Polycystic Ovary Syndrome (PCOS) is a problem connected with hormone imbalance that I commonly see in my family practice. Women of different age groups present to my office with various concerns- from irregular periods to fertility problems to blood sugar dysregulation. These are the reasons why PCOS might affect you:

Teenagers: Getting your period for the first time (known as ‘menarche’ in medical terms) is an exciting event. This usually happens between ages of 9 and 15. The first year or two after menarche your periods may be irregular. Young women with PCOS, however, may continue to have irregular, infrequent or prolonged periods. Many patients may have cycles (from first day of period to the next time you have your period) longer than 35 days. Although having infrequent periods may feel like a positive thing for some people (especially those who have premenstrual cramps or mood changes) it can lead to problems with fertility or increase chances of uterine lining thickening or cancer in the future.

Other symptoms associated with PCOS include acne, hair growth (facial hair or hair on chest, belly and back) and weight gain.

All of these symptoms can be very difficult to manage physically and socially. Problems with acne or weight can lead to other mood issues. Talk to your doc if you think any of these symptoms might apply to you and some tests can be done to see if you have PCOS.

20’s and 30’s: The biggest concern that I see in this age group of women with PCOS is considerations for fertility. Due to irregular and infrequent cycles the number of ‘windows of opportunity’ for pregnancy are also more sparse.

It is important to see a doctor if you think you might have PCOS because there are tests that we can do and also some treatments to help with the symptoms and aid fertility. If you need a referral to see a fertility specialist it would also be useful to have this done earlier.

40’s and beyond: Oftentimes women with PCOS may present to my clinic with problems with blood sugar. This is because PCOS can cause insulin resistance and can lead to diabetes or heart disease. Men and women over 40 are recommended to have a blood test of their blood sugar and cholesterol levels to check for any risks that may lead to other health problems. Talk to your doc if you are in this age group and are concerned.

Next time I’ll talk a bit more about tests that we do for PCOS and things that can be done to help with different symptoms. Stay tuned!

As mentioned in my previous post, polycystic ovary syndrome (PCOS) is an illness affecting women that I commonly see in my family practice office.

The name PCOS comes from the fact that ultrasound imaging of the ovaries of PCOS patients often show small cysts. The cysts result from incomplete ovulation (release of an egg from the ovary). The reason cysts form is because of hormone imbalances in the body. These cysts, in turn, cause over production of male hormones that are normally produced in small amounts and can lead to other symptoms like acne, excessive hair growth and blood sugar dysregulation.

We do not know why PCOS occurs (may be partly due to genetics) and there is no ‘cure’ for PCOS but there are things we can do to help manage the symptoms. Tests that we do to confirm a diagnosis of PCOS may include:

1. A visit with your doctor- the doctor will discuss with you about your cycles (which is why it’s a good idea to keep track of your periods with an app or calendar), family history, weight changes, eating habits, other medical illnesses etc. Your doc may also do a simple physical examination to see the extent of other symptoms like hair growth or acne.
2. Blood tests- the doctor may request blood tests to check your hormone levels, and also other tests such as thyroid test, blood sugar and cholesterol levels to make sure the symptoms are not caused by something else or affecting other body functions.
3. Ultrasound- a transvaginal ultrasound (where a wand-like device is placed in the vagina) may be done to check the lining of your uterus and also for the appearance of your ovaries.

There are different concerns that we have in different age groups so tests will be personalised for your individual needs. If you have questions or concerns, talk to your doc!

Stay tuned for my next entry about things you can do to help with PCOS symptoms!

So you’ve been diagnosed with PCOS- what can you do about it?

As mentioned in my previous blog post we unfortunately do not have a ‘cure’ for PCOS. But given the different symptoms there are certainly things that we can do to optimize the associated problems:

• Irregular periods- If you’re not considering having a baby then birth control pills may be used to help control menstrual cycles. This will help regulate the timing of your periods and also normalize the hormones to reduce excess production of androgens (male hormones that are normally produced in small amounts in women)
• Acne- Since acne is usually related to androgen levels birth control pills will also help with reducing acne. Other medications (either topical or oral) may also help with acne so talk to your fam doc about this.
• Excessive hair growth- Also a side effect of excess androgens hair growth will benefit from regulation of hormones, likely through use of birth control pills or other medications to decrease the effect of androgens. For more cosmetic effects women may also consider hair removal through laser or electrolysis.
• Weight control- Losing 5-10% of your body weight can help regulate your menstrual cycles. A combination of dietary choices (such as low glycemic index diet high in fresh food and low in processed foods) and exercise (150 minutes of mild to moderate exercise per week) is useful. Talk to you doc or dietitian (call 8-1-1 for free dietitian advice in BC) about ways to help with weight control
• Fertility problems- medications may be used to promote ovulation (release of the egg from the ovary). There are some risks associated with these medications such as multiple births (twins or more) or hyperstimulation of the ovary. The expertise and guidance of a reproductive endocrinologist is extremely useful to consider other options as well.
• Insulin resistance- medications may be used to help control blood sugar and prevent diabetes-related health problems. Exercise can also help muscles utilize sugar more efficiently. Diets that are lower in carbohydrates and include more complex carbohydrates will help control blood sugar levels.

All of these suggestions and treatments (especially dietary choices and exercise) are much easier said than done! I trust that a fam doc’s can help with navigating some of these challenges and choices together- so don’t hesitate to talk to us!

Hopefully these blog posts about PCOS have been useful. If you have any other questions or other topics you’d like to hear about, drop me a message!

Fertility medicine is a very subspecialized field under obstetrics and gynecology. I have the great privilege to work alongside some amazing, dedicated and expert reproductive endocrinologist here at Olive.

I have a passion for fertility in family medicine, however, because fertility is a bio-psycho-social, whole-person experience that may manifest in a person’s interaction with their family doc long before they may even be considering “fertility”.

Whether it’s a young woman with irregular cycles, a couple who have tried for many months, a woman who’ve gone through unexpected losses or an individual contemplating ways to preserve fertility in light of other health issues- you have come through my office. We have shared moments of fear, grief, surprise, guarded hope, relief and joy.

Together I hope that we can navigate some of the common questions and fears that may spring up in your health. In the upcoming months I will be blogging on various health topics that I see in my family practice office and chat about how it may relate to fertility.

To walk alongside my patients during their different stages of life is my honor as a family doc and I hope that the info I share will also be informative and helpful. If you have any specific topics or questions you would like to learn about, feel free to let me know: IG @askdrma; cma@olivefertility.com 

Have you noticed more men with mustaches lately? Hopefully only through social media because it should’ve been covered by a mask! But if you’ve wondered what the moustache is all about- welcome to Movember!

According to Wikipedia and their website movember.com, Movember started almost two decades ago when a group of young men in Australia decided to grow moustaches to raise awareness for men’s health (including prostate cancer, testicular cancer and male suicide). This has since evolved into a global awareness campaign every November.

On the topic of men’s health I wanted to share some interesting facts and resources for you and the important men in your lives:

• You may know: Men have shorter life expectancies than women (68.9 yrs. vs 70.4 yrs. in Canada)
  But did you know: The life expectancy for Canadian men has actually been stagnant for a few years. Unfortunately this is due to the increased mortality among men between the ages of 20 to 45. Statistics Canada postulate that this increase may be due to the opioid crisis affecting various regions of the country.
• You may know: Men seek healthcare less frequently than women
  But did you know: Studies have shown that potential reasons men may avoid the doctor include embarrassment, fear of bad news or being judged and reluctance to take time off work. A GP survey conducted in the UK show that men see their doctors as much as women do- once they retire. Other studies show that men fear that taking time off for medical reasons (especially mental health) will jeopardize their job security.
• You may know: Diabetes is on the rise among adults.
  But did you know: Men are more likely to be diagnosed with diabetes than women? According to Statistics Canada the rate of diabetes among adults have almost doubled from 2000-2011 and men are more likely to have worse outcomes or death due to diabetes compared to women. Diabetes can have negative impacts on heart health but can also affect fertility and sexual function.
• You may know: Cancer remains the leading cause of death in Canada
  But did you know: Men are more likely to be diagnosed with, and die from, three of the four most common cancers (lung, colorectal, prostate). Breast cancer is the exception.
• You may know: Suicide is a leading cause of death in young people.
  But did you know: Suicide rate in men is three times higher than it is in women. Those aged between 40-59 had the highest rate of suicide. Mental illness is the most important risk factor for suicide and depression is the most common illness among those who die from suicide. If you want more information, check out this resourceful website by the University of British Columbia: https://headsupguys.org/mens-depression/

Men’s health is a huge topic and deserves more attention! If you haven’t already, please check out Olive Fertility’s new “Techno Tuesdays” series written by Dr Gary Nakhuda focusing on men’s health. The link can be found here: https://www.olivefertility.com/blog/gary

Cheers to the gentlemen in our lives- fathers, spouses, brothers, friends. Stay safe, healthy and fertile!

References:

Movember. Wikipedia. Available at: URL: https://en.wikipedia.org/wiki/Movember
Our Story: Movember through the years. Available at: URL: https://ca.movember.com/about/history
Health adjusted Life expectancy, by sex. Statistics Canada. Available at: URL: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310037001
Cancer statistics at a glance. Canadian Cancer Society. Available at: URL: https://www.cancer.ca/en/cancer-information/cancer-101/cancer-statistics-at-a-glance/?region=on
Health status of Canadians 2016. Public Health Agency of Canada. Available at: URL: https://healthycanadians.gc.ca/publications/department-ministere/state-public-health-status-2016-etat-sante-publique-statut/alt/pdf-eng.pdf
Health at a glance. Suicide rates: an overview. Health Canada. Available at: URL: https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.htm

Dr Charmaine Ma, BSc(Pharm), MD, Dip Fam Med (HK), CCFP

November 2, 2019 is World Fertility Day! Did you know that the first baby conceived via in vitro fertilization (IVF) was born in 1978? Since that milestone more than 40 years ago millions of babies have been born through IVF assistance. Improved medical technology and ongoing research continue to help women and families achieve their goal of having a successful pregnancy.

One in six Canadian couples who are trying to get pregnant are diagnosed with infertility. Traditionally people jump straight to thinking they need IVF. As a family doctor, however, there are many things that should be investigated, factors that can be optimized and also options that can be considered before embarking strictly on IVF. Furthermore there are many options for women who are simply thinking about preserving their best fertility chances through treatments like egg freezing. If you have would like to find out more about your best options make an appointment with us today!

References:

Wang J, Sauer M. In vitro fertilization (IVF): a review of 3 decades of clinical innovation and technological advancement. Ther Clin Risk Manag. 2006 Dec; 2(4): 355–364. Available at: URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936357/

Johnson, M. (2018). A short history of IVF. International Journal of Developmental Biology https://doi.org/10.17863/CAM.34238

Dr Charmaine Ma, BSc(Pharm), MD, Dip Fam Med (HK), CCFP

I recently came back from a holiday trip and, as usual, became the ‘blood donor winner’ of the family by acquiring the most mosquito bites. This got me thinking back to the Zika virus terror that stunned the world in 2015. As the summer draws to a close many of my patients are now planning their snowbird trips to warmer climates during the winter. Although the Zika infection is no longer headline news, should we still be worried when planning our holiday destinations?

What is Zika Virus?

Zika virus is a mosquito-spread infection that was first identified in Uganda in 1947 in monkeys. From the 1960’s to 1980’s there were reported mild cases in humans in Africa, Asia, the Americas and the Pacific. The major outbreak that stunned worldwide media first occurred in Brazil in March 2015 and was found to be associated with microcephaly (a condition in which babies were born with smaller head circumferences than average) and other pregnancy risks such as miscarriage and preterm birth.

How is it spread?

The virus is primarily spread through the Aedes mosquito and the symptoms (which may not show up for 3-14 days) include fever, rash, red eyes, muscle and joint pain and fatigue which may last about a week. Most people, however, do not develop any symptoms at all. Infection with the virus in adults and older children may become a trigger for other medical conditions such as Guillain-Barré syndrome (a condition where the body’s nervous system attacks our own nerves causing weakness to paralysis) or inflammation of the spinal cord.

It is important to note that Zika virus may be spread from humans through pregnancy (mother to child), sexual contact or transfusion of blood or blood products. This is why it is important to note the travel destinations for both partners if considering pregnancy.

Are there any treatments available?

Unfortunately there is no current treatments available for Zika virus. Most people who develop the flu-like illness should recover in about a week but should consider plenty of rest and fluids. Pregnant women who think they may have visited Zika infected areas or contracted Zika virus should see their doctor for testing.

How do I prevent getting Zika virus?

As there is no treatment available I always recommend my patients to take as many precautions as possible. There is no vaccine available for Zika virus. If men or women are thinking about pregnancy within the next 3 months they should reconsider and discuss with their doctor the risks of visiting areas that may risk exposure to the virus. The CDC has a great website with maps of areas of risk: https://wwwnc.cdc.gov/travel/page/zika-travel-information

Prevention of mosquito bites should always be a top priority for travellers to all areas at risk of insect bites. Apart from the Zika virus, the Aedes mosquito is also responsible for spreading Yellow Fever and Dengue Fever. Prevention includes wearing light coloured clothing that cover as much of the body as possible, using window screens and mosquito nets and applying insect repellent such as DEET. Mosquitoes breed around areas of still water so precautions should be made to remove potential standing water (such as flower pots or trash).

Due to our cold weather there have been no cases of Zika in Canada. Fortunately there are no current outbreaks in any country around the world. It is best to browse the CDC website and speak with your doctor if you are planning to visit warmer climates. Visiting a travel clinic before traveling outside of the country (to discuss vaccines or prevention tips) and staying vigilant upon return (for signs of fever or other illness) is always a great idea. Happy planning and bon voyage!

Resources:

Zika Virus. World Health Organization. 2019. Available at: URL: https://www.who.int/news-room/fact-sheets/detail/zika-virus

Guillain-Barré-Syndrome. National Institute of Neurological Disorders and Stroke. Available at: URL: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Guillain-Barré-Syndrome-Fact-Sheet

Zika Travel Information. Centers for Disease Control and Prevention. Available at: URL: https://wwwnc.cdc.gov/travel/page/zika-travel-information

Dr Charmaine Ma, BSc(Pharm), MD, Dip Fam Med (HK), CCFP

In today’s multimedia age, coupled with endless food choices and specific meal plans, it is often difficult to differentiate what type of diet we should have in order to stay healthy. If you’ve tried typing in ‘diet and X’ (X can be anything from fertility to finding a date) into a search engine, you’ll be bombarded by advice on how specific diets can lead to desired outcomes. We will have a look at some basics on diet and how it may affect fertility.

What is a healthy weight

You may have heard it time and time again- the most common way to calculate healthy weight is through the body mass index (BMI). BMI is calculated through taking a person’s height (in kg) and dividing it by their height (in meters) squared. The formula is BMI=kg/m². The normal range of BMI is between 18.5-24.9 for both men and women.

This ‘magic number’ is an estimate of the amount of body fat compared to height and may differ depending on your body composition, ethnicity, age or activity level. It is used as a gauge but cannot determine your health based on other factors (such as blood pressure, blood sugar or cholesterol). A conversation with your family doctor would be useful if you have any questions.

Supplements, Diet and Fertility

A recent article from Harvard reviewed the effects of diet and fertility. The basic take-away points I concluded from the review include:

• Women trying to conceive without assisted technologies (such as IVF) may benefit from folic acid, Vitamin B12, omega-3 fatty acids and healthy diets (such as the Mediterranean diet).
• Vitamin D (when not deficient originally), dairy and soy products, caffeine, alcohol and antioxidants didn’t seem to have any positive or negative effects
• Trans fats and diets high in red or processed meats, sweetened beverages, sugars and potatoes had negative effects
• Men had improved semen quality with healthy diets, seem unaffected by alcohol and caffeine and had negative effects from trans fat and processed diets.

The conclusions from this review are similar to those that I had written about in our Natural Medicines series and focus should be put on the fact that even though some products do not seem to have any positive or negative effects currently we should be skipping or overindulging in them (e.g. caffeine or alcohol).

Mediterranean Diet and Pregnancy Outcomes

Along the same lines of diet and fertility a recent trial in the UK looked at the pregnancy outcomes of over 1200 pregnant women based on whether they followed a ‘Mediterranean’ diet (higher in nuts, olive oil, fish, non-refined grains and vegetables) versus a more ‘traditional’ diet (higher in sugary drinks, fast food, animal fats).

The general outcome of the study showed no significant change in outcomes of mom or baby but did see a reduction in risk of gestational diabetes (which can lead to larger babies and poorer outcomes). This may be due to less weight gain in the Mediterranean group compared to the traditional group.

The overall takeaway message I gained from this study is that, as many studies are now showing, a diet that avoids processed, sugary or animal fats is generally more healthy. I think this is a good rule-of-thumb even for the general public and would lead to better health when coupled with appropriate exercise.

Next steps for researchers would be to observe whether diets during pregnancy can affect childhood outcomes such as obesity, allergy or asthma. Stay tuned!

References:

Gaskins AJ, Chavarro JE. Diet and Fertility: A Review. Am J Obstet Gynecol. 2018 Apr;218(4):379-389. doi: 10.1016/j.ajog.2017.08.010. Epub 2017 Aug 24. Available at: URL: https://www.ncbi.nlm.nih.gov/pubmed/28844822

Al Wattar BH, Dodds J. et al. Mediterranean-style diet in pregnant women with metabolic risk factors (ESTEEM): A pragmatic multicentre randomised trial, PLOS Medicine (2019). DOI: 10.1371/journal.pmed.1002857

Dr Charmaine Ma, BSc(Pharm), MD, Dip Fam Med (HK), CCFP

Natural health products are often a topic that comes up during consultations. Many people are interested in improving their health through non-medicinal supplementations. But do we really need them? And when we buy them, do we know if they are safe?

Natural Product Number

The first thing I tell my patients when looking for a natural health product is to check its source. Back in the 2004 the Government of Canada implemented the Natural Health Products Regulation under the Food and Drugs Act to protect the public and ensure that all self-claimed natural products contained the ingredient it claimed in the amount published. The stringent licensing process also ensures safe production facilities prior to granting an NPN (natural product number).

Are there specific brands that are better than others?

Various drug companies make different natural health products. The most important thing is that the product receives proper licensure and regulation from our FDA (through a Natural Product Number- see previous section). Furthermore it is important to make sure to compare ingredients and also read the instructions on the label. Some companies make products that require it to be taken multiple times a day or in multiple doses to reach its ideal dose. Price is often not a major defining point when differentiating between ‘good quality’ vs. ‘poor quality’ products, especially in common supplements (such as folic acid or vitamins and minerals). Some private companies will have a hefty price tag claiming better absorption or safety but lack regulation from the government. 

Check for interactions

If you are taking prescription medications or other over the counter products make sure you check with your pharmacist or doctor before starting any new supplements. Although a natural health product is called ‘natural’ it can potentially be very dangerous for you if it competes with the way your medications works or is cleared from your body. Side effects from medications or natural products may potentially be accentuated if they interact.

How much is enough?

When I worked as a pharmacist I would often see patients on multiple supplements or over the counter medications that contained the same product. This runs a risk of exceeding our “tolerable upper intake level” of any given supplement product. The government of Canada has released a good reference guide for some common vitamins, elements and nutrients (see Dietary Reference Intake Tables below). When in doubt ask your pharmacist or doctor about how much you should be taking and be aware of taking multiple products containing the same ingredients. 

Check your own eating habits

The question of whether you need supplements really depends on whether or not your body is lacking them. Out of all the vitamins only vitamins A,D, E and K are stored in our body when taken in excess of what it needs. In other words, other vitamins are simply cleared out of our body through liver or kidney. Taking too much of a product runs the risk of harm to the body while taking too little runs the risk of deficiency. So if you keep a specific type of diet, or a restricted diet of any sort, talk to your physician or dietitian about whether you need to supplement.

Can I get some supplements from food?

Other than some specific supplements that I recommend in particular circumstances (e.g. Folic acid in women thinking about pregnancy or iron supplementation in iron-deficiency anemia) I usually encourage my patients to seek food sources of nutrients. The Dietitians of Canada website has comprehensive lists of food sources of many nutrients such as calcium, folic acid and iron. They specify how much is needed in each age group and follows with a long list of food sources as well as serving size and amount of nutrients per serving (see below for link). This is a website that I often go back to even for nutritional planning for my own family.

Fertility effects?

There are no conclusive human trials in literature currently to support the use of specific supplements. But there is ongoing research for the effectiveness and safety of various products including:

Vitamin E- One study showed improved pregnancy rates with oral Vitamin E supplementation in men with low sperm count or poor motility. Another study of men in IVF trials showed increased fertilization rates after three months of Vitamin E. The combination of Vitamin E and Selenium or Vitamin C, however, did not appear beneficial.

L-carnitine- Studies show conflicting results but some clinical studies show L-carnitine (especially when taken orally in conjunction with acetyl L-carnitine) increases sperm count and mobility in men with infertility.

Coenzyme Q10- Preliminary research shows that taking daily oral coenzyme Q10 300mg may increase sperm mobility and density in men with low sperm count and poor sperm motility but this did not seem to significantly increase pregnancy rates.

Also there is some evidence that in a 600mg oral daily dose, it may improve egg quality. More research needs to be done before a definitive recommendation can be made regarding coenzyme Q10.

Vitamin C- There is preliminary evidence that suggests women who do not ovulate or have low progesterone may increase their progesterone levels with oral intake of Vitamin C.

Vitamin D- There is some evidence that 2000IU of oral Vitamin D daily can improve egg quality.

Inositol- This supplement when taken at 4g daily may improve insulin sensitivity in women who are diabetic or have problems with polycystic ovarian syndrome (PCOS). 

Zinc- Men should consider a multivitamin with vitamins C, E and zinc to help in sperm production.

Omega oils- There is some potential in omega oil supplements being beneficial to both men and women.

References:

1. Government of Canada. About Natural Health Product Regulation in Canada. Available at: URL: https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation.html
2. Government of Canada. Dietary Reference Intake Tables. Available at: URL: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/dietary-reference-intakes/tables.html
3. Dietitians of Canada. Food sources. Available at: URL: https://www.dietitians.ca/search.aspx?searchtext=food+sources&searchmode=exactphrase
4. Vitamin E. Natural Medicines Database. Accessed July 5, 2019. Available at: URL: https://naturalmedicines.therapeuticresearch.com
5. L Carnitine. Natural Medicines Database. Accessed July 5, 2019. Available at: URL: https://naturalmedicines.therapeuticresearch.com
6. Coenzyme Q10. Natural Medicines Database. Accessed July 5, 2019. Available at: URL: https://naturalmedicines.therapeuticresearch.com
7. Vitamin C. Natural Medicines Database. Accessed July 5, 2019. Available at: URL: https://naturalmedicines.therapeuticresearch.com