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Women in their 20s often present to gynecologists with the following complaints: "I'm gaining weight and it does not make sense!" And, "My periods are irregular and heavy. Is something wrong?"
But, as physicians, are we using the presentation of these symptoms as a chance to intervene and potentially prevent their heart attacks when they're in their 60s?
Mapping the Road to Prevention
A 24-year-old patient, I'll call her Cindy, came into my clinic with a long list of complaints. She had recently graduated from college and began job hunting for teaching gigs here and abroad. Looking forward to the next chapter of her life, she was desperately frustrated with how she felt physically.
The lack of control she felt over her body sparked a growing anxiety. She complained of heavy irregular periods, painful cystic acne, weight gain around her waist, which persisted despite exercise, and oily skin. She had been very active in sports in high school, and loved to run like her dad.
Once in college, she managed to eat well and exercise regularly until a study abroad trip. While traveling, she gained 10 pounds. When she returned for her last year of college, life was crazy with exams, student teaching, and planning her future.
Eating well was more of a challenge and her diet became reliant on cereal and other simple carbs. Exercise became less regular, too. And then the real frustration began -- she felt like she was treading water. She would try to fight the weight gain, but her efforts wouldn't produce the results she expected.
To top it off, her periods were becoming a nuisance and her acne was affecting her confidence. She wanted answers fast.
Discussions That Are Worth Every Minute
Her family history gave me a few more clues. Many women in her family suffered from type II diabetes and obesity. She had an aunt who'd had an early heart attack, her grandma had heart failure, and her mom had diet-controlled gestational diabetes when she'd been pregnant with her.
Her physical exam showed normal vitals, cystic acne, mild hirsutism, and central obesity. Her labs showed normal thyroid function and prolactin, normal CBC, mildly elevated lipids with triglycerides of 197, and an elevated fasting insulin. Her HbA1c was 5.6%, and DHEA-S, free testosterone, and 17-OHP normal.
My assessment was early spectrum polycystic ovarian disease (PCOD), and insulin resistance, which was causing easy weight gain, acne, hirsutism, and irregular heavy periods.
The time we spent discussing her physiology was worth every minute. I explained that her individual system would always be prone to flipping into fat storage mode, and becoming insulin resistant at a lower weight than someone else's system.
I explained that as she would gain even a small amount of belly fat, it would lead to more insulin resistance, and that as she became busy, stressed, and sleep deprived, her system became less responsive to exercise or healthy changes in her diet. And, that the belly fat and increase in estrone and free testosterone led to her acne and hirsutism.
As her insulin levels increased, her ovaries became less responsive to follicle-stimulating hormone, and less able to make good, quality ovulation events with subsequent anovulatory cycles, and irregular heavy bleeding.
Although these genetics are not fair, the prize of knowledge was that she could fix the situation before it became worse.
Giving a Patient a Plan-of-Attack
We came up with a plan. In acknowledgement of her barrier of limited time, we were able to come up with personalized solutions: shorter exercise events with interval training and strength training.
She joined a 6:00 am boot camp program she could do before student teaching. We discussed menu choices and replaced simple carbs, like packet oatmeal, with slow cooked oatmeal she would heat up later, or sorted grain bread with peanut butter and honey.
She started packing salads with baked chicken from the night before, a fruit, and brown rice and sweet potatoes. Cindy made it a priority to drink adequate water, eat a snack of almonds and an apple in the mid-afternoon for energy, and to plan a dinner with protein, salad, and vegetables -- no carbs.
She also prioritized bedtime to allow for adequate sleep. In terms of medications, Cindy chose a low-dose oral contraceptive pill, and thanks to its effect of increasing sex hormone binding globulin and reducing free testosterone, she was able to find relief from irregular heavy periods, acne, and the mild hirsutism.
After 5 months of this regimen, she felt back in control and well on her way to getting her life on the track of her choice.
Outcomes
The short-term benefit of applying such knowledge is having Cindy feeling better with symptom relief. However, the long-term benefit is far-reaching in that she now has a better understanding of her body, and how easily her health can get off track. She's also empowered by the success of turning a downward spiral around.
She will need this knowledge for the rest of her life to manage the challenges her metabolism will face with pregnancy, a busy life with small children, a job, minimal sleep, and the inevitable changes of perimenopause and menopause.
Instead of feeling out of control, and complaining of unexplained weight gain, a path to an elevated risk for cardiovascular disease such as heart attack and stroke, as well as significant obesity and diabetes, she will more likely avoid these co-morbidities and live a healthy, informed life.
"Lady Doc" is Diana L. Bitner, MD, NCMP, director of Women's Health Network at Spectrum Health in Grand Rapids, Mich. After 20 years in obstetrics and gynecology, Bitner wrote "I Want to Age Like That! Healthy Aging through Midlife and Menopause" (2014), an educational tool for patients and providers.