A Morning of Gynecology

This morning, we had three gynecology lectures. The first two were about menopause and the third was about PCOS. The menopause lectures were bearable; the PCOS lecture was not.

Some points that bothered me:

• An example used in lecture was, "This week, I am treating an 11-year-old girl with PCOS who weighs (pause for effect) TWO HUNDRED KILOGRAMS!" (The class responds "Ooooooohhh".) Yes, this child is unusually fat for her age. No, we don't have to present her as a freak. Let's keep in mind that the vast majority of 11-year-olds couldn't weigh that much no matter how hard they tried.

• The oft-repeated statistic that "even a 5% reduction in body mass improves ovulation and fertility" was used. That always seems to me to be evidence that your behaviors matter more than your absolute body mass.

• A slide quoted "Obese women (BMI > 27 kg/m2)" I guess this is a typo, but it seems to me that more often than not the typos classify people as fat when they are not. For the record, the current cutoffs define BMI of 30 as obese, and before the cutoffs were changed about ten years ago a BMI of 27 was considered the cutoff for overweight (ie BMI of 26.9 was considered normal.) So, in this slide we present a weight that a few years ago was on the cusp of normal as "obese". Sigh.

The part that bothered me most was when I spoke to her after class. I asked whether she uses metformin as a first-line treatment for PCOS. I was particularly curious about this given the recent NEJM review that recommends metformin as a first line treatment. The lecturer responded that she doesn't use it as first line treatment. She gave several good reasons: the evidence is unclear, there isn't yet a consensus, patients could end up taking the medication for decades, etc. I generally agree with all that.

Her last reason, though, was along the lines of: "If we give metformin to teens with PCOS, then we negate the importance of lifestyle changes." That really gets me. If the medication is effective at treating PCOS then teens should have access to it! The alternative, telling teens that their facial hair and acne is because they are fat, just leads to a lifetime of yo-yo dieting and self-loathing.

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Background:

PCOS stands for Polycystic Ovarian Syndrome. It is a common condition where women have varying symptoms that might include irregular periods, excess facial and body hair, acne, and type II diabetes. Many women with PCOS are fat.

Metformin is a medication that is mostly used for diabetes that makes the body more sensitive to insulin. Insulin resistance is currently thought to be the main mechanism causing PCOS. Metformin, then, is often helpful in reducing symptoms for women with PCOS.