difficult. On the other hand, if doctors jump to cesareans too quickly, many obese women who might have given birth vaginally are exposed to the substantial risks of surgery. And since many women of size these days are strongly discouraged from VBAC, this often means further cesareans, which is even more risky.

It's important to acknowledge that it can be difficult for providers to judge whether or not labor should continue in obese women with slow labors. However, provided the fetus is doing well, this study suggests that care providers should be more patient in the labors of women of size. 

Yes! That's something I've been saying for a while now.

Digging Deeper

However, I'd also like researchers to dig even further into why our labors may be longer.

There is some research to suggest that women of size have higher rates of posterior (OP) babies, and OP babies often have prolonged labors. I wish this study's database had fetal position recorded so they could have checked out this possibility.

Do obese women really have more posterior babies? Is that why they tend to have longer labors and more cesareans for dystocia? Or is it a relative lack of responsiveness to oxytocin, as some authors have suggested?

A number of older studies on obesity and pregnancy noted higher rates of fetal malpositions, particularly OP. Most newer studies have not looked for a connection, although the study linked above does note higher OP rates in obese women. Anecdotally, my own birth stories and the birth stories of many fat women I've received over the years for my website seems to support the idea of a higher rate of malpositions as well. All this suggests a connection, but of course we need data to back that up.

I would love to see someone, somewhere research the fascinating question of whether women of size have more malpositioned babies and whether this is one factor behind slower labor rates in this group. I'm sure it's not the only factor, but I would guess that it is a significantly underestimated factor.

If you are a woman of size reading this post, don't panic and think you're doomed to have a really long labor just because you are heavier. On average, our labors tend to be longer, but there's no way to predict labor length for any one person.

SO MUCH of labor length has to do with the position of the baby, whether or not labor is induced, how ripe the woman's cervix is, whether the woman can be mobile in labor, and many other factors. I've known fat women who have had 2 hour labors, and I've known fat women who have had very long labors. My own four labors varied from 8 hours to nearly 20 hours ─ same-sized woman every time but the difference was well-positioned babies vs. OP babies. So labor length really can be highly variable, even within the same person's experiences.

Summary

A combination of a tendency towards longer labor and a lower surgical threshold for cesarean, along with more inductions, is probably why the cesarean rate in high BMI women has risen so high. Because obese women have more complications with cesareans, it is important to discover how to lower this rate.

The take-away message from this study is that, on average, the labors in high BMI women were longer, and their care providers probably should take that into account and wait a little longer before diagnosing a labor arrest disorder and doing a cesarean.

If you are a woman of size, find a care provider who truly believes that you can have a vaginal birth and who is willing to be more patient in labor before resorting to a cesarean. (Generally speaking, midwives tend to be more willing to wait, although some OBs are great about this too. Don't depend on a title but ask careful questions to better understand a provider's practice style.)

If you are a researcher, dig a little deeper and explore why women of size have longer labors, including whether or not there is a higher rate of fetal malpositions. I suspect there is but I'd love to see recent data to confirm this.

If there are more OP babies in heavier women, then there are things that women of size can do that might help lower their chances of a malpositioned baby before labor (chiropractic care is what helped me). Additionally, there are things a care provider can do during labor to help turn a malpositioned baby if needed (research on manual rotation is very promising). And of course, sometimes all that's needed for an OP baby is to have a little more patience in labor.

Whether it's being more patient in labor, doing fewer inductions, or being more proactive about fetal position in women of size, there are things we can do to lower the cesarean rate in this group. It's about time we start doing them. 


Reference

Eur J Obstet Gynecol Reprod Biol. 2013 Nov;171(1):49-53. doi: 10.1016/j.ejogrb.2013.08.021. Epub 2013 Aug 29. Maternal body mass index and duration of labor. Carlhäll S1, Källén K, Blomberg M. PMID: 24041847

OBJECTIVE: To evaluate whether the duration of the active phase of labor is associated with maternal body mass index (BMI), in nulliparous women with spontaneous onset of labor. STUDY DESIGN: Historical prospective cohort study including 63,829 nulliparous women with a singleton pregnancy and a spontaneous onset of labor, who delivered between January 1, 1995 and December 31, 2009. Data were collected from the Perinatal Revision South registry, a regional perinatal database in Southern Sweden. Women were categorized into six classes of BMI. Overweight and obese women were compared to normal weight women regarding duration of active labor. Adjustments were made for year of delivery, maternal age and infant birth weight. RESULTS: The median duration of labor was significantly longer in obese women (class I obesity (BMI 30-34.9) = 9.1h, class II obesity (BMI 35-39.9) = 9.2h and class III obesity (BMI > 40) = 9.8h) compared to normal-weight women (BMI 18.5-24.9) = 8.8h (p < 0.001). The risk of labor lasting more than 12h increased with increasing maternal BMI: OR 1.04 (1.01-1.06) (OR per 5-units BMI-increase).The risk of labor lasting more than 12h or emergency cesarean section within 12h, compared to vaginal deliveries within 12h, increased with increasing maternal BMI. Duration of the second stage of labor was significantly shorter in obese women: in class III obesity the median value was 0.45 h compared to normal weight women, 0.55 h (p < 0.001). CONCLUSION: In nulliparous women with a spontaneous onset of labor, duration of the active phase of labor increased significantly with increasing maternal BMI. Once obese women reach the second stage they deliver more quickly than normal weight women, which implies that the risk of prolonged labor is restricted to the first stage of labor. It is clinically important to consider the prolonged first stage of labor in obese women, for example when diagnosing first stage labor arrest, in order to optimize management of this rapidly growing at-risk group of women. Thus, it might be reasonable to adapt the considered upper limit for duration of labor, according to maternal BMI.

Increase in Cesarean Rate in Morbidly Obese Women Over Time

Here's the abstract of an interesting new study. I haven't seen the full text yet but it appears to show that while the cesarean rate has gone up over time in all sizes of women, it's gone up the most in the higher BMI categories.

In other words, a high BMI woman is far more likely to have a cesarean now than she was in 1990.

This shows that the high cesarean rate in obese women is not just about obesity itself, but also how obese women are managed in labor and the lowering of the surgical threshold for performing cesareans in high BMI women.

I've been saying this for years. Some care providers like to pretend that the high cesarean rate in obese women is only about the woman's fatness, as if this somehow prevents a fat woman from giving birth vaginally (the classic "fat vagina" theory).

But if it was really only about physical barriers, then you would see a relatively consistent cesarean rate in this group over time, and you DON'T. This study shows that there used to be much lower cesarean rates in women of size than there is today, and older studies show that the cesarean rate wasn't always higher in obese women than in average-sized women.

Critics would point out that the cesarean rate has increased in all groups over time, not just in obese women. Sad, but true.

But the cesarean rate has not increased equally in every group, as this study points out. Look at their comparison of cesarean rates between 1990 and 2012 by BMI group*:

                              1990                     2012                   Increase

Underweight         14.4%                   27.9%                  13.5%
Normal                  16.1%                   31.4%                  15.3%
Overweight           19.5%                   38.8%                  19.3%
Obese I                 22.3%                   45.1%                  22.8%
Obese II                25.0%                   50.2%                  25.2%
Obese III               26.9%                   55.2%                  28.3%

The increase in cesarean rates was not uniform across BMI categories. The increase in "normal" weight women was 15.3%, but the increase in Obese Class III women was nearly twice that at 28.3%.

In 1990, Obese class III women had a 26.9% cesarean rate in 1990....just over 1 in 4.

In 2012, Obese Class III women  had a 55.2% cesarean rate instead, or more than 1 in every 2 "morbidly obese" women.

In just 22 years, the cesarean rate in Class III Obese women went from 26.0% to 55.2%. How far will it go in the next 20 years?

Something has changed...and that something is probably how those women are managed in labor (more interventions), the exaggeration of fear around their pregnancies, and the resulting lowering of the surgical threshold for a cesarean in that group.

Similarly, research shows that cesarean rates in the same BMI group can vary dramatically between locations. For example, recent studies from Tennessee and Kentucky show an abysmal cesarean rate of nearly 60% in "morbidly obese" women. One particularly appalling study from Michigan shows a cesarean rate of over 80% in women with a BMI over 50.

Yet a large study from the U.K. shows a cesarean rate of about 30% in the same population.

This shows that practice variation is an issue not only in the overall population, but perhaps particularly in high BMI women.

It's time for care providers to examine not only how to prevent questionable cesareans in women across the board, but also to focus on how to prevent questionable cesareans in high-BMI women. Given that cesareans carry more risks in women of size, especially multiple repeat cesareans, it's inexcusable to be exposing so many of these women to these risks unnecessarily.

The cesarean rate is high is women of size, but the variation in rates over time and between locations shows it doesn't have to be, and that there are things we could be doing to bring the cesarean rate down in this group.

It's long past time to be looking into that question. Some researchers are starting to ask these questions or propose solutions, but few have actually tested these theories.

Where are the researchers and providers willing to actually study how to lower the cesarean rate in women of size?


References

J Perinat Med. 2014 Jun 10. pii: /j/jpme.ahead-of-print/jpm-2014-0126/jpm-2014-0126.xml. doi: 10.1515/jpm-2014-0126. [Epub ahead of print] Impact of maternal body mass index on the cesarean delivery rate in Germany from 1990 to 2012. Kyvernitakis I, Köhler C, Schmidt S, Misselwitz B, Großmann J, Hadji P, Kalder M. PMID: 24914711

ABSTRACT AIMS: Maternal obesity is a risk factor for cesarean delivery (CD). The aim of this analysis was to determine the association between early-pregnancy body mass index (BMI) and the rate of CD over the past two decades. METHODS: We retrospectively analyzed data from the perinatal quality registry of singleton deliveries in the state of Hesse in Germany from 1990 to 2012. We divided the patients into groups according to the WHO criteria for BMI: underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), obese class I (30-<35), obese class II (35-<40), and obese class III (≥40). RESULTS: The analysis included 1,092,311 patients with available data regarding maternal BMI and mode of delivery. The CD rates for underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), obese class I (30-<35), obese class II (35-<40), and obese class III (≥40) women increased from 14.4%, 16.1%, 19.5%, 22.3%, 25%, and 26.9% in the year 1990 to 27.9%, 31.4%, 38.8%, 45.1%, 50.2%, and 55.2% in the year 2012, respectively (P<0.001). CONCLUSION: Maternal BMI in early pregnancy is linearly associated with the incidence of CD. We found a disproportionate increase of CD in morbidly obese women compared with the CD incidence in the reference BMI population over the past two decades.

* Standard BMI classifications: 

• "Underweight" = BMI less than 18
• "Normal" weight = BMI 18-24.9
• "Overweight" = BMI 25-29.9
• Class I Obese = BMI 30-34.9
• Class II Obese = BMI 35-39.9
• Class III Obese = BMI of 40 plus
• "Super Obese" = BMI of 50 plus

See my Practice Variation Post at Science and Sensibility

My recent post on Practice Variation in Cesarean Rates went a bit viral. (Thank you to those of you who shared it on Facebook!)

The blog, Science and Sensibility (Lamaze International’s “Research Blog About Healthy Pregnancy, Birth & Beyond”), picked it up and asked to run it since it's very topical right now, what with the recent important study on Practice Variation.

I revised my very-quick original post and expanded on a few points, added some new research, reformatted it a bit, and generally prettified it up. (I spent all my time on that, so no new post here till next week.)

In the meantime, the revised post is now up on Science and Sensibility. You can go and read it here.

Practice Variation in Cesarean Rates: Not Due to Maternal Complications

Photo courtesy "Angela"

There's a new study out that discusses the variation in cesarean rates between hospitals in the United States.

Practice variation is a serious problem in obstetrics. Women are often far more at risk for a cesarean in certain hospitals than in others, even when the hospitals serve the same geographical area and population.

Of course, care providers protest that some hospitals have higher cesarean rates because they serve higher-risk patients. This is a valid point, but it still doesn't explain the wide variation in rates between many hospitals.

For example, in the study above, the mother's risk status and diagnoses did not explain the variation in cesarean rates between hospitals:

“We found that the variability in hospital cesarean rates was not driven by differences in maternal diagnoses or pregnancy complexity,” said [lead study author] Kozhimannil. “This means there was significantly higher variation in hospital rates than would be expected based on women’s health conditions. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

There were several key points highlighted in the article about the study, including:

• Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
• Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
• Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother's risk level. 

Perhaps now we can stop playing the mother blame-game when we talk about cesarean rates?

This study is not the first to show that the culture of a hospital, their policies, and their routine practices all help determine how likely a woman is to "need" a cesarean in that hospital.

This is important because while cesareans can be life-saving at times, they present more risk for infection, bleeding, pain, neonatal breathing problems, and complications in future pregnancies. It matters where and with whom a woman gives birth.

But many women naively choose their care provider for pregnancy based mostly on convenience and location, not realizing that their chances of surgical birth may vary greatly depending on which hospital and caregiver they use. 

One leading consumer education site points out, "Research suggests that the same woman might have a c-section at one hospital but a vaginal birth if she gave birth at another, just because of the different policies and practices of those hospitals. One of the most effective ways to lower your chance of having a c-section is to have your baby in a setting with a low c-section rate."

Yet it is not always easy to find out the cesarean rates* of local hospitals in some states, and many hospitals remain largely unaccountable for sky-high cesarean rates, although we are beginning to see marginal progress in some places towards accountability. But even when a cesarean is truly necessary, there can be large discrepancies in complications afterwards between hospitals. How is a woman to know which hospital to choose?

Bottom line, more transparency and accountability are needed. As the lead author of the study states: 

Women deserve evidence-based, consistent, high-quality maternity care, regardless of the hospital where they give birth...and these results indicate that we have a long way to go toward reaching this goal in the U.S.

**An additional suggestion: Researchers should start examining cesarean practice variations in obese patients too. Research strongly suggests there are major practice variations in cesarean utilization for "obese" mothers between hospitals, yet this is a topic that is rarely broached in research. More exploration of this dichotomy might help reduce the cesarean rate in this group.

***Post received minor reference and picture edits on 11/6/14.

References

*See www.cesareanrates.com for hospital level cesarean rates in most U.S. states. Consumer Reports also has a recent article with some hospital-level c-section rates in the U.S.

PLoS Med. 2014 Oct 21;11(10):e1001745. doi: 10.1371/journal.pmed.1001745. eCollection 2014. Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database. Kozhimannil KB1, Arcaya MC2, Subramanian SV2. PMID: 25333943

BACKGROUND: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. METHODS AND FINDINGS: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project-a 20% sample of US hospitals-we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. CONCLUSIONS: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors-such as hospital policies, practices, and culture-in determining cesarean section use.

Am J Obstet Gynecol. 2007 Jun;196(6):526.e1-5. Variation in the rates of operative delivery in the United States. Clark SL1, Belfort MA, Hankins GD, Meyers JA, Houser FM. PMID: 17547880

OBJECTIVES: This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making. STUDY DESIGN: We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. RESULTS: In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. CONCLUSION: Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.

Neonatology. 2014 Oct 4;107(1):8-13. [Epub ahead of print] Women Are Designed to Deliver Vaginally and Not by Cesarean Section: An Obstetrician's View. Visser GH. PMID: 25301178

Worldwide, there is a rapid increase in deliveries by cesarean section. The large differences among countries, from about 16% to more than 60%, suggest that the cesarean delivery (CD) rate has little to do with evidence-based medicine. In this review, the background for the increasing CD rate is discussed as well as the limited positive effects on neonatal outcome in both term and preterm neonates. Negative effects of CD, including direct maternal morbidity, complications of subsequent pregnancies and iatrogenic early delivery resulting in increased neonatal morbidity, are discussed in addition to long-term implications for the offspring involving altered development of the immune system. The 'battle' to lower the CD rate will be difficult, but we should not forget that women are designed to deliver vaginally and not by cesarean section. 

A Weight-Inclusive Approach to Health

J Obes. 2014;2014:983495. doi: 10.1155/2014/983495. Epub 2014 Jul 23. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. Tylka TL1, Annunziato RA2, Burgard D3, Daníelsdóttir S4, Shuman E5, Davis C2, Calogero RM6. PMID: 25147734 Free full text available here.

Using an ethical lens, this review evaluates two methods of working within patient care and public health: the weight-normative approach (emphasis on weight and weight loss when defining health and well-being) and the weight-inclusive approach (emphasis on viewing health and well-being as multifaceted while directing efforts toward improving health access and reducing weight stigma). 

Data reveal that the weight-normative approach is not effective for most people because of high rates of weight regain and cycling from weight loss interventions, which are linked to adverse health and well-being. Its predominant focus on weight may also foster stigma in health care and society, and data show that weight stigma is also linked to adverse health and well-being. 

In contrast, data support a weight-inclusive approach, which is included in models such as Health at Every Size for improving physical (e.g., blood pressure), behavioral (e.g., binge eating), and psychological (e.g., depression) indices, as well as acceptability of public health messages. 

Therefore, the weight-inclusive approach upholds nonmaleficience and beneficience, whereas the weight-normative approach does not. We offer a theoretical framework that organizes the research included in this review and discuss how it can guide research efforts and help health professionals intervene with their patients and community.

PCOS and Birth Control Pills, Part 3: Use for PCOS

In honor of the recent PCOS Awareness Month, we are continuing our periodic series on PCOS, Polycystic Ovarian Syndrome.

Here are some of the previous entries so far in the series:

• The definition and symptoms of PCOS
• How it presents
• Its testing and diagnosis
• Its possible causes

Now we are discussing common treatment protocols for PCOS (and the pros and cons of each) ─ from a Health At Every Size®, size-friendly point of view (meaning improving health without making the scale the focus; no diet/weight loss talk).

We've already discussed:

• Metformin (Glucophage) 
• TZDs (Avandia, Actos) 
• Inositols 
• Other medication options for those with diabetes
• Progesterone treatments for bringing on a long-overdue period

Now we are talking about using birth control pills to regulate the menstrual cycle, reduce androgen levels, and control unpleasant PCOS symptoms like hirsutism and acne.

Part One was background about how oral contraceptives work, the different types available, and side effects to be aware of. Part Two looked at whether there were special considerations for oral contraceptive use in women of size.

Today, we discuss more about the use of oral contraceptives for treating symptoms of PCOS.

Disclaimer: I am not a medical health-care professional. Always do your own research. This information is not a complete explanation of all the risks and benefits of a particular medication, nor is it medical advice about a health condition or treatment. Consult your healthcare provider before making any decisions about your care.

Advantages of The Pill for PCOS

Among care providers trained in the traditional medical model, the use of oral contraceptives is considered standard of care for women with PCOS who are not actively trying to conceive.

In their view, the many potential benefits outweigh any potential risks. It is considered a standard-of-care first-line therapy for PCOS women who are not trying to conceive.

From this point of view its biggest benefit is that it regulates the cycle, preventing the missed periods so common to many women with PCOS. In this way, it is thought to strongly reduce the risk for the endometrial cancer, which is increased in women with PCOS. But while some short-term and long-term evidence is promising on its effectiveness against endometrial cancer, high-quality long-term evidence is still somewhat lacking. We need more long-term studies to be sure it truly lowers the risk for endometrial cancer.

The risk for ovarian cancer may also be increased in women with PCOS, and oral contraceptives clearly lower the risk for ovarian cancer, so that is a solid advantage to using oral contraceptives.

In addition, oral contraceptives tend to decrease Luteinizing Hormone (LH) levels and this leads to a subsequent decrease in androgen production. Oral contraceptives also increase Sex Hormone Binding Globulin (SHBG) production, decreasing free testosterone levels.

Because the Pill tends to lower androgen levels, it often lessens acne, hirsutism, and other skin-related symptoms common to PCOS. To many women with PCOS, this is a very important benefit.

Oral contraceptives also inhibit development of egg follicles. Fewer follicles may lessen the severity of polycystic ovaries, and therefore lower additional production of androgens.

Research shows that oral contraceptives can greatly improve menstrual regularity in women with PCOS, and that certain types can also lessen androgens and distressing symptoms of PCOS like hirsutism and acne.

In this way, the use of oral contraceptives in PCOS has significant benefits.

Risks of the Pill for PCOS

As we have discussed more extensively in Part One and Part Two of this series, oral contraceptives are associated with several risks that are particularly pertinent for women with PCOS. These include:

• a possibly increased risk for insulin resistance/glucose intolerance
• a definitely increased risk for blood clots
• an unknown risk for cardiovascular disease and mortality

Therefore, the choice about using oral contraceptives has to consider the balance of benefits vs. risks, which may be unique to each woman.

Glucose Tolerance

Some studies have found an increase in insulin resistance/decrease in insulin sensitivity in women on oral contraceptives, while other studies have not. Some have found an increased fasting glucose, while others have found lower blood glucose levels or no increase in diabetes cases.

Since there are so many formulations, a lot depends on the type of oral contraceptive used; high-dose combination pills (30+ mcg of ethinyl estradiol) seem to have a more negative effect on insulin sensitivity. Low-dose pills seem to have less effect or even possibly beneficial effects.

Most studies focus on non-diabetic women of average BMI in the general population; less is known about its effect in obese women, let alone obese women with PCOS. But one recent review concluded that while there were mild fluctuations in glucose and insulin levels in a few studies, overall there was "no significant effect" of oral contraceptives on carbohydrate metabolism in women with PCOS.

If there is an effect in women with PCOS, it probably is a very modest one, especially with low-dose combination pills. However, for very high-BMI women, those with severe insulin resistance, or those who are borderline diabetic already, it's possible that some types of oral contraceptives may somewhat increase the susceptibility to diabetes or glucose intolerance.

As a result, some care providers prescribe a combination of certain oral contraceptives (for their anti-androgenic effects) plus metformin or inositol (to help counteract any increase in insulin resistance from the oral contraceptives) for women with PCOS who are particularly at risk for diabetes and metabolic syndrome. This combination of oral contraceptives and an insulin sensitizing medication seems particularly effective for some women with PCOS.

Blood clots

Oral contraceptives of any dose clearly increase the risk for blood clots in the general population, particularly in the first year of use. The risk is strongest with high-dose pills (50 mcg ethinyl estradiol) and mildest with low-dose pills (20 mcg ethinyl estradiol). Risk also depends on the type of progestin used.

However, what the clot risk is in women with PCOS is less clear. Research shows that women with PCOS tend to have a higher risk for blood clots than the rest of the population; the concern is that use of the Pill in women with PCOS might elevate that risk even further.

And in fact, one study showed that women with PCOS on the Pill had about twice the risk for blood clots as other women on the Pill, and women with PCOS not taking the Pill had about 1.5x the risk for clots.

However, not all studies agree; one large study found oral contraceptives to be mildly protective against blood clots in women with PCOS.

Further muddying the waters is the fact that the progestins with the most potent anti-androgenic properties tend to be the ones associated with the greatest risk for blood clots. The progestins associated with the least risk of clots tend to have strong androgenic side effects.

Therein lies the dilemma for women with PCOS; if you use the oral contraceptive with the most potent anti-androgen effects, there is a considerably higher risk for blood clots. If you opt for the safer oral contraceptives in order to at least regulate your cycles, you will not help and may even worsen any hirsutism and acne.

All women with PCOS who are considering the Pill should discuss the risk for blood clots with their care providers. If you have further risk for clots, such as a first-degree relative who has experienced blood clots or poorly-controlled hypertension, you will need to consider the use of the Pill especially carefully with a care provider. They might suggest you consider other alternatives instead.

Cardiovascular Disease

Most PCOS research does not follow its subjects long-term, so there is a dearth of research on the long-term risks for cardiovascular disease and mortality in women with PCOS.

Because of an increase in blood clots plus risk factors like hypertension, diabetes, and abnormal lipids, most researchers have assumed for years that women with PCOS are at extremely high risk for cardiovascular disease and early death. Women with the hyperandrogenic "classic" PCOS phenotype have been thought to be particularly at risk.

Interestingly, what research we have so far does NOT suggest an increase in cardiovascular and mortality risk for women with PCOS, and only a small increase for non-fatal cerebrovascular disease. One very small study that followed women for 21 years found more hypertension and lipid abnormalities in women with PCOS, but no more heart attacks, strokes, or mortality than the controls from the general population.

Since oral contraceptives tend to worsen lipid profiles, increase the risk for blood clots, and perhaps worsen cardiovascular risks in the short-term, the question is whether oral contraceptive use would worsen cardiovascular risks in women with PCOS. Bottom line, we just don't have much data on this:

Only a few studies assessing the metabolic effects of OCPs in PCOS are available in the literature. The randomized controlled trials are even fewer. Most of the studies had a small number of participants with a limited follow-up period, and several confounding factors that might have influenced the results were not taken into account in these studies...the use of OCPs combined with other treatment modalities such as antiandrogens or insulin sensitizers remain largely unknown. Larger randomized controlled studies are undoubtedly needed to resolve controversies about OCPs....

Several sources have speculated that oral contraceptives may actually be protective against cardiovascular issues in women with PCOS in the long run. One review suggested that the lack of increased cardiovascular disease and mortality seen thus far in PCOS women may actually suggest "unproven preventive alterations" of oral contraceptives because the Pill is such a common treatment in PCOS. However, without specific data on outcomes in PCOS women who are on oral contraceptives vs. those who are not, this is completely speculative at this point.

Of course, even if oral contraceptives did increase the risk for cardiovascular disease, you also have to remember that oral contraceptives probably lower the risk for ovarian cancer and possibly endometrial cancer. So there is a trade-off of risk to consider.

At this point, it is anyone's guess how much risk vs. benefit oral contraceptives have in the long run for women with PCOS.

More long-term data is urgently needed.

Which Pill should be prescribed for PCOS?

There are SO many oral contraceptives to choose from that it is difficult to know which is the best version for women with PCOS.

Oral contraceptives differ by estrogen dose (20 mcg, 25 mcg, 30 mcg, 35 mcg, 50 mcg), by whether medications change throughout the cycle (monophasic, biphasic, triphasic, etc.), and by cycle length (traditional cycle length vs. extended or continuous cycle formulations).

In addition, they differ by type and generation of progestins used (1st generation = norethindrone and ethynodiol acetate pills; 2nd generation = levonorgestrel and norgestrel; 3rd generation = desogestrel, gestodene and norgestimate; 4th generation = drospirenone and dienogest).

In addition, oral contraceptive availability and formulation can differ significantly by country. In the United States alone, one survey found 88 different formulations of oral contraceptives ─ and that doesn't include oral contraceptives using gestodyne and dienogest, which are not currently available in the U.S. Outside the U.S., some countries also have combined oral contraceptives using cyproterone acetate for treating severe acne and hirsutism but not as an oral contraceptive alone.

As noted, some oral contraceptives with the best anti-androgen activity have even greater risks for blood clots, so a delicate balance between anti-androgen benefits and clotting risks must be walked. The interaction between different PCOS phenotypes and a person's personal medical history and risk factors may also influence which oral contraceptive is most appropriate, making the discussion even more complicated.

Therefore, a specific discussion of which oral contraceptive is best for PCOS is far beyond the scope of this blog. No medical advice should be inferred.

Only general considerations will be presented below. Discuss your medical history and treatment goals with your provider to determine the best choice for your situation.

Oral Contraceptives to Treat PCOS Symptoms

As we have seen, oral contraceptives can help lessen some of the most distressing PCOS symptoms, such as acne or excess body and facial hair. They also help regulate the menstrual period, hopefully lowering the risk for endometrial overgrowth and cancer.

However, all oral contraceptives are not alike. Some work better for PCOS than others.

For example, combination oral contraceptives that use progestins like levonorgestrel tend to worsen androgenic symptoms in women with PCOS, so they are often avoided. However, because these pills tend to have the best safety profile, some providers prescribe them anyway to women with PCOS in order to achieve menstrual regulation while incurring the least risk for blood clots. Some care providers feel they are fine for PCOS women with mild androgenic symptoms, but avoid them for women with strong androgenic symptoms.

Some resources report that pills using progestins desogestrel, norgestimate, and gestodene are less androgenic compared with those using levonorgestrel, norethindrone, or norgestrel. At least one source considers oral contraceptives using norgestrel to be "unsuitable" for women with PCOS.

Oral contraceptives with later generations of progestins are often prescribed for women with PCOS, as these tend to be more anti-androgenic. These include dienogest and drospirenone, as well as cyproterone acetate:

Cyproterone acetate is derived from 17-hydroxyprogesterone, whereas dienogest and drospirenone are derivatives of 19-nortestosterone and 17-α-spirolactone, respectively. Cyproterone acetate is the most potent antiandrogenic progestin...Drospirenone was approved by the U.S. Food and Drug Administration (FDA); in 2000, whereas cyproterone acetate and dienogest containing OCPs are not marketed in the United States.

In areas outside the U.S., low-dose combination pills with anti-androgenic progestins like drospirenone and cyproterone acetate are usually favored. Research shows that these pills have greatly helped many women with significant facial hair and acne. One study showed that cyproterone acetate was more effective over the longer-term than drospirenone or desogestrel.

Again, low-dose combination pills with these anti-androgenic progestins also present more risk for blood clots. Therefore, some providers avoid these progestins, preferring other combination pills with more neutral androgen profiles. Others prescribe combined pills with drospirenone or cyproterone acetate but advise taking a low-dose aspirin with them to help counteract the clotting risk.

Some providers favor continuous combined pills in women with severe androgen excess. In this approach, low-dose combined pills are given for 3-6 months, with no placebo pills for withdrawal bleeding. Some research has shown this approach to be quite effective for those with severe hirsutism, and of course has significant benefits to those with endometriosis, iron-deficiency anemia, or debilitating periods. Another advantage is that continuous oral contraceptives tend to have less breakthrough bleeding, which can be an issue with some oral contraceptives. However, some critics question how an unrelenting dose of hormones might affect a woman's long-term health. Short-term safety data seems acceptable, but longer-term studies and research that looks at multiple endpoints (including cardiovascular, breast cancer, and bone health) are urgently needed.

A low-dose combination pill with the addition of metformin or inositol is another option favored by many providers for some in order to counteract the significant insulin resistance common to many with PCOS, while also countering any possible decrease in insulin sensitivity or glucose tolerance due to the Pill. A low-dose aspirin may also be suggested by some providers for anti-clotting purposes, although this must be carefully monitored due to the risk of internal bleeding.

Some providers prefer progestin-only Mini-Pills for very obese women with PCOS, seeing these women as at extremely high risk for blood clots. They reason that Mini-Pills provide contraception, do not increase risk for blood clots, only minimally increase risks for insulin resistance, and regulate the menstrual cycle (thus lessening the risk for endometrial cancer). Since some countries strongly counsel against the prescription of any combined oral contraceptives to women with a BMI over 40, Mini-Pills can be one alternative for these women.

Some researchers have suggested that ALL oral contraceptives be avoided for women with PCOS with significant risk factors like strong insulin resistance, clotting disorders, hypertension, metabolic syndrome, or other cardiovascular risk factors. They have suggested that vaginal contraceptive rings or hormonal intrauterine devices be used instead. These will not help androgen-related symptoms like hirsutism or acne, but will help menstrual regularity and may lessen endometrial cancer risk.

Summary

Obviously, there is not a general consensus on the "best" oral contraceptive (if any) for women with PCOS. Complicating the decision is the huge variety of oral contraceptive formulations available and the variation of risk profiles among women with PCOS.

It is vitally important to consult your health care provider to determine what the best oral contraceptive (if any) is best for your circumstances.

Don't restrict yourself to only the information above to make your choice; discuss the pros and cons in great detail with your care provider. You may also want to consider getting a second opinion since different providers often provide different perspective and advice.

Specific topics to discuss with your provider include:

• Low-dose vs. high-dose pills
• Type of progestin used, how anti-androgenic it is, and the benefit/risk of each type of progestin
• Your family's medical history of diabetes and blood clots (including heart attacks and strokes)
• Other significant risk factors like smoking, age, hypertension, or other co-morbid conditions 
• Your PCOS symptoms 
• Your PCOS treatment goals (menstrual regularity, androgenic issues, insulin resistance, etc.)
• Your tolerance of risk vs. benefit trade-offs

Only when all of these factors are weighed can an individualized decision be made about which type of oral contraceptive (if any) is best for you.

Concerns with the Use of The Pill for PCOS

Of course, not everyone thinks that The Pill is a great idea for women with PCOS.

The main objection seems to be that The Pill simulates normalcy through added hormones, instead of promoting normal functioning of your own systems.  In the words of one site:

Taking the pill will provide your body with artificial hormones to simulate what a normal cycle is supposed to be...[but] the pill is not really regulating your cycle because it is not allowing your body to do the work, it is doing the work for your body.  

In other words, the Pill is a band-aid approach to treating a symptom. It simulates a period but does not help your body create a true regular menstrual cycle. It does not adequately address the underlying cause of problems or help the body to normalize its own insulin signaling and hormone levels.

People who feel this way believe that the best treatment for PCOS is to help a woman's body correct her own hormone levels and insulin signaling, instead of superimposing artificial hormones on it to create a fake semblance of normalcy.

Furthermore, the use of the Pill to regulate irregular cycles in young women may delay diagnosis and effective treatment of other PCOS symptoms. Many teens with irregular cycles are placed on the Pill to regulate their cycles without being told they may have PCOS and without receiving counseling about treatments to improve other PCOS symptoms.

As noted above, another significant concern is whether the Pill worsens insulin resistance, already a concern for PCOS women. Critics argue that at the very least, being put on the Pill alone does not lessen the underlying insulin resistance common to PCOS, and at worst, may actually make it worse. It certainly doesn't fix any defects in insulin signaling that may be happening.

For some women with PCOS, treating the underlying insulin resistance may regulate the cycle without needing birth control pills, while for others, a combination of insulin-sensitizing medications and oral contraceptives may be needed.

Long-term study of the relative benefits and risks of various protocols ─ with a focus on clinical endpoints of diabetes, heart disease, hypertension, and mortality specific to women with PCOS and not just extrapolated from other populations ─ is urgently needed.

Anecdotally, some women with PCOS find that when they come off of oral contraceptives in preparation for trying to conceive, their cycles are so messed up that it's very difficult to regulate them again or to re-establish ovulation. It's like their body has "forgotten" how to do it on its own and they often feel that they would have been better off not being on oral contraceptives at all. This is difficult to prove, but is plausible.

Some limited research supports this idea that regulating cycles with oral contraceptives before trying to conceive does not improve or may even harm the odds of success during fertility treatment. However, some research is contradictory and more data is needed.

Some women with PCOS believe that their hair loss issues (alopecia) were worsened by use of oral contraceptives, even as it helped with issues like acne and menstrual regularity. This is hard to prove and little research exists on it, but should be mentioned as a possible consideration for those already struggling with hair loss.

Bottom line, while birth control pills can be very effective for regulating menstrual cycles, decreasing androgenic side effects, and for decreasing the risk for ovarian and possibly endometrial cancer, it may neglect addressing the underlying cause of PCOS and may worsen metabolic profiles and certain symptoms in some.

Alternatives to Oral Contraceptives 

As we've discussed before, there are alternative treatments out there. It's important to keep reminding women with PCOS that the usual prescriptions of oral contraceptives, weight loss, and anti-androgen drugs are not the only way to treat PCOS.

Alternatives can include acupuncture, herbs like vitex/chasteberry, insulin-sensitizing medications like metformin and inositol, and perhaps vitamin D supplementation. It can also include lifestyle approaches that are compatible with Health At Every Size® and do not fixate on weight loss; these might include moderating carb intake, enhancing nutrition, increasing exercise, avoiding hormone-laden foods, and avoiding gluten. Although good long-term research is needed, many PCOS women find results just as good with these approaches as they do with traditional medical treatments.

Women with PCOS should also be checked for hypothyroidism. A number of studies have found that women with PCOS have a higher rate of abnormal thyroid function. Some studies suggest that hypothyroidism is associated with menstrual disturbances, insulin resistance, and infertility. A number of women with PCOS have found that treating even marginal cases of hypothyroidism helped improve menstrual regularity.

Of course, weight loss is often considered the top therapy for PCOS, even over oral contraceptives, since some research shows it can be effective for resuming ovulation, reducing androgens, and lowering insulin resistance in some women. However, studies on this have many weaknesses; they are often very small, extremely short-term, and do not show what happens if weight loss rebounds (which happens to most). Nor do they acknowledge that weight loss/weight cycling has risks as well as benefits, and that the oft-quoted "just a 5% weight loss" can trigger a rebound to a higher weight than before the diet.

Furthermore, not everyone responds to weight loss; quite a number of women with PCOS still experience missed periods and significant symptoms even after considerable weight loss. It is another tool that can be considered if you wish, but it is far from the magic bullet that doctors pretend it is and may actually be counter-productive for many due to regain and yo-yoing. For some, it even leads to eating disorders and unhealthy behaviors.

Because of these issues, hypocaloric diets for PCOS should not be mandatory for all PCOS women. Those who want to partake in them should be supported, but those who decline them should have their right to patient autonomy respected. Nor should weight loss be a requirement for accessing fertility services or other treatment, a restriction fraught with ethical issues and more than a whiff of the repulsive stench of eugenics.

Remember, there is no one "right" treatment protocol for PCOS. Each woman must find the right combination of treatments that work best for her circumstances and needs. For some, this may include oral contraceptives/birth control pills or even weight loss. For others, it may involve alternative therapies. For many, it involves a combination of a number of different approaches, but no one approach should be mandated across the board.

Summary

For some women with PCOS, oral contraceptives are extremely helpful in regulating menstrual cycles, preventing endometrial hyperplasia, reducing the risk for ovarian cancer, and probably also in decreasing the risk for endometrial cancer.

In addition, some combined oral contraceptives have an anti-androgen effect, so problems such as hirsutism and acne may be lessened while on The Pill.

However, not all women with PCOS feel that oral contraceptives are beneficial in the long run. PCOS communities online tend to be very divided in their views of oral contraceptives for PCOS. Many believe that greater improvement will result from addressing underlying hormonal issues and insulin resistance, seeing oral contraceptives as a "band-aid" that treats the symptoms instead of the cause.

Some women with PCOS find oral contraceptives to be a lifeline in their treatment of the condition, while others report that using them was not helpful or even harmful. Some find insulin-sensitizing medications (metformin, TZDs, the inositols) more useful. Still others benefit most from a combination approach (oral contraceptives plus insulin-sensitizing medications or anti-androgens) or from alternative protocols (herbs, lifestyle modifications, or alternative medicine).

Each woman with PCOS has to make up her own mind on the value of these approaches for treating her PCOS.

As always, you have to determine the right treatment protocol for your needs.


References

*These are just a few sample references. Many more can be found in the links inside the post.

References About PCOS

• http://verity-pcos.org.uk/guide_to_pcos/pcos_books/general_pcos - Verity's guide to books on PCOS; a more varied list than many organizations have
• American College of Obstetricians and Gynecologists (ACOG). Polycystic ovary syndrome. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Oct. 14 p. (ACOG practice bulletin; no. 108). Summary can be found here.
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872139/?report=classic - 2013 review on diagnosis and treatment of PCOS

General Information about The Pill

• http://www.webmd.com/sex/birth-control/birth-control-pills - overview from webmd
• http://www.plannedparenthood.org/health-topics/birth-control/birth-control-pill-4228.htm - simple overview from Planned Parenthood
• http://en.wikipedia.org/wiki/Combined_oral_contraceptive_pill - Wikipedia entry on the combo pill
• http://women.webmd.com/features/comparing-birth-control-pill-types-combination-minipills-more - info on the various types of pills and their pros/cons
• http://www.mayoclinic.com/health/best-birth-control-pill/MY00996 - overview of different types of pills from the Mayo Clinic
• http://www.medscape.com/viewarticle/572203 - article on evaluating the cardiovascular risks of the Pill in PCOS; has info on the various types of Pills available and how they differ
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3469779/pdf/nihms382411.pdf - information about the main types of oral contraceptives currently in use in the United States

Information about Different Types of The Pill

• http://bedsider.org/features/89 - information about different brand names of The Pill
• http://www.medicinenet.com/oral_contraceptives_birth_control_pills/page3.htm - various versions of The Pill and the type of progestin used in each, etc.
• http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601050.html - brand names of the various types of Pill and the type of estrogen and progestin in each

Information about Side Effects of The Pill

• http://www.health.com/health/condition-article/0,,20326842,00.html - various side effects of The Pill and how to deal with them

Information about PCOS and the Pill

• http://pcos.about.com/od/pcos101/a/ocp.htm - general info about the Pill and PCOS
• http://www.ovarian-cysts-pcos.com/birth-control-pills.html - general info about the Pill and PCOS
• http://www.3fatchicks.com/3-contraceptive-options-for-women-with-pcos/ - options for the Pill and PCOS in simple terms
• http://www.medscape.com/viewarticle/572203 - 2008 article on risk-benefit assessment on using the Pill for PCOS; lots of information on the various types of Pills available

Research Studies on PCOS and the Pill

Gynecol Endocrinol. 2008 Oct;24(10):590-600. The effects of Diane-35 and metformin in treatment of polycystic ovary syndrome: an updated systematic review. Jing Z, et al. PMID: 19012104

...A systematic review and meta-analysis were conducted. Randomized controlled studies applying Diane-35 and metformin for treating PCOS were included. The primary outcome was hirsutism...Twelve studies were included. The effect on improving hirsutism was not different between Diane-35 and metformin. Compared with Diane-35, metformin appeared to protect patients against glucose metabolic abnormality with treatment of at least 6 months. Except for triglycerides, no difference in lipid profile existed between Diane-35 and metformin. The evidence that Diane-35 deteriorates lipid and glucose metabolism was insufficient. Diane-35 could result in hypertension and headache. Methodological quality was still the key problem for studies. CONCLUSIONS: Diane-35 is superior to metformin in reducing androgens, but inferior to metformin in reducing insulin. Whether Diane-35 deteriorates lipid metabolism and insulin resistance is still unclear. [Diane-35 is not available in the U.S. or France because of the risk for clots with cyproterone acetate. The 35 stands for 35 mcg ethinyl estradiol dose. It is available as an acne medication in Canada and many other countries.]

Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005552. Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome. Costello M, Shrestha B, Eden J, Sjoblom P, Johnson N.  PMID: 17253562

...Insulin-sensitizing drugs (ISDs) have recently been advocated as possibly a safer and more effective long-term treatment than the oral contraceptive pill (OCP) in women with polycystic ovary syndrome (PCOS). It is important to directly compare the efficacy and safety of ISDs versus OCPs in the long-term treatment of women with PCOS...Six trials were included for analysis, four of which compared metformin versus OCP (104 participants) and two of which compared OCP combined with metformin versus OCP alone (70 participants)...AUTHORS' CONCLUSIONS: Up to 12-months treatment with the OCP is associated with an improvement in menstrual pattern and serum androgen levels compared with metformin; but metformin treatment results in a reduction in fasting insulin and lower triglyceride levels than with the OCP. Side-effect profiles differ between the two drugs. There is either extremely limited or no data on important clinical outcomes such as the development of diabetes, cardiovascular disease, or endometrial cancer. There are no data comparing ISDs other than metformin (that is rosiglitazone, pioglitazone, and D-chiro-inositol) versus OCPs (alone or in combination).

CMAJ. 2012 Dec 3. [Epub ahead of print] Risk of venous thromboembolism in women with polycystic ovary syndrome: a population-based matched cohort analysis. Bird ST, Hartzema AG, Brophy JM, Etminan M, Delaney JA. PMID: 23209115

...RESULTS:The incidence of venous thromboembolism among women with PCOS was 23.7/10 000 person-years, while that for matched controls was 10.9/10 000 person-years. Women with PCOS taking combined oral contraceptives had an RR for venous thromboembolism of 2.14 (95% confidence interval [CI] 1.41-3.24) compared with other contraceptive users. The incidence of venous thromboembolism was 6.3/10 000 person-years among women with PCOS not taking oral contraceptives; the incidence was 4.1/10 000 personyears among matched controls. The RR of venous thromboembolism among women with PCOS not taking oral contraceptives was 1.55 (95% CI 1.10-2.19). INTERPRETATION: We found a 2-fold increased risk of venous thromboembolism among women with PCOS who were taking combined oral contraceptives and a 1.5-fold increased risk among women with PCOS not taking oral contraceptives. Physicians should consider the increased risk of venous thromboembolism when prescribing contraceptive therapy to women with PCOS.

Possible Disadvantages of The Pill for PCOS

• http://www.soulcysters.net/showthread.php?1398-MUST-READ-Do-BCP-s-*really*-help-PCOS-or-just-cover-it-up - questions whether the Pill is just a band-aid approach to symptoms and harms more than helps in the long run
• http://pcos.insulitelabs.com/blog/5/can-birth-control-pills-affect-pcos/ - questions whether the Pill harms more than helps in the long run, especially in terms of insulin resistance; note the sponsor of the site has a treatment protocol (and associated products) for alternative treatment of PCOS
• http://pcosinfo.com/birth-control-and-pcos/ - also questions the use of the Pill, although does not give study references to back up claims that BC pills worsen PCOS
• http://www.livestrong.com/article/477290-can-birth-control-pills-lower-blood-glucose/ - states that some types of the Pill can increase blood sugar/insulin resistance, although unlikely to cause diabetes on its own without other factors

Contraception. 2009 Feb;79(2):111-6. Epub 2008 Oct 16.  Insulin sensitivity and lipid metabolism with oral contraceptives containing chlormadinone acetate or desogestrel: a randomized trial. Cagnacci A, et al. PMID: 19135567

...Second-generation and third-generation oral contraceptives containing 30 mcg or more of ethinylestradiol (EE) decrease insulin sensitivity (SI). In this study, we investigated whether SI is decreased by contraceptives containing lower doses EE or by progestins with antiandrogenic properties...Twenty-eight young healthy women were randomly allocated to receive 20 mcg of EE and 150 mcg of desogestrel (DSG) (n=14) or 30 mcg of EE and 2 mg of chlormadinone acetate (CMA) (n=14) for 6 months. SI and glucose utilization independent of insulin (Sg) were investigated by the minimal model method. Lipid modifications were also analyzed...The present study confirms that DSG, even when associated with low EE dose, decreases SI. By contrast, EE/CMA does not deteriorate SI and induces a favorable lipid profile.

Int J Clin Pract. 2009 Jan;63(1):160-9. Epub 2008 Sep 13. Metabolic and cardiovascular impact of oral contraceptives in polycystic ovary syndrome. Soares GM, et al. PMID: 18795969

...This paper presents a critical evaluation of combined oral contraceptives (COCs) metabolic effect - carbohydrate metabolism and insulin sensitivity, lipid metabolism, haemostasis, body weight, arterial pressure and cardiovascular impact - on PCOS women. Because of the paucity of data on the impact of COCs on cardiovascular and metabolic parameters in PCOS patients, most of there commendations are based on studies involving ovulatory women. The use of low-dose COCs is preferable in PCOS, especially among patients with glucose intolerance, insulin resistance and uncomplicated diabetes mellitus. Although reported as a side effect of COCs, marked weight gain has not been confirmed among users. However, when arterial hypertension or elevated risk for thromboembolism is present, progestogen-only hormonal contraceptives should be used instead of COCs. Regarding dyslipidaemia, COCs reduce low-density lipoprotein and total cholesterol and elevate high-density lipoprotein and triglycerides, and therefore are not recommended for women with high triglycerides levels. The choice of a COC, which alleviates the PCOS-induced hyperandrogenism without significant negative impact on cardiovascular risk, is one of the greatest challenges faced by gynaecologists nowadays....