It isn’t often that you get a good chuckle while reading a medical journal. But today I did. I am on a plane again (not United Airlines, thank heavens). I am flipping through some recent issues of the Journal of the American Medical Association (JAMA). One article catches my eye. It describes the case of a woman with polycystic ovary syndrome (PCOS). I decided to read it in detail to see if there was anything new in the cause, diagnosis, or treatment of women PCOS since I last wrote about it—there wasn’t.
PCOS is one of the most common causes of anovulatory infertility. Women with the condition have irregular periods and cycles where they don’t ovulate. They also have physical findings related to hyperandrogenism (excess hair growth, acne), and they are frequently overweight or obese. Many are insulin resistant and some will go on to develop Type 2 diabetes. PCOS is the risk factor for that condition.
As I read through this case study, I found that I didn’t really agree with the physician expert’s take on the case. The patient, “Ms. R”, was worried because she had gained weight despite a pretty rigorous exercise regimen (she bikes 20 miles a day and swims regularly). She was described as 59 inches and 122 pounds with a BMI of 25. Did I do the math right? That means she is quite short to be packing around 122 pounds. She says she eats the same as she always has, but at the ripe old age of 27, she finds that she has gained weight.
The doctor discussing this case kept saying it was good that Ms. R was “normal” weight, but we never learn whether she is slender or, in fact, is “abdominally” obese. And, he doesn’t mention whether he actually assessed how much she eats in a typical day or if he just believed her uncritical self-assessment. Before I started logging my food intake, I probably would have told you that I ate the same amount of calories as I did when I was thirty and thin. But once I started weighing and measuring and counting and recording my intake, surprise, surprise, I was actually quite an oink-oink. The weight started dropping when I decreased my intake to a caloric amount more appropriate for my height.
This article also does not mention Ms. R’s ethnic background. Asians and South Asians can have abdominal obesity (and associated insulin resistance) at BMIs that are considered “normal”. It isn’t the BMI that is the problem, it is the abdominal and, in particular, the intraabdominal or visceral fat. That is the problem. (I am willing to bet Ms. R has plenty of fat around her middle.)
Although her most recent fasting glucose level is normal, this woman is at risk for Type 2 diabetes because her father had it. And, as the doctor discussant pointed out, he didn’t test her to see if she was glucose intolerant. You have to do a glucose tolerance test (drink a sugary substance and have blood drawn at regular intervals after that) to detect this type of insulin-resistance-related abnormality in glucose metabolism.
So I am already a little annoyed by the way this case is being discussed, but then, on the last page, this doctor says that he would counsel the patient that she appears to have a mild case of PCOS (not sure if this is the equivalent of doctors who tell their patients that they have a “touch of sugar”.) He recommends she keep on taking birth control pills that help her have regular periods and counteract the hair growth and acne caused by the increased androgen levels characteristic of PCOS (I agree). He enthuses that Ms. R has “done an admirable job at weight control”. Yeah? But he did say he would refer her to a dietitian for further counseling on diet.
And then comes the comic bombshell: He says, “I would counsel her against excessive ‘Googling’ of PCOS on the web. I kid you not…I can hear it now, ‘No excessive googling, dear, you might learn something I don’t agree with?’”
This doctor has taken “Googling” to a new level by including this admonition in his case discussion in a respected medical journal. What a hoot.