2:1 LH:FSH ratio, but probable PCOS misdiagnosis

[merle]

I will include a long history below, but my main question is...can it be normal to have the "PCOS presentation" of 2:1 LH:FSH but *not* have PCOS? Why would I have this ratio if I am ovulating regularly (confirmed with blood progesterone) if not PCOS? And also can PCOS be an HA misdiagnosis if Provera *did* work and you got a bleed?

My hormonal issues began about 8 years ago at 24 when I suddenly experienced an 8 months of amenorrhea. Previous to this my cycles were basically regular, give or take a few days here and there. No idea if I was ovulating.

At the time I had gone from nearly underweight to a healthy weight but probably lower body fat percentage-- I went from never exercising and being skinny to working out daily, lifting heavy weights, and eating a ton of protein. However, I was eating a lot (of healthy foods, and carbs) and not restricting...if anything, eating more than I ever had. I had also gone from vegetarian to pescatarian.

I was given Provera and I think about 10 days after finishing the course, I got my period (not sure of this timing since i didn't record it, I do remember thinking the Provera hadn't worked but eventually I did bleed).

The reproductive endocrinologist saw me within the first couple days of my bleed that cycle. I was given a blood test and a vaginal ultrasound. The ultrasound showed "string of pearls" follicles that I now know are to be expected just from a period of anovulation like I had, regardless of cause. I had no acne at the time (although I had sudden bouts as an adult previous to this after perfect teenager skin), no hair loss, and no hirsutism.

My blood test showed all normal hormones. Insulin was 4.3. Free testosterone was on the way lower end of normal. Normal DHEAs. The RE diagnosed me with PCOS regardless. Looking back at my blood work now, I see that my LH:FSH ratio was not in line with PCOS. LH was 5.2 and FSH was 7. It's my understanding that this may be more indicative of HA.

I did not go on medication since my cycles became regular again from this point on and I had no symptoms. However, within the following 6 months to a year, I lost a good amount of hair along my hairline. Following that, I developed a lot of acne which persisted despite good skincare practices. Testing at the gyno at this time (probably 2 years after diagnosis, luteal phase) showed a typical PCOS 2:1 LH:FSH ratio (LH 18, FSH 9). Also slightly high prolactin. I was put on Spironolactone, which helped with the deep acne but not the hair. Eventually I noticed my TSH creeping up and was diagnosed subclinical hypothyroidism, without Hashimoto's (no antibodies multiple times, no inflammation markers high whatsoever, no damage on ultrasound). Treatment with t4 did nothing for my hair. I assumed my hair loss was PCOS related and went on low carb and inositol. I also stopped the Spironolactone. I didn't get any improvement and my insulin went very low to 1.2, so I went back to healthy, moderate carb and stopped the inositol.

In the time since, I have come to believe my hair loss may be a vitamin deficiency and not hormonal in origin (it seems to be responding to zinc but it's too early to tell). I have had several free testosterone tests and never has it been elevated. Now that I see my first test LH:FSH ratio was more typical of HA, I am wondering if I was misdiagnosed with PCOS to begin with (and actually had HA?) But if I had HA, why did the Provera course work to bring back my period? And why did my LH ratio come up as typical PCOS a couple years later?

I just had LH/FSH tested again, this time mid-luteal cycle because I was also testing my progesterone. I am ovulating regularly (I use surge strips and look for negative/positive/negative results due to rule out false positives from possibly sustained higher LH). This time it was yet again nearly 2:1, indicative of PCOS. I am wondering why this is happening and why it reversed from the first time I was tested? Is it possible this is just a result of testing in the luteal phase instead of follicular?

[Lara]

In answer to your question about LH:FSH ratio, it's only a valid ratio when it's on day 2 or 3 of the cycle (ie. baseline levels of the hormones). Mid-cycle or mid-luteal readings cannot be used for assessment.

When you say "Testing at the gyno at this time (probably 2 years after diagnosis, luteal phase) showed a typical PCOS 2:1 LH:FSH ratio," -- on which day of your cycle were you?

[merle]

Hi Lara, thank you so very much for your response. The second LH/FSH test was also done sometime during my luteal phase. Do you think it's likely my PCOS diagnosis was a misdiagnosis, considering the 5.2LH to 7FSH (during first few days of my period), even though the Provera seemed to induce a bleed?

I am hoping to get my LH/FSH retested again on day 3.

Thank you again and thank you for your book which has been life changing for me.

[Lara]

If you were my patient, I might be focussing on the high prolactin finding. High prolactin is another cause of irregular periods and symptoms, separate from the PCOS-hypothalamic amenorrhea side of things.