High androgens but regular ovulation.. still PCOS?

[Mary]

Hello,

I'm 33 years old and have been 'diagnosed' with PCOS several times in my life. I have a higher androgen level but it doesn't seem to stop my body from ovulating regularly. I have done a lot of tests but I am very confused about what could explain my PCOS and if it even is PCOS... (even after reading the book many times!)

I have tracked my BBT since 4 years, I have a consistent rise in BBT 2 weeks before menstruation. Cycle is pretty regular (34 days, sometimes a day more or less). Cervical mucus pattern matches cycle.
My previous gynecologist (after seeing polycystic ovaries on several ultrasounds), eventually also believed I was ovulating after seeing a 'burst' at one ultrasound, and seeing progesterone go from 3.9 nmol/l at 'burst/ovulation time' to 33.9 nmol/l a week later.

However, I do have high androgens: androstendione (14.2 nmol/l) and some dark hairs on my chin.
Other measures were normal:
- Fasting insulin = 4.8 mU/L
- BMI always around 19
- estradiol in blood = 579 pmol/l
- DHEA-S = 5.7 umol/L
- testosterone = 1.2 nmol/l
- SHGB = 94 nmol/l
- All thyroid measures normal (TSH, FT3, FT4, no issues with thyroid antibodies)
- Cortisol spit test was good
- Vitamin D, zinc, B12 & B6 are in good ranges.

Some confusing measures:
- LH/FSH ratio at day 2 of the cycle was 1, both 6.5 U/l. At ovulation time the measurement of LH was 15.3 U/l and FSH was 4.3 U/L.
- Consistently low iron (ferritin) levels (20 ug/L) despite daily iron supplementation
- High prolactin at some measurements (24.6 ug/L during a stressful period, 10.7 ug/L at other time).

I am not a vegetarian and I consume practically no gluten and no cow-milk.

My current doctor says my LH/FSH ratio and the androstendione level are proofs of PCOS, and wants to give me metformin. I am very skeptical about this treatment, as I don't fit the insulin-resistant type. I am wondering about the following and hope answers to my questions could help others understanding PCOS better as well:

- If you are ovulating regularly, can you still have PCOS? (I thought being anovulatory was part of the PCOS definition..? )
- If you ovulated, does it by definition mean that a follicle was able to mature? In other words, can you only reach ovulation when a follicle was able to mature and therefore it was released?
- About the LH/FSH ratio: can this vary widely throughout the cycle? Should we only interpret the LH/FSH results in the beginning of the cycle (menstruation time)?
- Could an iron deficiency be the cause of higher androgen levels?
- Any ideas on where to look for clues regarding reasons for the higher androgen levels...?

I'm trying to remain positive about my ovulation despite all negative/demotivating comments from doctors based on the androgen level / polycystic ovaries...
Thanks a lot in advance for all your amazing insights

[Lara]

First, about the LH/FSH ratio: It should ONLY be interpreted on day 2 or 3 of the cycle. It is perfectly NORMAL for LH to be high leading up to ovulation.

Technically, it is possible to fall under the PCOS diagnostic umbrella with ovulatory cycles, but as you are not the classic insulin-resistant PCOS, the PCOS label may not have much clinical significance for you. For example, the fact that you're ovulating is really good!

What is your main symptom or health problem? If the only symptom is the dark chin hairs, I might be tempted to just look at natural androgen blockers like zinc. And maybe lowering prolactin (because high prolactin can cause androgen symptoms). See my androgen excess blog post.

[Mary]

Dear Dr. Briden,

Thanks a lot for your reply, I'm happy to hear that I should not worry about the LH/FSH ratio in that case.

My main symptom with regards to the androgens would indeed be the dark chin hairs. More generally I do suspect to have an issue with estrogen and/or histamine because I get anxious and I sleep really bad around ovulation time and a few days before the period. Taking B6 and calcium-d-glucarate makes a big difference for those issues though.

At the same time I am wondering if iodine would be something I should try, as I have sharp pains in my breasts during some days of the cycle and generally my breasts typically increase in size in the luteal phase (though they're not necessarily painful). I do have a cyst on my thyroid, but all thyroid blood values are normal. Would a cyst on the thyroid be an indicator of a potential iodine deficiency or a reason to better not supplement too much iodine..?

Thanks again so much for all your work!