Blog

PCOS in Pregnancy

March 20, 2020

When people with PCOS become pregnant, this may lead to some pregnancy complications. Complications are dependent on which PCOS criteria the pregnant person fulfilled prior to pregnancy.

Polycystic ovary syndrome (PCOS) is the most common hormonal disorder in reproductive-aged women. To be diagnosed with PCOS, you need at least 2 of the 3 following criteria:

  1. Delayed ovulation or irregular menstrual cycles (oligomenorrhea)
  2. High androgenic hormones like testosterone
  3. Polycystic ovaries on ultrasound

Although not a criteria of PCOS, insulin resistance is also a hallmark of PCOS. High insulin (known as hyperinsulinemia) is more prevalent when features of high androgens (like testosterone) are present.

PCOS and Pregnancy Complications

Miscarriage

During pregnancy, miscarriage is more frequent in those with PCOS. It’s specifically influenced by BMI. High androgens as well as high insulin levels cause inflammation within the body that may lead to difficulties in embryo implantation, miscarriage and adverse pregnancy outcomes, some of which are outlined below.

Gestational Diabetes

Gestational diabetes is pregnancy-induced diabetes, that usually resolves in the postpartum. Studies show that women with PCOS have a 3x higher chance of gestational diabetes, from high androgen levels.

Risk Factors for developing gestational diabetes are:

  • Over 35 years old
  • Pre-pregnancy BMI is over 30 kg/m2
  • Ethnicity (Aboriginal, African, Asian, Hispanic, South Asian)
  • Family history of diabetes
  • Polycystic ovary syndrome, and acanthosis nigricans (a skin condition causing hyperpigmentation of skin, especially in the folds)
  • Corticosteroid use
  • Previous diagnosis of gestational diabetes
  • Previous ‘big’ baby

Around 24-28 weeks, pregnant people are offered screening for gestational diabetes. However, if there’s a high risk of gestational diabetes based on the above risk factors, screening or testing may be offered earlier and then repeated at 24-28 weeks if it was normal.

Pre-eclampsia

Pre-eclampsia is pregnancy-induced high blood pressure (formally known as hypertension) and protein in the urine, or other adverse symptoms; at or after 20 weeks gestation. Studies show that women with PCOS have a 3x higher chance of pre-eclampsia due to high androgen levels.

Symptoms of pre-eclampsia include:

  • Persistent headache
  • Visual disturbances
  • Abdominal pain at the upper right quadrant
  • Nausea and/or vomiting
  • Chest pain/shortness of breath

Risk factors in developing preeclampsia are:

  • Antiphospholipid antibodies
  • Previous pre-eclampsia
  • Pre-existing diabetes
  • Family history of pre-eclampsia
  • Raised pre-pregnancy BMI

Blood Work to Consider

If you’re planning on becoming pregnant or are in the early stages of pregnancy, it may be worthwhile to do some blood work to assess your risk and possibly decrease it.

  • Complete blood count
  • Blood lipids
  • Fasting insulin and fasting glucose
  • Free testosterone, total testosterone, Sex hormone binding globulin (SHBG)

Final Thoughts

Unfortunately there isn’t much treatment for people who have PCOS during pregnancy, although adopting a healthy diet and physical activity is recommended – check with your health care provider to see what’s right for you.

References

Christ, J., Gunning, M., Meun, C., Eijkemans, M., van Rijn, B., & Bonsel, G. et al. (2018). Pre-Conception Characteristics Predict Obstetrical and Neonatal Outcomes in Women With Polycystic Ovary Syndrome. The Journal Of Clinical Endocrinology & Metabolism104(3), 809-818. doi: 10.1210/jc.2018-01787

GESTATIONAL DIABETES MELLITUS: A review for midwives. Retrieved 20 March 2020, from https://www.ontariomidwives.ca/sites/default/files/Gestational-diabetes-mellitus-backgrounder-PUB_0.pdf

Hart, R. (2019). Generational Health Impact of PCOS on Women and their Children. Medical Sciences7(3), 49. doi: 10.3390/medsci7030049

Hypertensive Disorders of Pregnancy. Retrieved 19 March 2020, from https://www.ontariomidwives.ca/sites/default/files/CPG%20supplemental%20resources/HDP%20Summary.pdf

Palomba, S., de Wilde, M., Falbo, A., Koster, M., La Sala, G., & Fauser, B. (2015). Pregnancy complications in women with polycystic ovary syndrome. Human Reproduction Update21(5), 575-592. doi: 10.1093/humupd/dmv029

Fertility and Hypothyroidism

August 1, 2019
fertility hypothyroidism, fertility hashimotos, conception, ovulation, toronto naturopath, naturopathic doctor toronto

Becoming and staying pregnant can be difficult (and heartbreaking if the latter occurs). Oftentimes we don’t know exactly why miscarriage happens, but we do know about the involvement of the thyroid in some women. Recent studies have looked at the association between fertility and the thyroid gland and found that conditions like hypothyroidism and Hashimoto’s Thyroiditis are contributors to infertility. 

Thyroid disorders may affect your period in the following ways:

Hormones such as thyroid stimulating hormone (TSH) and thyroid hormones (T4 and T3) are important for menstrual regularity, egg development and implantation. 

Hypothyroidism

Hypothyroidism occurs when TSH levels are increased beyond their normal limits, when there is not enough T4 secretion, or when there isn’t enough conversion of T4 to T3. The latter means that you can have NORMAL TSH levels but T4 and T3 could be off.

Hypothyroidism signs and symptoms look like:

  • Low metabolism, which can lead to weight gain
  • Low basal body temperature
  • Low pulse or blood pressure
  • Dry and/or scaly skin
  • Dry hair and/or hair loss
  • Slowed reflexes
  • Intolerance to cold
  • Depression

Hashimoto’s Thyroiditis

Hashimoto’s is essentially an autoimmune version of hypothyroidism. It occurs when the body doesn’t recognize the thyroid gland as its own and attacks it, leading to the production of thyroid antibodies such as anti-TPO and thyroglobulin.

Additionally, there is also a connection between Hashimoto’s and gluten sensitivity/celiac disease. So if you’ve been looking for a reason to limit your gluten intake, here it is!

TSH During Pregnancy

During pregnancy, having ideal levels of TSH and thyroid hormones is important because they are associated with increased gestation (time between conception and birth), hypertension, growth restrictions, premature delivery and fetal hypothyroidism. It’s clear that the thyroid should be monitored throughout pregnancy.

Thyroid Testing

The American Thyroid Association recommends that TSH should be checked in all women experiencing infertility, and some groups indicate that TSH should be equal to or less than 2.5mIU/L to reduce miscarriage risk.

Here’s the thing though, usually only TSH will be tested but this isn’t good enough! It’s important to understand everything that’s going on with the thyroid so ask for a comprehensive workup that looks like:

  • TSH
  • T4
  • T3
  • Anti-TPO
  • Thyroglobulin

Thyroid and IVF

IVF can be a stressor to the thyroid. And although no studies have showed that treating hypothyroidism leads to an increase of live births, one study has shown that hypothyroid women have less of a response to ovarian stimulation and a lower rate of embryo transfer.

Next Steps

With infertility being so common nowadays, it’s important to take a good look at the thyroid – especially if you have a family history of thyroid disorders or experiencing any of the above signs or symptoms.

Treating thyroid conditions does not just require medication, particular nutrients like selenium or Vitamin D can also be helpful, as well as trying out some dietary changes if you happen to have high antibody levels. Speak to your naturopathic doctor to see how they can complement your treatment plan.

References

Busnelli, A., Somigliana, E., Benaglia, L., Leonardi, M., Ragni, G. and Fedele, L. (2013). In Vitro Fertilization Outcomes in Treated Hypothyroidism. Thyroid, 23(10), pp.1319-1325.

Biondi, B., Cappola, A. and Cooper, D. (2019). Subclinical Hypothyroidism. JAMA, 322(2), p.153.

Maraka, S., Singh Ospina, N., Mastorakos, G. and O’Keeffe, D. (2018). Subclinical Hypothyroidism in Women Planning Conception and During Pregnancy: Who Should Be Treated and How?. Journal of the Endocrine Society, 2(6), pp.533-546.

Green, K., Werner, M., Franasiak, J., Juneau, C., Hong, K. and Scott, R. (2015). Investigating the optimal preconception TSH range for patients undergoing IVF when controlling for embryo quality. Journal of Assisted Reproduction and Genetics, 32(10), pp.1469-1476.

Orouji Jokar, T., Fourman, L., Lee, H., Mentzinger, K. and Fazeli, P. (2017). Higher TSH Levels Within the Normal Range Are Associated With Unexplained Infertility. The Journal of Clinical Endocrinology & Metabolism, 103(2), pp.632-639.

What is Postpartum Depression?

December 7, 2018
postpartum depression, PPD, postpartum naturopath, toronto naturopath, naturopathic doctor toronto

Happiness always follows after the birth of your baby, right?

Nope, not always. 

Postpartum depression (PPD) is a condition that between 7-20% women experience after delivery. Nowadays more light is being shed on PPD because it’s a serious public health issue that affects women, children, and families. Even though the defined postpartum period is between 2-6 weeks after birth, postpartum depression can happen anytime between 2 weeks to 1 year after birth. 

About 7% of women experience a major depressive episode within the first 3 months, but if you factor minor depressive episodes, about 20% of women experience those within the first 3 months. 

Within the 2 week to 1 year time period, women may experience major depressive episodes. And other common symptoms mainly experienced in PDD (when compared to major depressive disorder) are psychomotor agitation (ex. anxiety or nervous excitement) and lethargy. You may also notice exaggerated changes in mood and pre-occupation with your baby’s well-being. Anxiety, ruminative thoughts and panic may also happen too. 

PPD is a little different than postpartum blues and postpartum psychosis:  

  • Postpartum bluesmild dysphoria occurring in the first week after delivery

  • Postpartum psychosisa condition with a rapid onset associated with hallucinations or bizarre delusions, mood impairment swings, disorganized behaviour, and cognitive dominant symptoms, including extreme sadness and loss of interest or pleasure in things previously enjoyed. Usually occurs in conjunction with bipolar disorder. 

Risk Factors of Postpartum Depression

  • Depression or anxiety during pregnancy

  • Depression prior to pregnancy

  • Changes in hormone levels

  • Your age

  • Chronic health problems

  • Psychological stress

  • Lack of social support from friends and relatives

  • History of pregnancy loss

  • Unwanted pregnancy

  • Socioeconomic status

Symptoms of Postpartum Depression

  • Depressed mood or severe mood swings

  • Excessive crying

  • Difficulty bonding with your baby

  • Withdrawing from your family and friends

  • Loss of appetite or eating much more than usual

  • Inability to sleep (insomnia) or sleeping too much

  • Overwhelming fatigue or loss of energy

  • Reduced interest and pleasure in activities you used to enjoy

  • Intense irritability and anger

  • Fear that you’re not a good mother

  • Feelings of worthlessness, shame, guilt or inadequacy

  • Diminished ability to think clearly, concentrate or make decisions

  • Severe anxiety and panic attacks

  • Thoughts of harming yourself or your baby

  • Recurrent thoughts of death or suicide

Criteria for a Major Depressive Episode

At least five of the following nine symptoms in the same 2-week period:

  • Depressed mood

  • Loss of interest or pleasure

  • Change in weight or appetite

  • Insomnia or hypersomnia

  • Psychomotor retardation or agitation

  • Loss of energy or fatigue

  • Feeling worthlessness or guilt

  • Impaired concentration or indecisiveness

  • Recurrent thoughts of death and/or suicidal ideation or attempt 

And also have to meet this criteria:

  • These symptoms cause significant distress or impairment

  • The episode is not attributable to substance abuse or a medical condition

  • The episode is not better explained by a psychotic disorder

  • The patient has never experienced a manic or hypomanic episode

Next Steps

May moms are reluctant to seek help because they’re unable to recognize their own mental health symptoms and accessing care can be difficult. An easy screening tool that will help you determine is PPD is affecting you is the Edinburgh Postnatal Depression Scale. This scale is used by most health practitioners like myself. 

If not treated properly, PPD can affect your overall functioning. While untreated PPD may cause health and developmental problems in your baby – and even affect the whole family. Treatment does not always have to be simply holistic. It may involve medications, and that’s perfectly okay. The important thing is that you’re getting the support that you need and deserve. 

If you prefer to approach PPD from a holistic lens, be sure to check out postpartum depression and Naturopathic Medicine.

References

Horibe M, Hane Y, Abe J et al. Contraceptives as possible risk factors for postpartum depression: A retrospective study of the food and drug administration adverse event reporting system, 2004-2015. Nurs Open. 2018;5(2):131-138. doi:10.1002/nop2.121.

Polmanteer, R., Keefe, R. and Brownstein-Evans, C. (2018). Trauma-informed care with women diagnosed with postpartum depression: a conceptual framework. Social Work in Health Care, pp.1-16.

Schiller, C., Meltzer-Brody, S. and Rubinow, D. (2014). The role of reproductive hormones in postpartum depression. CNS Spectrums, 20(01), pp.48-59.