PCOS Treatment Guidelines: Lifestyle, Medications and Fertility Options
This blog is the second part of Dr. Laurence Jacobs’ series on Polycystic Ovary Syndrome (PCOS). In part one, he discussed the signs, symptoms and diagnostic criteria for PCOS.
In this follow-up, Dr. Jacobs outlines the latest PCOS treatment guidelines, from lifestyle modifications and metabolic therapies to fertility medications and assisted reproductive technology (ART). PCOS is a complicated disease, understand your treatment options based on your fertility goals.
About PCOS
As discussed in part I, Polycystic ovary syndrome (PCOS) is characterized by a combination of excess hair growth, ovulatory dysfunction, and polycystic ovarian morphology on vaginal ultrasound, associated with insulin resistance. Latest treatment guidelines focus on lifestyle modifications, medications, and careful fertility care, including the role of newer agents such as GLP-1 receptor agonists.
Lifestyle Modification for Preconception Health
Lifestyle intervention, overlooked by many physicians for decades, remains the cornerstone of PCOS management. Weight management, improved nutrition, and physical activity are consistently associated with improved metabolic health, ovulation, and higher pregnancy rates. Even modest weight loss of 5–10% can often restore ovulation and/or improve pregnancy rates naturally, as well as with medication/IUI and IVF treatments. Programs that offer qualified medical nutrition therapy (MNT), regular exercise training, and behavioral modification via personalized provider telehealth have excellent outcomes for preconception health (WINFertility and OvumHealth).
Medical/Surgical Therapies for Weight and Metabolic Management
Metformin continues to be used as first-line pharmacologic therapy for metabolic abnormalities, such as impaired glucose tolerance and insulin resistance in women with PCOS. The supplement Myo-Inositol has also demonstrated significant benefit in dealing with insulin resistance.
GLP-1 receptor agonists (tirzepatide, semaglutide and related agents) are a major addition in the treatment options for weight loss. These medications significantly reduce body weight, and insulin resistance in PCOS patients. Current evidence also suggests improvements in menstrual cycle regularity and ovulation. They can be helpful as an adjunct to lifestyle changes for overweight/obese women but are most effective when used in conjunction with lifestyle improvements. Careful collaborative decision making is vital, as side effects (nausea, vomiting, pancreatitis, gallbladder disease, etc.), high costs with little insurance coverage and long-term safety remain an issue. Since pregnancy safety studies are lacking, contraception should always be utilized when GLP-1s are used in women planning pregnancy in the future and stopped when attempting conception.
Bariatric surgery may be considered for women with PCOS and severe obesity who meet criteria for surgical weight management. While not specific to PCOS, weight reduction from bariatric surgery may restore ovulation and improve metabolic health.
Laparoscopic ovarian drilling, another surgical option, has a very limited role in modern infertility practices, but in the past has helped some women by reducing ovarian testosterone and other male hormones (androgens). This option is rarely used today due to costs and potential damage to ovaries leading to adhesions.
Ovulation Induction and Infertility Management
Infertility is very common in PCOS, primarily due to anovulation and/or poor egg quality.
Letrozole has become the first-line medication therapy for ovulation induction in women with PCOS and anovulation, among most Reproductive Endocrine/Infertility specialists and many Ob/Gyns. Many well-controlled randomized studies have demonstrated higher ovulation, pregnancy, and live birth rates, as well as lower multiple birth rates with letrozole compared with clomiphene citrate.
Clomiphene citrate (Clomid) remains a popular option, particularly among Ob/Gyns. Combination therapy with clomiphene plus Metformin improves ovulation and live birth rates compared to clomiphene alone.
Metformin when used alone is less effective for ovulation induction but may be considered in combination with Letrozole and/or Gonadotropin medications (Menopur, Gonal F and Follistim), when doing ovarian stimulation for ovulation induction or IVF.
Gonadotropins are second-line therapy when oral ovulation induction fails. Careful monitoring is required to minimize the risk of ovarian hyperstimulation (OHSS) and multiple pregnancies. IVF is far more effective and safer regarding multiples.
Assisted Reproductive Technology (ART) and IVF
In vitro fertilization (IVF) is often reserved for women who fail less invasive ovulation induction therapies or who have additional infertility factors such as tubal disease or male factor infertility. In PCOS, IVF requires particular caution due to the high risk of OHSS. The newest guidelines emphasize the use of GnRH antagonist protocols (Ganirelix; Cetrotide) and individualized low dose stimulation strategies with Lupron triggers to minimize this OHSS risk. Pre-treatment with metformin may also reduce OHSS risk in women still undergoing IVF with GnRH agonist protocols. As noted above, Preconception care—including optimization of weight, hormones and metabolic status—is recommended prior to doing ART.
A Comprehensive Approach to PCOS Treatment
PCOS is a complex condition requiring an individualized, comprehensive approach. Preconception health with lifestyle modification remains first-line therapy. Medication therapy has improved. Metformin and Myo-Inositol supplements maintain their roles. GLP-1 receptor agonists, with proper counseling and informed consent, represent a new option for weight loss and metabolic improvement.
For infertility treatments, letrozole is clearly the first-line option for ovulation induction. Clomiphene, metformin (alone), and gonadotropins are occasionally used. IVF is very effective but requires careful strategies to minimize OHSS risk. Single frozen embryo transfers greatly reduce the risk of multiples. (1-2% identical, if embryo splits).
Expert Care for PCOS
Dr. Jacobs has helped women manage their PCOS for more than 40 years and was formerly the Director of the PCOS Center of Excellence. He understands firsthand how medications, supplements and lifestyle modifications can profoundly impact the health and fertility of PCOS patients.
If you think you may have PCOS or are struggling with symptoms, Dr. Jacobs and our team can help with the correct diagnosis and treatment options. Click here to schedule a consultation.
To understand more about PCOS, read part one of this blog discussing symptoms and diagnosis.
PCOS Awareness Month: Signs, Diagnosis and Treatment Options
Polycystic Ovarian Syndrome (PCOS) is one of the most common hormonal conditions affecting 1 out of 10 women of reproductive age. Yet, it often goes undiagnosed because the signs and symptoms can be subtle and inconsistent. In this blog, Dr. Laurence Jacobs shares important information about how to know if you have PCOS and how different lifestyle and treatment approaches can improve your health.
Understanding PCOS
A common misconception is that all women with PCOS experience irregular periods, excess hair growth, ovarian cysts or weight gain. However, not every woman with PCOS has all of these symptoms. Because there is no single test to diagnose PCOS, some doctors may miss the correct diagnosis, especially in young women, by only treating irregular periods with birth control pills.
Signs and Symptoms of PCOS
PCOS may present differently from woman to woman, but symptoms often include:
- Irregular or absent periods
- Infrequent or absent ovulation
- Infertility
- Hirsutism (excessive hair growth) of face, chest or abdomen; acne
- Weight gain or obesity
- Insulin resistance
How is PCOS Diagnosed?
Women must have two out of three of the following diagnostic criteria:
- History of irregular or absent menstrual cycles and/or no ovulation since puberty
- Hirsutism and/or high blood levels of male hormones: Testosterone and Androgens
- Vaginal ultrasound evidence of polycystic ovaries (20 or more follicles in one or both ovaries)
It is also important to note:
-Other endocrine issues, such as various thyroid and adrenal diseases, must be ruled out as their symptoms can mimic signs of PCOS.
-Ultrasound diagnostic criteria no longer applies to teenage girls.
Key Considerations
- Not all PCOS patients are overweight (Classical PCOS). Some may have what is known as Lean PCOS.
- Women with PCOS often experience irregular periods and infertility due to lack of ovulation and/or egg quality.
- Insulin resistance is common in PCOS patients. This means their bodies do not respond to glucose properly. In order to maintain normal blood glucose levels, the pancreas produces excessive insulin, which then increases fat storage and disrupts hormone levels. This leads to symptoms such as irregular periods, obesity, infertility and excess hair growth.
Lifestyle and Treatment Approaches
The good news is that addressing insulin resistance can help restore normal ovarian function. Research shows that lifestyle and medical strategies can improve fertility and overall health in women with PCOS:
- Nutrition: A balanced, lower-carb diet can help regulate blood sugar and hormone levels.
- Exercise: Regular activity supports insulin sensitivity and weight management.
- Supplements: Vitamins like Inositol may help regulate insulin resistance and menstrual cycles.
- Medications: Insulin-sensitizing medications such as Metformin are often used to improve ovulation and restore hormone balance. The beneficial use of GLP-1 agonist medications, such as Semaglutide (Ozempic or Wegovy) and Tirzepatide (Zepbound) along with proper nutrition and lifestyle changes will be discussed in part 2 of this PCOS blog.
- Weight reduction: Even a weight loss of 5–10% can enhance fertility, improve natural ovulation and increase success rates with fertility treatments, including IVF.
Expert Care for PCOS
Dr. Jacobs has helped women manage their PCOS for more than 40 years and was formerly the Director of the PCOS Center of Excellence. He understands firsthand how medications, supplements and lifestyle modifications can profoundly impact the health and fertility of PCOS patients.
If you think you may have PCOS or are struggling with symptoms, Dr. Jacobs and our team can help with the correct diagnosis and treatment options. Click here to schedule a consultation.
Stay tuned for part two of this PCOS blog which will discuss management and treatment options for those PCOS patients dealing with infertility issues.
Abdominal Cerclage and IVF: How We Overcame Recurrent Pregnancy Loss
Amanda and Paul’s journey to parenthood was anything but simple. In this blog post, Amanda shares her six-year journey through IVF, pregnancy loss, abdominal cerclage and finally, the joy of welcoming her son Dimitri.
Our Dream of Starting a Family
My husband, Paul, and I always knew we wanted kids. We always talked about having two but were open to the idea of three. I never suspected anything was wrong because my cycles were pretty regular, and I had no signs or symptoms of any issues.
We got married in the summer of 2018 and were anxious to start trying. After several months of negative tests, I talked to my OBGYN, and he put me on Clomid. I took Clomid for about six months, and after that didn’t work, we started to explore other options and began working with a fertility clinic. We started the IVF process in November 2019 and finally had our first retrieval in March 2020. When the lockdown mandate was ordered, we were too far into the cycle to cancel, so we were able to proceed with the retrieval.
By the fall of 2020, we were ready for our first transfer. It worked—or so we thought. The embryo stopped growing and resulted in a loss. We decided to move forward with another transfer toward the end of 2020. That one also worked, and I was released from my IVF clinic at six weeks. A few weeks later, I went in for an ultrasound and was told there was no longer a heartbeat. Because we were still in the midst of COVID, I was alone. The ultrasound tech was the only person in the room. She was so kind—she hugged me and cried with me. It was something I’ll never forget. I had my first D&C right before Christmas.
Finding Dr. Miller and a New Plan
After talking to a friend who was already with Dr. Miller, she recommended that I switch doctors. The one I was with didn’t want to change anything in my protocol, and it was time for a change. We started the process of switching over to Dr. Miller and moved our remaining embryos. I had a phone consultation with him in early 2021, and we began the necessary genetic testing for both my husband and me. Everything came back completely normal, so we were still at a loss as to why we couldn’t get pregnant.
We had our first transfer with Dr. Miller at the end of July 2021. We got pregnant! Everything looked good—until it didn’t. This pregnancy also ended in a loss and required another surgery. We had another consultation with Dr. Miller, and he suggested a trial cycle. We started it and had to push the transfer date back one day. I also had some inflammation due to endometriosis. Around that time, Dr. Miller spoke to Dr. Jubiz, who suggested I have an endometrial scratch before the next transfer.
An endometrial scratch is created when a small catheter is inserted into the uterus, then moved back and forth and rotated in order to cause some disruption to the uterine lining. It may be helpful in women with recurrent implantation failure by increasing endometrial receptivity. Once I got the all-clear from Dr. Miller, we prepped for the next transfer. I had the endometrial scratch in the cycle prior, and the transfer was done on April 29, 2022.
This transfer would prove to be both the most successful and the most gut-wrenching. After all the surgeries, retrievals, and losses, I wasn’t hopeful. My husband remained positive and supportive—my rock. I tried to stay open-minded, but after almost two years of heartbreak, I was losing hope. To my surprise, this transfer worked! My beta numbers were the highest they’d ever been, and we made it to another OB ultrasound. Our baby boy was growing and developing perfectly! It was surreal to finally start believing I was truly pregnant. We relaxed a little and began dreaming of the day we’d bring our baby home.
Everything was going perfectly. We finally got to announce our pregnancy on July 20, 2022—our fourth wedding anniversary. He was healthy and growing beautifully. Then my husband and I both got COVID.
We scheduled our gender reveal for August 6, 2022. It was hot, and our cake melted—but it was a perfect day. Our family found out we were having a boy. We had known from genetic testing, but we still wanted to share the moment with them.
A few days later, I noticed more discharge than normal. Research suggested it was fine, so I didn’t worry. But on August 13th, I went to the bathroom, pushed, and heard a loud pop. It sounded like a gasket breaking. I checked but saw nothing unusual. Later, as I turned on the couch, I felt a gush of liquid. I ran to the kitchen, and it was pouring out of me. I called my husband—he was in disbelief. I called my OBGYN, who suggested I lie down and elevate my feet since I wasn’t bleeding. Moments after I hung up, I started gushing blood. I got into the bathtub, and my husband rushed home. We went to the ER.
After hours of waiting, we were told my water had broken. While the baby still had a heartbeat, he wouldn’t survive. I was 18 weeks pregnant. We were given the option to go to a hospital equipped for babies born at 18 weeks, but the outcome would be the same. We went home, and I prayed harder than I ever had that he would make it to 22 weeks. I played lullabies and told him I loved him.
The next day, I began cramping. We rushed to the hospital. Everything escalated quickly. Our son was born sleeping about 45 minutes after we arrived. It was the hardest moment of my life. The hospital staff gave us as much time as we needed with him before saying goodbye.
Discovering the Need for an Abdominal Cerclage
When we were ready, I called Dr. Miller to get back on the schedule. About a month later, we created a new plan. Dr. Miller was kind and compassionate. I asked him not to give up on us, and he promised he wouldn’t. We also met with a Maternal Fetal Medicine doctor and discussed a cerclage This is a small stitch to close the cervix. Initially, I thought a vaginal cerclage was best, but Dr. Miller strongly recommended an abdominal cerclage.
An abdominal cerclage is a surgical procedure where a strong stitch is placed around the cervix through the abdomen to help keep it closed during pregnancy. It’s most often recommended for women with cervical insufficiency, a condition where the cervix opens too early, which can cause pregnancy loss or preterm birth. By reinforcing the cervix, the cerclage gives the pregnancy a better chance to continue safely.
When an abdominal cerclage is placed prior to pregnancy, it avoids the risks associated with a vaginal cerclage, such as infection or an inability to place the cerclage due to cervical thinning. It has a success rate of about 98%. Paul and I knew this was the right choice. We had it placed in early 2023.
We did another endometrial scratch, this time two cycles before the next transfer. That transfer didn’t take. I started spiraling, truly believing I might never be pregnant again.
Hope After Heartache: A Successful Transfer
We still had four embryos left. We proceeded with another scratch the month before our next transfer in August 2023. I wasn’t hopeful. But we were pregnant again. Instead of joy, I felt dread. Our first beta was decent, not great, but it continued to rise. We made it to another OB ultrasound at the Naperville office. I couldn’t bring myself to get excited. My heart was guarded. I told myself that if we lost this one, at least I wouldn’t be attached.
But another week passed, and the baby was thriving—already a day ahead in growth. The heartbeat was strong. We graduated and saw my OBGYN that same week. We agreed I’d see him or the MFM every other week to ease my anxiety. At 18 weeks, the anxiety was intense, but thankfully, I had an appointment. Our son was growing, moving, and the cerclage was holding strong. We passed 18 weeks, then 20 weeks, then reached viability. I felt a wave of relief. Before I knew it, it was time for my baby shower. I was 37 weeks—the cerclage had done its job.
Because I have an abdominal cerclage, I could only deliver via C-section unless it was removed. To protect the stitch, my OBGYN scheduled a C-section at exactly 38 weeks: May 1st.
But our son had other plans.
Welcoming Our Rainbow Baby
On Sunday, April 28, 2024, after dinner, I started having contractions. After about 12 in an hour, I called my doctor. He said, “That’s it—we’re having a baby.”
Our beautiful baby boy, Demetrios Bartho, was born at 37 weeks and 5 days, weighing 9 lbs 1 oz and measuring 22 inches long, on April 29, 2024, at 4:38 a.m. What we had prayed for and hoped for over nearly six years was finally a reality. He was—and is—absolutely perfect.
We recently celebrated his first birthday and are now beginning a sibling cycle.
A Message to Others Facing Loss
Without Dr. Miller’s knowledge, persistence, and innovative care, we probably would not have our beautiful son today. If you’ve experienced loss due to an incompetent cervix, I highly recommend finding a qualified doctor capable of placing an abdominal cerclage. It was—and is—a life saver.
We will be forever grateful to Dr. Miller and his staff, my OBGYN Dr. Tom Kazmierczak, and the MFM doctors at Duly.
-Paul, Amanda, and Demetrios (Dimitri)
How Uterine Fibroids Can Affect Your Fertility
Did you know that 30% of all women have fibroids by the time they’re 30? While fibroids are incredibly common, for some women, they can be a cause of infertility, especially when their location affects the uterus. We asked Dr. Charles E. Miller to help us better understand how fibroids affect fertility and the recommended treatment options.
Why Fibroid Location Matters
The problem lies in where the fibroids are located. Fibroids in the uterine cavity or near the cavity are particularly concerning when it comes to fertility.
In the past, we always recommended surgery for women with fibroids in the cavity. But over the years, we’ve learned that fibroids near the cavity can be just as problematic.
Back in the 1990s, I conducted a study on women who were either miscarrying or unable to get pregnant and had fibroids within 4mm of the endometrial cavity. After surgery, 70% of them went on to have a successful delivery.
Treatment Options for Fibroids
Surgery remains the primary mode of treatment for fibroids that need to be removed. The approach depends on the size and location of the fibroid:
- If the fibroid is in the cavity or small and close to the cavity, we typically remove it using a procedure called hysteroscopy. This involves placing a small telescope into the uterus and removing the fibroid without any incisions.
- When the fibroid is firmly in the muscle wall or is larger, it needs to be removed laparoscopically. At our practice, we take great pride in performing these procedures minimally invasively.
Unfortunately, at other places, fibroids are sometimes removed via a mini laparotomy, a small but still open incision, similar to a C-section cut. My concern with this method is that it increases the risk of scar tissue, which can further impact fertility.
The Bottom Line
If you’re having trouble achieving a successful pregnancy and you have fibroids, don’t wait. Seek out a specialist with the expertise to evaluate and treat those fibroids properly.
I absolutely recommend a hysteroscopic or laparoscopic approach whenever possible. It’s effective, minimally invasive and gives women the best chance at a healthy pregnancy.
The Importance of Single Embryo Transfer in Modern IVF
Dr. Charles E. Miller has practiced fertility medicine for more than 35 years, witnessing firsthand how technology and standards of care have evolved. One of the most significant shifts in modern IVF is the move toward Single Embryo Transfer (SET) as the recommended best practice. In this blog, Dr. Miller explains the change and how it benefits patients today.
Background
When Dr. Miller first opened his IVF clinic in Naperville, Illinois in September 2001, the common practice was to transfer multiple embryos at one time. Two embryos would typically be transferred in hopes of increasing the chances of a successful pregnancy. Dr. Miller’s practice was successful, and the clinic soon earned the reputation of the “Twin Capital.” Because this was the standard at the time, patients going through treatment accepted it and sometimes even favored the practice, “embracing the idea of being ‘one and done’ in terms of family building” as put by Dr. Miller. However, sometimes multiple embryo transfers came with complications, or resulted in triplet pregnancies.
Hidden risks with multiple embryos transfers
In addition to the occasional triplet pregnancy, Dr. Miller noted that once per quarter, his patients would deliver prematurely. Most of the twin pregnancies would be delivered nearly at full term (36-38 weeks) but premature deliveries were usually due to cervical incompetence, where the cervix dilates too early. According to Dr. Miller, “the risk of delivery prior to 32 weeks was 2% for singleton pregnancies, 8% for twins, and 26% for triplets (i).” Even with healthy pregnancies and births, children were left with long-term health impacts like cerebral palsy, profound developmental delays, and severe sensory and motor disabilities. Other risks associated with multiples include:
- Preterm birth
- Low birth weight
- Higher rates of Neonatal Intensive Care Unit (NICU) admission
- Maternal complications
How technology changed the game
Thanks to advancements in the embryology lab, including cryopreservation techniques and having the ability to select a genetically normal embryo, via Preimplantation Genetic Testing for Aneuploidy (PGT-A), SET is the optimal method of transfer. Dr. Miller no longer performs two-embryo transfers, only SET, and has delivery rates of over 65%.
Why is SET the recommended approach?
The values of SET extend beyond its clinical outcomes. Not only is it more cost-effective with saved NICU visits, but it also reduces the emotional strain that can come with a high-risk pregnancy. Elevated stress from pregnancy with multiples is well documented, Dr. Miller citing a study in which “22% of mothers of multiples had Parenting Stress Index scores in the severe range, compared to 5% of mothers with singleton pregnancies conceived via IVF and 9% with singleton pregnancies conceived naturally (ii).” By shifting to SET, clinics and patients can experience reduced risks from multiple pregnancies and reach their family building goals more safely.
i Practice Committee of American Society for Reproductive Medicine. Multiple gestation associated with infertility therapy: an American Society for Reproductive Medicine Practice Committee opinion. Fertil Steril. 2012 Apr;97(4):825-34.
ii. Glazebrook C, et al. Parenting stress in first-time mothers of twins and triplets conceived after in vitro fertilization. Fertil Steril. 2004 Mar;81(3):505-11.
What to Expect at Your First Fertility Consultation with Dr. Jacobs
Starting your fertility journey can feel scary and intimidating, yet also hopeful. Knowing what to expect can help ease anxiety and make you feel more comfortable before beginning this process.
With more than 45 years of experience, Dr. Laurence Jacobs has guided thousands of families through their fertility consultations. Here’s what to expect when you schedule yours:
First Steps:
You and your partner (if applicable) should plan to attend the first consultation together; it usually lasts about an hour.
What We’ll Review:
- Medical records and history, menstrual cycle, past surgeries or complications
- Lifestyle factors and any medical issues (for you or your partner)
After that, we’ll outline the infertility workup to determine why pregnancy isn’t happening. This includes:
- Hormone blood tests
- Diagnostic ultrasounds
- X-rays
- Semen analysis
5 Key Fertility Factors We Evaluate (you may have more than one)
1. Male Factor
- Semen analysis
- Sperm function test, including strict morphology, to identify if there is any difficulty in being able to fertilize an egg
2️. Ovarian Reserve (Egg Supply)
- On cycle days 2-4, you will come into the office so we can check your hormone levels, including AMH, which helps assess your egg supply.
- We’ll also do an antral follicle count transvaginal ultrasound to measure how many egg sacs (follicles) are present. The sonographer will count the antral follicles on both ovaries, looking for them to be 2-10 mm in diameter. The more follicles the better!
3️. Ovulation Evaluation
- Ovulation predictor kits, which look for a rise in a hormone called LH that tells us when you’re about to ovulate
- Ultrasound to check egg sac (follicle) size
- Follow-up progesterone test about a week later to confirm ovulation and assess if you have produced enough progesterone to be able to build up the lining of the uterus to get it ready for a pregnancy
4️. Uterine and Tubal Factors
- HSG, an X-ray using contrast dye, to view the uterus and fallopian tubes or a saline sonogram to check for fibroids, adhesions or polyps
- We also flush the fallopian tubes (part of the HSG) to make sure the fluid goes through the tubes so we know if the tubes look healthy and are functioning properly.
5. Pelvic Factors
- Check for adhesions from endometriosis, pelvic inflammatory disease or past surgeries
- Assessment for fibroids that could impact fertility
Next Steps:
After your workup (typically completed in a few weeks), we’ll schedule a follow-up appointment to review results, discuss medications and consider options like IUI or IVF if necessary. We’ll also recommend lifestyle changes to help support your fertility.
Ready to schedule?
Call us at 630-428-2229 or fill out this request form to get started.
About Dr. Laurence Jacobs
Dr. Laurence Jacobs is a Mayo Clinic fellowship-trained Reproductive Endocrinologist with over 45 years of experience helping thousands of families build their dreams through personalized fertility care.
Board-certified in Obstetrics and Gynecology, Dr. Jacobs brings deep expertise in IVF, PCOS, male and female infertility and second opinions for complex cases. After decades in leadership and practice, he is proud to provide consultations at Charles E. Miller, MD & Associates | CCRM Fertility’s Naperville office. Known for his compassionate approach and trusted by both patients and peers, Dr. Jacobs has been recognized nationally as a Top Infertility Doctor and consistently honored for his patient-centered care.
Understanding Menopause: Real Talk About What’s Happening And What You Can Do
Menopause is a major life transition, but for many women, it can feel confusing, frustrating and even a little scary. That’s why Dr. Molly McKenna recently gave a presentation all about understanding what’s happening in your body and treatment options available.
Here’s a recap of what she shared.
What Is Menopause?
Menopause marks the permanent end of menstrual periods after the ovaries stop releasing eggs. It’s officially diagnosed after 12 months of no bleeding.
The average age for menopause is 51, but symptoms and changes can begin much earlier.
Definitions:
- Perimenopause: The transitional time leading up to menopause, where hormone levels begin to fluctuate.
- Menopause: The moment 12 months have passed without a period.
- Postmenopause: The time after menopause.
- Primary Ovarian Insufficiency: When menopause-like symptoms occur before age 40.
What to Expect: Common Symptoms
Menopause doesn’t affect everyone the same way, but hot flashes are the most common symptom. Dr. McKenna estimates 95% of her patients have them.
Other common symptoms include:
- Vaginal dryness or discomfort (reported by 10–40%)
- Sleep disturbances
- Mood changes like irritability, anxiety, or depression
- Changes in libido
These symptoms are not just "in your head," they are a real response to shifting hormones.
Do You Need Tests?
Sometimes, blood work can be supportive, but it’s important to remember that hormone levels fluctuate daily and this is merely a snapshot in time. One helpful marker is an elevated FSH (follicle-stimulating hormone), especially levels above 15–25 IU/L during the menopausal transition.
But diagnosis is primarily based on your symptoms and menstrual history.
Treatment Options: You Don’t Have to Live with the Symptoms
Let’s be clear: You do not have to tough out these symptoms. There are several options available, depending on your needs and health history.
1. Lifestyle Changes
Healthy habits, like regular exercise, sleep hygiene and balanced nutrition, can help support your body during this time.
2. Non-Hormonal Medications
- SSRIs/SNRIs like Venlafaxine (Effexor) and Paroxetine (Paxil) can significantly reduce hot flashes (up to 62% improvement).
- Gabapentin, although off-label, has shown up to 45% symptom reduction in clinical trials.
- Fezolinetant (Veozah) is a newer, non-hormonal option.
3. Herbal and Natural Remedies
Some women report symptom relief from:
- Black Cohosh
- Evening primrose oil
- Ginseng
- Soy products
- Vitamin E
However, keep in mind the evidence for effectiveness is mixed.
4. Hormonal Therapy
Hormone therapy is still the most effective treatment for hot flashes, vaginal dryness, and bone loss prevention. Options include:
- Estrogen (oral, patch, gel, vaginal)
- Progesterone (needed if you still have a uterus)
Dr. McKenna emphasizes:
- Use the lowest effective dose for the shortest necessary time.
- Risks (like breast cancer) typically don’t increase until after 5+ years of use.
- Vaginal estrogen is a low-risk, localized option with no systemic absorption and it is safe for nearly everyone! This is one of Dr. McKenna’s favorite options.
Key Takeaways from the North American Menopause Society
- Hormone therapy is safe and effective for most women under 60 and within 10 years of menopause.
- Transdermal estrogen (patch or gel) may lower the risk of blood clots and stroke.
- Hormone therapy can be continued after age 65 if symptoms persist and benefits outweigh risks.
- Be cautious with compounded bioidentical hormones as they are not regulated by the FDA and may vary in dose or quality.
Menopause doesn’t need to feel overwhelming or isolating. Whether you’re in perimenopause, postmenopause or somewhere in between, you deserve real answers and personalized care.
Dr. McKenna and our team are here to support you every step of the way with compassionate care, up-to-date treatments and no judgment.
Have questions or symptoms you’re struggling with? Schedule a consultation with our team. You’re not alone and you don’t have to figure this out by yourself.
Patient Story- Kasi: Endometriosis, Infertility and the Path to Motherhood
As Endometriosis Awareness Month comes to a close, we wanted to share Kasi’s journey. It’s one of strength, resilience and hope. Kasi endured years of pain from endometriosis, multiple surgeries and several IVF cycles. Through every challenge, she never gave up on her dream of becoming a mother. Today she holds that dream in her arms- her beautiful son, Koah.
He has brown russet-colored eyes that are full of depth. They sparkle when he laughs and when he looks at me. He has his father’s hair and my jawline. His latte-colored skin comes straight from me. He is the light of my life and for many dark years, I wondered if he’d ever be here.
Years of Pain Without Answers
I had a plan for my life as many women do. The plan was to finish graduate school, get married, buy a house, and then start a family. My early twenties had their own hardships that centered around midterms and quarter-life crises. I also had unusually painful periods that most doctors dismissed with instructions to start taking ibuprofen a couple days before my period would start. But the pain would still leave me curled in a ball in the middle of my bed every few months. A doctor at the health services recommended taking birth control pills to help regulate my periods and reduce the pain. It worked for several years. When my husband and I turned 30 years old, we decided that we wanted to start our family. That required me to stop taking the birth control pills and to begin planning the next part of our lives. We planned on 2 or 3 children. We talked about the types of parents we would be, and we made plans around their impending arrival. But the arrival seemed stalled.
The pain was back. Sometimes it would be debilitating, and it would cause me to miss work. I was also having digestive issues that would cause chronic constipation and discomfort. I started a new job that could be stressful, so I thought it was all stress related. In the winter of 2012, the holidays were rough. After Christmas, I found myself in significant pain. I recently switched doctors and decided to see my new doctor to find out what was going on.
The Diagnosis That Changed Everything
Dr. Melissa Kwak was the first doctor who listened to me when I told her about all the pain I was having. She ordered an MRI that started me on my journey. The MRI found a fibroid the size of a grapefruit on my uterus. She sent me for further testing with Dr. Brett Cassidy and he recommended that I have surgery to have the fibroid removed in February 2013. I was 32 years old. I remember feeling so frustrated that my body could betray me in that way. I know the depth of the betrayal.
The surgery was meant to be laparoscopic. They explained that I would have tiny keyhole incisions made in my abdomen and another in my belly button so that the machine could excise the fibroid without them having to open me up with a lateral incision. They expected everything to go easily and after recovery, we could begin trying to have a baby again. When I woke up from anesthesia, I was in overwhelming pain. I began screaming and the nurses rushed to me. I heard one say, “We need to manage her pain!” I knew immediately that something went wrong. I kept asking over and over what happened, but no one answered me.
“You have endometriosis,” my doctor later explained to me. They had to abandon the laparoscopic surgery as soon as they could see what they were dealing with. They had to open me up laterally (like a c-section). I had adhesions all over and this was the reason for my extreme pain during menstruation. With endometriosis, endometrial tissue is found in other areas of the pelvis. When the body menstruates, the tissue in these other areas, outside the uterus, bleed as well. The body treats these areas as internal bleeding and rushes to heal it and create scar tissue around it. These are called adhesions. My doctor was able to save my reproductive system and remove the adhesions. He gave us the green light to begin trying to have a baby again. He explained that being on birth control was unknowingly treating the endometriosis. But to start our family, I could not take medication for the condition. The instructions were to get pregnant fast since there was no cure for endometriosis and the adhesions can return. We were optimistic, but another year passed without a baby.
IVF and the Emotional Toll of Infertility
We realized that it was time to talk to a fertility specialist to assist us. Dr. Cassidy recommended that we see Dr. Charles Miller in Naperville, IL to assist us. However, our insurance didn’t cover Dr. Miler. So, in 2014 we began working with another fertility clinic. The doctor with this center, decided quickly that IVF would be the best option. We were 33 years old, so the odds were in our favor.
At this clinic, we ran into more complications. They had trouble with egg retrieval. They sent me back to Dr. Cassidy for another laparoscopic surgery to remove more endometrial adhesions. We finally got 10 embryos but only 4 survived. They transferred 2 embryos in December 2014. We would have to wait 2 weeks to find out if the embryos took and if we were going to be parents. During that 2-week wait, my father-in-law passed away from heart disease and we were mourning. I look back on that period with a lot of pain. I often wonder if the grief and the negative emotions I felt made my body inhospitable for those little babies. We found out that the embryos didn’t take a couple days before the funeral, so we grieved my husband’s father, and the loss of the embryos. I fell into a mild depression after that. I admitted this to my doctor, and she suggested that I begin seeing a therapist. I was dealing with a lot of guilt and grief over my father-in-law passing. I felt like I was selfish in his last days because I was so focused on the embryo transfer, but I also felt that I was a terrible mother to those embryos because I did not provide a positive environment where they could grow.
Infertility can be a lonely thing. Even though I was surrounded by doctors and nurses and friends and family who encouraged me, I still felt alone. I felt profound shame and inadequacy. I didn’t think that I was worthy to be a mother and maybe somehow God had ordained it to be this way. I received confirmation of my own perceived condemnation when a second embryo transfer did not yield a pregnancy. I needed time off. For a year, I didn’t want to think about fertility or trying to have a baby. But during this time off, the endometriosis did not leave me. The pain became severe again and I knew that I’d need to address it and decide if we’d want to try to be parents again. Through this time, we switched to a new insurance. I went to see Dr. Cassidy to ask about another surgery for the endometriosis. He asked us again if we thought about Dr. Charles Miller. He said he was one of the leading specialists in the area for endometriosis and he could do the surgery. We investigated our insurance coverage, and we were happy to find that Dr. Miller was covered.
Finding the Right Specialist
When we first met with Dr. Charles Miller, it was on a Sunday. He was dressed in a beautiful suit. He looked outstanding. He immediately helped us feel at ease. He tailored the treatment plan to me and my unique circumstances. That was refreshing, because our last doctor wanted to use the same protocol with me that she used for every woman she treated, regardless of the diagnosis. We were 35 years old and desperate to make things work. The fertility world talks about age 35 as the gateway into geriatric pregnancy. The percentages of successful live births begin to go down at this point and risks of birth defects and other issues increase. We were anxious to get started. I had 4 or 5 surgeries, numerous egg retrievals and 3 embryo transfers with Dr. Miller. I remember, after a disappointing cycle, we sat in Dr. Miller’s office with him. He was quiet after explaining what happened and we were quiet. I remember asking him not to give up on me. I remember he took my hand and told me that he was willing to fight along with us for as long as we were willing to fight.
In January 2020, I needed another surgery for endometriosis. I was 39 years old and desperate to try again before I turned 40. We had one frozen embryo left from the previous cycle. The plan was to have the surgery, do a few more egg retrievals so we could transfer more than one embryo. The odds are always better when you have more than one embryo to transfer. By the summer of 2020 I went for tests, that showed that I wasn’t ovulating after the last surgery and there wasn’t much hope of getting more embryos. Dr. Miller talked to us about donor eggs, but my husband and I didn’t want to give up on the dream of having a child that was a little bit of both of us. So, we decided to transfer the one embryo we had. We decided we were done with the whole IVF process. We started looking into foster care and adoption. It took another 6 months to get insurance and all other circumstances to line up.
One Last Chance at Motherhood
In February 2021, a few months after I turned 40-years-old, I came into the office to transfer the last embryo we had frozen. We were in the thick of COVID protocols so my husband couldn’t come in with me. When the doctor came in, I tearfully told him about the amazing impact he had on my life. I told him that no matter the outcome, I was just so grateful that I had the opportunity to reach for my dream when so many other women didn’t even get the chance to try. We both cried and he told me that he had a great feeling about that transfer. I had a sense of peace after that last cycle. In the past I did acupuncture after the embryo transfers to increase the odds of the embryo taking. But this last time, we chose to go to my father’s house and pray. My husband, my father, and I joined hands and prayed the most beautiful prayer about gratitude and joy regardless of the outcome.
The Call That Changed Everything
On the morning of my blood test after the 2-week-wait, I felt hopeful and peaceful. I knew this was going to be my last time going through the process and maybe knowing this gave me peace that day. Normally, the results of the pregnancy tests came to us on a portal app on my cell phone. I thought that I wouldn’t hear anything until the afternoon. During my morning break from work, I decided to lay down and take a nap. Before I could fall asleep, my phone started ringing and it was Dr. Miller’s office. They never called before on pregnancy test day, so my heart was in my throat when I answered the phone. The nurses in the office had me on speaker phone. The phlebotomist, the ultrasound tech, and two of the nurses were gathered around the phone. They asked me if I was sitting down. When I told them I was, one of the girls screamed, “You’re pregnant!” I immediately fell on my knees. I cried on the phone with them for what felt like an hour. I could hear a few ladies crying with me and I heard them yelling “Congratulations!’ I couldn’t even speak. It was 10 years of waiting. 10 years of crying. 10 years of wondering what I had done wrong, 10 years of disappointments. The emotion that flowed through my body in that moment was pure joy.
A Dream Come True
My pregnancy went forward without any complications. We were blessed because I was healthy, and the baby was healthy. I gave birth to a beautiful baby boy named Koah. I am certain that I just gazed at him for hours. I still love to look at him. We had waited so long for him, and he had waited for us as a frozen embryo. He was the very last to be transferred, but he was destined to make it into our arms. Koah is our only child, but our hearts remain open and excited about this beautiful life we will have with our son. I knew from the moment that my pregnancy was confirmed that I would share this story. I knew that I wanted to encourage other women who feel isolated while going through this journey. I persevered and I was able to experience the miracle of feeling a life growing inside me. I can watch him grow as a walking and breathing testament to my own strength and endurance. The journey taught me to feel worthy regardless of the outcome and I am looking forward to helping other women feel empowered and strong.
-Kasi
How Endometriosis Affects Fertility: Causes, Symptoms, Diagnosis and Treatment
We spoke with Dr. Laurence Jacobs, a reproductive endocrinologist with over 30 years of experience, to explore how endometriosis impacts fertility and how to recognize the signs of this often misunderstood condition.
How Does Endometriosis Affect Fertility?
Endometriosis can make it much more difficult to get pregnant. In fact, 20-50% of all infertile women have endometriosis, making it a prevalent issue in reproductive health.
One of the main ways endometriosis affects fertility is through scar tissue formation. When endometrial tissue grows outside the uterus, it can create scar tissue, adhesions and inflammation around the ovaries and fallopian tubes. This can often distort the normal anatomy of the pelvis, making it harder for the fallopian tubes to move over to the ovary and pick up the egg during ovulation.
Endometriosis can also interfere with ovulation. Endometriomas, which are cysts formed by endometriosis growing deep within the ovaries, can disrupt ovulation by affecting both the development and/or release of eggs. Additionally, some research suggests endometriosis can negatively affect the egg quality due to the inflammatory environment it creates within the pelvis.
Another concern is embryo implantation. The inflammation caused by the endometriosis can make it more difficult for the embryo to successfully implant within the uterine endometrial lining, leading to infertility or recurrent pregnancy loss.
The severity of endometriosis plays a significant role in its impact on fertility.
- Stages 3 or 4 (more advanced endometriosis) involve severe adhesions and endometriomas, which can have a major impact.
- Stages 1 or 2 (milder cases) may only involve small implants of endometriosis, which can still affect fertility but to a lesser degree.
The stage, severity and location of lesions and implants all play a significant role in how endometriosis affects fertility.
How Can You Tell If You Have Endometriosis?
The most common symptoms of endometriosis include:
- Pelvic pain
- Moderate to severe menstrual cramps
- Pain during sexual intercourse
Although some women with endometriosis have no symptoms at all. A pelvic exam can sometimes reveal signs of endometriosis, such as hard nodules at the bottom of the pelvis.
Ultrasound is another useful tool for identifying endometriosis. Endometriosis growing very deep inside the ovaries, can form a cyst called an endometrioma and these cysts can be seen on ultrasound. However, most smaller implants of endometriosis cannot be seen on ultrasound. Ultrasound can only detect advanced stage 3 or 4 endometriosis, while smaller implants and adhesions seen in Stage 1 or 2 may not be visible.
How Is Endometriosis Diagnosed?
Symptoms and signs of endometriosis and even ultrasounds can make one suspicious of endometriosis, but the only way to definitively diagnose the condition is through laparoscopy. A laparoscopy is a minimally invasive procedure that allows a surgeon to look inside the pelvis using a laparoscope, which is a thin, telescopic rod with a video camera on the end. Not only can laparoscopy surgery confirm endometriosis, but the procedure can treat it as well.
Why does surgical expertise matter?
Because advanced endometriosis (Stage 3 or 4) often involves severe adhesions affecting the ovaries, intestines, bladder and ureter, it is highly recommended that the laparoscopy be performed by a skilled reproductive surgeon rather than a general gynecologist.
- A skilled reproductive surgeon can both diagnose and remove endometriosis in one procedure.
- You don’t want to undergo surgery just for diagnosis, only to need a second procedure for treatment.
- A less experienced surgeon may leave some endometriosis behind or be unable to treat complex adhesions.
New Advances in Endometriosis Testing
In the last seven years, innovative diagnostic measures have been developed to help determine if a woman with no symptoms or ultrasound evidence might have endometriosis. It also helps physicians decide who would be a good candidate to undergo laparoscopy.
Back in the 1980s and 1990s, it was standard procedure that everyone with infertility undergo laparoscopy, but now we try to be much more selective. The ReceptivaDX test, an endometrial biopsy performed in the office, checking or sampling the uterine lining, measures a protein called BCL6, a marker usually associated with endometrial uterine inflammation and potentially silent endometriosis.
An abnormal biopsy result usually means there is endometriosis or inflammation in the pelvis. This biopsy can be very helpful for women who have no symptoms, evidence of endometriosis on ultrasound or unexplained fertility.
Seeking Expert Care
If you think you might have endometriosis, it is imperative to seek out an experienced reproductive surgeon specialized in treating advanced endometriosis. In my opinion, Dr. Charles Miller, Dr. Kirsten Sasaki, and Dr. Molly McKenna are among the best reproductive surgeons for endometriosis treatment in the Midwest. Their expertise ensures that patients receive the highest level of care for both diagnosis and treatment, improving their chances of achieving a successful pregnancy.
Request a consultation or call 630-428-2229 to schedule.
Understanding Endometriosis: What Patients Need to Know
In honor of Endometriosis Awareness Week, we asked Dr. Kirsten Sasaki what she thought patients need to know about this disease that affects 1 out of 10 women.
What to Expect During Your Endometriosis Appointment
If you think you may have endometriosis, being prepared for your medical appointment can help you get the most out of your visit. Here’s what you can expect:
- Thorough medical history including any surgeries and menstruation history
- Physical exam including pelvic exam and pelvic ultrasound
- Depending on findings, your doctor could recommend further lab work and/or an MRI
How to Advocate for Yourself During Your Appointment
Advocating for your health is important, especially with a condition like endometriosis that is often misdiagnosed or overlooked. Here’s how you can make the most of your appointment:
- Tell the physician about any pain, discomfort, bloating or abnormal bleeding you are experiencing
- Don’t wait for your physician to bring up these questions. Write them down before the appointment. Writing down your questions and symptoms ensures you don’t forget to mention any concerns.
- Be direct with your physician. Ask if any of these symptoms might be occurring because of endometriosis.
Key Endometriosis Symptoms to Track
Tracking your symptoms can help with diagnosis and treatment. Pay attention to:
- Pain both on and off your period
- Pain during intercourse
- Painful bowel movements
- Changes in bowel habits during and around your period
- Heavy or prolonged bleeding (periods lasting more than seven days or needing to change protection every 1–2 hours)
- Frequency of NSAID use for pain relief
- Missed work or social activities due to pain
Common Misconceptions About Endometriosis
One of the biggest myths about endometriosis is that if your imaging (such as an ultrasound) is normal, you don’t have the disease. In reality, many patients have normal imaging results yet still experience all the symptoms of endometriosis. A laparoscopy can definitively diagnose the condition by allowing the doctor to confirm the presence of endometriosis and remove the diseased tissue via excision.
Finding Relief from Endometriosis Symptoms
Various treatments can help manage endometriosis symptoms and improve quality of life. Patients may find relief through:
- Pelvic physical therapy can help reduce pain and improve mobility.
- Acupuncture may help alleviate symptoms by promoting circulation and reducing inflammation.
- Exercise and regular movement can help reduce pain and improve overall well-being.
- Eating a healthy diet rich in vegetables while limiting processed foods and red meat may help manage inflammation and symptoms.
Endometriosis is often underdiagnosed and misdiagnosed leaving many patients to endure years of pain and countless doctors appointments before receiving a diagnosis. No one should have to leave their pain untreated.
Our dedicated team is here for you, request a consultation.