Dear Friends,
It’s Adar! We all relish this time of joy, celebration, and triumph. At Tahareinu, we celebrate daily: breakthroughs discovered, burdens eased, and solutions applied. Thank you for always supporting us in this mission.
Last month, we brought The Essential Guide for Every Couple: Achieving Tahara and Pregnancy. (If you haven’t seen it, reach out for a copy.) The feedback we received from dozens of readers was very heartwarming – and prompted us to continue to bring you succinct guides on various crucial topics.
This month, we focus on PCOS, a very common condition which we deal with every single day at Tahareinu. Read it and be informed – and please share it with anyone else who may find it helpful.
Wishing everyone a Freilichen Chodesh Adar,
Rabbi Yitzchok Melber
PCOS: The basic guide for every patient, couple, and parent
By: Rabbi Yitzchok Melber
Welcome to our comprehensive guide on Polycystic Ovary Syndrome (PCOS), a hormonal disorder that affects millions of women worldwide. The traditional way to diagnose PCOS is to confirm at least 2 of the 3 following symptoms: Irregular cycles, increased androgen hormone levels (which can cause acne and abnormal hair growth), and an ultrasound showing many small follicles.
Although PCOS has no cure, it can be effectively managed with proper lifestyle and medical care.
If you have been recently diagnosed with PCOS or suspect you may have this condition, it can be overwhelming to navigate through the symptoms, diagnosis, and treatment options available. This guide aims to provide you with a synopsis of the most up-to-date and accurate information on PCOS, but of course, we encourage you to reach out if you have any further questions.
PRE-MARRIAGE PCOS: 5 FAQ’S
These are some of the most common questions we receive at Tahareinu, particularly regarding teenagers and single girls with PCOS.
1.
Q. Do I need to go to a doctor or can I wait until after my wedding?
A: There are several reasons people hesitate to take their girls to doctors before marriage to investigate PCOS. On the other hand, they want to be proactive and take care of anything possible before they get married. Which is the right approach?
The answer is: It depends. If her only symptom is an irregular cycle, there is no medical need – or benefit – of visiting a doctor early on. Since there is no cure for this and it can only be regulated medically, there is no reason to do this before marriage.
2.
Q: Is it dangerous for a girl not to get her period? Do doctors recommend bringing on a
period?
A: It is not healthy to get a period very infrequently, i.e. once a year or less. That puts the girl at a greater risk for cancer as the uterine lining can grow very thick. Every girl should get a period at least every 3-4 months, and if that doesn’t happen naturally, it should be induced. This can be done using the medicine Aygestin, which can be prescribed by any family doctor. Some doctors will perform an ultrasound to measure the uterine lining, but Aygestin on its own is fine.
3.
Q: What type of doctor should be seen for PCOS?
A: The best choice is a reproductive endocrinologist, who can perform a complete hormonal profile and ultrasound as necessary. Although a gynecologist can certainly perform first-line investigations, if they see a hormonal abnormality in the bloodwork they will refer the patient to a reproductive endocrinologist. To be clear: No doctor will provide a cure for PCOS. But a competent one can help the patient manage it effectively.
4.
Q: What can a patient do now to improve chances of pregnancy after marriage?
A: In order to improve chances for the future, it is crucial to have a healthy lifestyle. Of course, this is important for everyone, but particularly vital for PCOS patients. Whether she has symptoms or just knows that PCOS runs in the family, she should minimize her symptoms by eating healthy and exercising. If a girl is overweight, she should lose 5-10% of her body weight. If this is difficult to do naturally (given insulin resistance), she should be prescribed medication for insulin resistance – Metformin, or injections. 60% of PCOS sufferers are overweight, and losing weight has been proven to help tremendously.
In addition, the WHO recommends the Agnus Castus (Vitex) vitamin – 700 mg or for an overweight individual, 1000 mg a day This should take effect after approximately 6 months.
5.
Q: Do you need to reveal this condition before a Shidduch is finalized?
A: Although everyone should ask their individual Rav, in Tahareinu’s experience it is not required to tell the other side. Of course, there is a difference whether a girl is getting her period every few months or once a year. In the latter case, the girl should do tests to verify that this is only PCOS and nothing more serious. The new way to do this is via an AMH (blood) test. If the AMH level is very high, that indicates PCOS and the rabbi will most likely advise not to say. To be clear: Everyone with PCOS can have children, most often without major intervention. There are 3 groups and the solution will be advised accordingly: Lifestyle change, medication, or more aggressive treatment including IVF. In fact, most women with PCOS can have children longer than other women (into their high forties) and as they get older they often need less or no intervention.
IMPORTANT NOTE: Every Kallah who has irregular cycle should be aware that she needs to tell this to the person she consults with to avoid Chuppas Niddah. She must be on combination birth control, and not not use the common method which is a Progesterone pill, or she might have breakthrough bleeding. The best method is to bring on period and start birth control at that time.
If a girl has an irregular cycle and suspects or knows she has PCOS, she must start this process early enough in the engagement . In Tahareinu’s experience, a lot of accidents happen with these girls. Of course, these medications might have some side effects, but they are not usually long term. If a girl has a regular cycle she doesn’t have to use the pills, but if it’s irregular she definitely should.
POST-WEDDING PCOS: MAXIMIZING TAHARA AND FERTILITY
Of course, a woman with PCOS will want to ensure that she is giving herself the best chance at getting pregnant despite the challenges. Here are the most important pointers for fertility with PCOS:
OVERCOMING FERTILITY CHALLENGES WITH PCOS: 3 LEVELS
Level One: The natural route
When a woman skips periods, getting one every 2-3 months, she will have difficulty in getting pregnant naturally because ovulation doesn’t occur or is not of good quality. When should someone suspect PCOS? If her cycle is over 36 days. Just skipping or late periods doesn’t mean PCOS, and on the other hand even with a steady monthly period she may have PCOS if she has other symptoms. She can regulate period with contraception, stopping every 24 days, but that’s not so effective because it doesn’t bring on ovulation. The most effective way to regulate periods is the natural way, with a lifestyle change of losing weight and exercising. In addition, the WHO recommends the Agnus Castus (Vitex) vitamin – 700 mg or for an overweight individual, 1000 mg a day This should take effect after approximately 6 months.
Level Two: Medications
If a woman has time to wait, she should follow the above steps. If she would like to take a more aggressive approach, the best medical route is to take Letrozole or Clomid from day 5 of her period (if necessary, brought on with Aygestin) for 5 days. In this group of PCOS patients, it is very important to follow up to see whether her body responded to the meds, because not everyone does with a low dose. The medication must begin with a low dose to avoid hyperstimulation, then go up to double, and if it’s not working switch to injections. She should maximize her window of opportunity for ovulation with an ultrasound to determine the size of the egg.
Many doctors, and Tahareinu as well, recommend adding a trigger injection called Ovitrelle to be administered as soon as the follicle measures 19-20 mm on an ultrasound. This will release it and up the chances of getting pregnant.
All of the above is recommended for a woman who is not overweight. For overweight patients, it’s crucial to get their weight reduced first.
This is not easy for many women, and should be abetted medically if necessary.
Do couples have to wait a year before intervening? No, if PCOS is suspected or diagnosed, they can take a more head-on approach to manage it at any time.
It bears repeating that weight loss is important, and exercise on its own helps as well. There are many excellent food plans and lifestyle plans by PCOS experts to tap into.
In 2018 a consensus book for PCOS was published by the ASRM, ESHRE, and experts from Australia. One of its strongest recommendations is a healthy lifestyle that includes eating properly and exercising regularly.
LETROZOLE OR CLOMID? A Quick Primer
In general, Letrozole is considered to be the healthier drug of the two. It also doesn’t increase the chance for multiples (which doctors recommend against) as much: Clomid causes a 20% chance for twins, while Letrozole only has 1%. Most importantly, Letrozole has an 80% success rate vs. Clomid’s 40%. The reason for this is that Clomid has several side effects that bring down a woman’s chances of conceiving.
Clomid is a reliable medication that has been used successfully millions of times; if a woman tried Letrozole without success she should definitely use it.
Letrozole also has a side effect of causing challenges with a Hefsek Tahara in time. If this occurs, she should take Estrogen for the first 3 days of the month, called Esterase in the U.S. or Progynova or Estrofem in Europe.
If these medications are causing hyperstimulation, they may be recommended to go straight to IVF.
Level three: Treatment
While most women will, at most, need intervention in order to ovulate, there is one group of less than a third of PCOS patients that will need more intense treatment. It is recommended to give the medication route 3-5 chances with a trigger shot. If they are still unsuccessful, they should investigate further and also explore the male factor with a semen analysis. Although medically it would be advisable to test the husband immediately, frum people should wait to test sperm until after exhausting the first-line treatments on the woman’s side.
The next step after medication would be injections. These should not be done until the male has tested for any issues. It is highly recommended to have these performed in an infertility setting and not a family doctor or gynecologist. It requires a very specific expertise and a lot of follow-up so as not to hyperstimulate the overies.
We are often asked whether these medications and injections have side effects. Although they should usually be mild, of course they are introducing powerful drugs into the body and side effects should always be monitored.
If a couple is unsuccessful with injections, they will be advised by their fertility team about more invasive options.
TAHARA AND PCOS: CHALLENGES AND SOLUTIONS
Young women with PCOS will sometimes actually have Tahara for longer due to long cycles, but at different times it may be the opposite – once she gets a period she may not be able to get clean for 2-3 weeks, she may have very short cycles because of a hormonal imbalance, or after giving birth she might get 2 periods a month.
Of course, having a regular cycle will help with this challenge. A helpful solution would be to take aygestin 3 times a day for 5 days to help induce the period which will shed the lining leading to continued healthy cycles, with this protocol hormones are not necessary. If this is not effective then traditional hormonal birth control cycle management will likely be required. The best way to control it would be birth control, but if she is trying to get pregnant she can take other medications.
Of course, any woman, couple, or parent that has specific questions about PCOS is welcome to get in touch via our hotline. We have a wealth of information to share, and offer case management as well.
Rabbi Melber will be in the tri-state area for a short visit next week. Get in touch with office@tahareinu.com if you would like to arrange an appointment.
Tahareinu extends our warmest Mazel Tov wishes to Rabbi Melber upon the engagement of his daughter! May we always share Simchos.
Call the Tahareinu Hotline!
Got a question about relieving tahara problems, infertility, reproductive health, pain or other related issues?
call the Tahareinu hotline
For ongoing infertility, recurrent pregnancy loss, or reproductive genetic issues,
you and your spouse are warmly invited to schedule an in-person, phone or Zoom consultation with our founder and president, Rabbi Yitzchok Melber.
Please send an email to rabbimelber@tahareinu.com Include your first name and location, and briefly describe your issue.
Personal consultations are for more involved reproductive issues. Note the Israel
office has reopened for in-person consultations, in line with the country’s coronavirus status.
IMPORTANT
Most Tahareinu issues are addressed by our hotline advisors, 13 hours a day, 5 days a week. If you are unsure whether to schedule a consultation, call the hotline first.
