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About Edward Joseph Ramirez, MD, FACOG
Expertise
I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience
I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 15 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

You are here: Experts > Health/Fitness > Women's Health > Infertility/Fertility > Absent periods

Infertility/Fertility - Absent periods

Expert: Edward Joseph Ramirez, MD, FACOG - 11/6/2009

Question
Dear Dr Ramirez

I am a 26 year old female. I have always had regular periods until three months ago. I was on birth control for a year until April 2009. I had regular cycles in May, June and July, with no periods in August, September or October.

After taking a pregnancy test, which was negative, I then went to see my gynaecologist. He conducted an ultrasound, from which he could not see any abnormailities, and then sent me for various blood tests and prescribed Primolut N for 10 days in order to induce a period. When the blood tests came back, the two abnormal results were my insulin levels, which were high (37), and my progesterone levels, which were very low (I was told below 1).

Based on the raised insulin levels, he advised that I may have PCOS (even though no cysts were visible from the scan). Is this possible, especially considering that my periods were previosuly normal? I do have a family history of diabetes, but do not have any of the other symptoms I have read about relating to PCOS (other than the high insulin levels and absent periods). Another thing that I am wondering about is whether the fact that I ate a meal about 20 minutes before going for the blood tests (I did not know that there was an insulin test involved) could have caused the raised insulin level (my understanding is that these tests are usually conducted after fasting).

As I would like to conceive, my gynaecologist then proceeded to prescribe clomid. Is this the correct cause of action or should we first try conceiving naturally? I have read the insert listing the possible side effects of Clomid and these are somewhat alarming. Assuming it is PCOS, is it possible to conceive by altering my diet etc before resorting to clomid?

Your comments would be greatly appreciated. Thanking you in advance.

Answer
Hello "F" from South Africa,

An elevated insulin level on its own does not make the diagnosis for PCOS. However, approximately 50% of PCOS patients are found to have an elevated insulin level, and treatment of this will result in normal ovarian function (regular period). If your insulin level was not a fasting level, then the result is NOT valid. It needs to be repeated.

If your insulin level returns elevated again, then you need to be evaluated by a medical endocrinologist because of the possibility of diabetes. This is not treated by your gynecologist. The elevated insulin could certainly be the reason for your ovarian dysfunction and the treatment of it could restore your ovulation to normal. More importantly, if you have diabetes, you need to undergo surveillance and treatment for that. This would involve taking a medication called metformin to reduce the insulin levels.

I think you need to go in that direction first before proceeding to Clomid, although treatment with Clomid is appropriate also. Your gynecologist is treating your desire to become pregnant, rather than the underlying problem. You need to treat the latter first.

I hope that helps,

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on facebook and twitter with me at @montereybayivf

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