Re: Nausea in pregnant woman with PCOS

[Guest guest]

Thanks this will certainly be helpful!--and here I am attributing authorship to you on something that hasn't been written!! Anyway, what I am recalling is that the usual dietary remedies were being questioned in the presence of insulin resistance--that giving complex carbohydrates with protein was the key??? otherwise intake of simple carbs might actually make a person who was insulin resistant feel worse. LeeOn 2/11/07, T. Goodwin <

tgoodwin@...> wrote:Dear ,I am not aware of any published material on a relationship between PCOS and NVP. This is a final draft of a recent summary of the problem of NVP published in the book " Progress in Obstetrics and Gynecology " this year.

Not too long ago there was a discussion about adjusting the diet in a woman who had nausea of pregnancy and also PCOS. Can someone give me the citation--I believe the article was written by T. Goodwin but I couldn't locate the article in a search. Thanks for your help! Lee

--

Lee Barron PhD©, APRN, BC, FNPAssociate Professor

Coordinator, Family Nurse Practitioner Program

Saint Louis University

T. Goodwin MDProfessor and Chief, Maternal-Fetal MedicineUniversity of Southern California

-- Lee Barron PhD©, APRN, BC, FNPAssociate ProfessorCoordinator, Family Nurse Practitioner ProgramSaint Louis University

[Guest guest]

Marilyn has addressed this. I have seen the article here:

http://cclsanantonio.org/resources/article.asp?cid=2 & AID=70

Hope this helps.

Penny on

Re: Nausea in pregnant woman with PCOS

Thanks this will certainly be helpful!--and here I am attributing authorship to you on something that hasn't been written!! Anyway, what I am recalling is that the usual dietary remedies were being questioned in the presence of insulin resistance--that giving complex carbohydrates with protein was the key??? otherwise intake of simple carbs might actually make a person who was insulin resistant feel worse. Lee

On 2/11/07, T. Goodwin < tgoodwinhsc (DOT) usc.edu> wrote:

Dear ,

I am not aware of any published material on a relationship between PCOS and NVP. This is a final draft of a recent summary of the problem of NVP published in the book "Progress in Obstetrics and Gynecology" this year.

Not too long ago there was a discussion about adjusting the diet in a woman who had nausea of pregnancy and also PCOS. Can someone give me the citation--I believe the article was written by T. Goodwin but I couldn't locate the article in a search. Thanks for your help! Lee-- Lee Barron PhD©, APRN, BC, FNPAssociate ProfessorCoordinator, Family Nurse Practitioner ProgramSaint Louis University

T. Goodwin MD

Professor and Chief, Maternal-Fetal Medicine

University of Southern California

-- Lee Barron PhD©, APRN, BC, FNPAssociate ProfessorCoordinator, Family Nurse Practitioner ProgramSaint Louis University

[Guest guest]

Dear Lee, Murph, and others,

I meant to respond to this earlier since it was I who questioned the traditional remedies. As more is learned about insulin resistance, it is clear to me, anyway, that it is the single greatest risk factor in the development of adult illness; affecting androgen, estrogen, growth factor, thyroid hormone, sex hormone binding globulin and a host of other hormones and processes. We know that Human Placental Lactogen in pregnancy increases IR, as does the normal weight gain of pregnancy. While respecting the peer reviewed studies available, and the invaluable contributions of Dr. Goodwin on the subject, I simply wish to posit that restricting simple carbohydrates and maximizing protein in the diets of pregnant women seems to make sense. My own anecdotal experience has shown that women who previously needed hyperalimentation because of severe hyperemesis gravidarum who maintained such diets were able to gain weight and avoid repeated hospitalizations and IV therapy while also using the recommended medical therapies for HEG. Anecdotal evidence is meaningless, but I suspect that somewhere, someone with the same idea and the ability to write a paper will eventually do so and prove me right.

Since I have already stuck my neck out, I'll go a little further. Brown (personal correspondence) has demonstrated that it is a poor follicular phase which results in a deficient luteal phase. While Dr. Hilgers recommends progesterone supplementation for deficient luteal phases, and it also appears, for HEG, might I respectfully suggest that IR is again the culprit, interfering with follicular progression resulting in suboptimal progesterone levels. Being a purist, I treat IR to ensure adequate luteal phases and have a very low index of suspicion for women who present newly pregnant with the following histories: recurrent pregnancy loss, irregular cycles, strong family history of diabetes, babies over 9 pounds, "hypoglycemia" and particularly, hyperandrogenism. The women with worst HEG seem not only have prominent vellus hair but acne, facial hair and lower abdominal hair despite being bone rack thin, whereas others will have the typical android obesity but still have the hair pattern described plus acanthosis nigricans. I screen such women immediately for adequate progesterone levels, then offer the one hour glucose tolerance test at 16-18 weeks. They are instructed about low glycemic index foods and offered the usual testing and medications of HEG becomes problematic. If the glucose test is abnormal they are offered glucose monitoring as an alternative to the 3 hour test and Glyburide when one third of the daily values are out of range. If the OGTT is normal at 18 weeks, it is repeated at 30 weeks.

Since I'm feeling exceptionally brave this morning, I'll put out one more provocative thought: poor follicular progression, suboptimal progesterone production and increased risk of preterm labor is also related to Insulin Resistance?

I'll look forward to the discussion this post stimulates, but please be kind; I've been sick recently!

W. , M.D.,FACOG

Thanks this will certainly be helpful!--and here I am attributing authorship to you on something that hasn't been written!! Anyway, what I am recalling is that the usual dietary remedies were being questioned in the presence of insulin resistance--that giving complex carbohydrates with protein was the key??? otherwise intake of simple carbs might actually make a person who was insulin resistant feel worse. Lee

On 2/11/07, T. Goodwin < tgoodwinhsc (DOT) usc.edu> wrote:

Dear , I am not aware of any published material on a relationship between PCOS and NVP. This is a final draft of a recent summary of the problem of NVP published in the book "Progress in Obstetrics and Gynecology" this year.

Not too long ago there was a discussion about adjusting the diet in a woman who had nausea of pregnancy and also PCOS. Can someone give me the citation--I believe the article was written by T. Goodwin but I couldn't locate the article in a search. Thanks for your help! Lee-- Lee Barron PhD©, APRN, BC, FNPAssociate ProfessorCoordinator, Family Nurse Practitioner ProgramSaint Louis University

T. Goodwin MD

Professor and Chief, Maternal-Fetal Medicine

University of Southern California

-- Lee Barron PhD©, APRN, BC, FNPAssociate ProfessorCoordinator, Family Nurse Practitioner ProgramSaint Louis University

[Guest guest]

I think Dr. 's comments are interesting as usual. Here is my opinion on nausea.

These therapies are effective for me, and they should be used in combinations rather than singly.

Pyridoxine 50 TID

Phenergan 25 TID (or any phenothiazine)

Doxylamine 1/2 TID (or any antihistamnine)

Each of these has been associated with an approximately 50% reduction in birth defects, either singly or in combination.

Also helpful are

Vitamin C in combination with Vitamin K 5 mg QAM

Ginger tea.

Protein intake.

Steroids as promoted by Dr. Goodwin.

For all of the above there is scientific literature.

I think the biggest problem is that practitioners often use one treatment, which doesn't work. They then stop that, and substitute another. Rather, I would suggest combining treatments which act by different physiologic mechanisms. Especially the first three above. If one is not achieving success then treatment should be increased by either

1.) add another treatment which acts by a different mechanism (better)

2.) substitute a stronger drug for a weaker drug within the same physiologic mechanism. Thus, Zofran is a stronger antihistamine, which could substitute for doxylamine. (less preferable)

Some patients are progesterone deficient, I believe. It is helpful, but should not stand alone.

Some patients are hyperthyroid and need treatment, but don't overdo it. (fetal brain development)

More seriously ill patients may be defeicient of magnesium and or potassium.

In general, I think expensive and exotic treatments, such as high powered phenothiazines and antihistamines as less effective than the approach I have outlined above. IV medications are less preferable to ones that can go home easily.

In general I think patients should rarely be made NPO. The goal is for them to go home on oral diet as rapidly as possible. If they are not tolerating the diet, treat hyperemesis more aggressively rather than restricting diet. Restricting the diet , which runs counter to the goal.

They also need continuous supervision by one physician. Frequently changing the plan or the physician will result in unproductive chaos. As more and more physicians are unsuccessful at treating the problem, the patient beciomes known as one who is impossible to treat or has a psychological problem. This is very unfair to the patient. One should be very hesitant to ascribe a medical problem to a psychological cause merely because we can't find the medical solution. More likely, the patient's ongoing misery, resulting from an unsolved medical problem, is the cause of psychopathology.

Thus I view it as a stair step program, beginning with the first three above. If two or one are sufficient, then fine. If not, increase treatment at frequent intervals until patient is comfortable.

This is my humble anecdotal opinion.

Reply-To: nfpprofessionals To: nfpprofessionals Subject: Re: Nausea in pregnant woman with PCOSDate: Thu, 15 Feb 2007 10:22:30 -0600MIME-Version: 1.0X-Originating-IP: 64.12.137.6X-Sender: OBDOC2000@...Received: from n15b.bullet.sp1.yahoo.com ([69.147.64.119]) by bay0-mc3-f6.bay0.hotmail.com with Microsoft SMTPSVC(6.0.3790.2444); Thu, 15 Feb 2007 08:23:47 -0800Received: from [216.252.122.217] by n15.bullet.sp1.yahoo.com with NNFMP; 15 Feb 2007 16:23:37 -0000Received: from [66.218.69.3] by t2.bullet.sp1.yahoo.com with NNFMP; 15 Feb 2007 16:23:36 -0000Received: from [66.218.67.83] by t3.bullet.scd.yahoo.com with NNFMP; 15 Feb 2007 16:23:36 -0000Received: (qmail 32130 invoked from network); 15 Feb 2007 16:23:34 -0000Received: from unknown (66.218.67.35) by m37a.grp.scd.yahoo.com with QMQP; 15 Feb 2007 16:23:34 -0000Received: from unknown (HELO imo-m25.mx.aol.com) (64.12.137.6) by mta9.grp.scd.yahoo.com with SMTP; 15 Feb 2007 16:23:34 -0000Received: from OBDOC2000@... imo-m25.mx.aol.com (mail_out_v38_r7.6.) id r.c5b.a8763a3 (47659) for <nfpprofessionals >; Thu, 15 Feb 2007 11:22:37 -0500 (EST)Received: from YOUR-6460E1885C.ok.cox.net (ip72-198-83-70.ok.ok.cox.net [72.198.83.70]) by air-id03.mail.aol.com (v114_r3.2) with ESMTP id MAILINID35-ba2b45d488cb138; Thu, 15 Feb 2007 11:22:36 -0500

Dear Lee, Murph, and others,

I meant to respond to this earlier since it was I who questioned the traditional remedies. As more is learned about insulin resistance, it is clear to me, anyway, that it is the single greatest risk factor in the development of adult illness; affecting androgen, estrogen, growth factor, thyroid hormone, sex hormone binding globulin and a host of other hormones and processes. We know that Human Placental Lactogen in pregnancy increases IR, as does the normal weight gain of pregnancy. While respecting the peer reviewed studies available, and the invaluable contributions of Dr. Goodwin on the subject, I simply wish to posit that restricting simple carbohydrates and maximizing protein in the diets of pregnant women seems to make sense. My own anecdotal experience has shown that women who previously needed hyperalimentation because of severe hyperemesis gravidarum who maintained such diets were able to gain weight and avoid repeated hospitalizations and IV therapy while also using the recommended medical therapies for HEG. Anecdotal evidence is meaningless, but I suspect that somewhere, someone with the same idea and the ability to write a paper will eventually do so and prove me right.

Since I have already stuck my neck out, I'll go a little further. Brown (personal correspondence) has demonstrated that it is a poor follicular phase which results in a deficient luteal phase. While Dr. Hilgers recommends progesterone supplementation for deficient luteal phases, and it also appears, for HEG, might I respectfully suggest that IR is again the culprit, interfering with follicular progression resulting in suboptimal progesterone levels. Being a purist, I treat IR to ensure adequate luteal phases and have a very low index of suspicion for women who present newly pregnant with the following histories: recurrent pregnancy loss, irregular cycles, strong family history of diabetes, babies over 9 pounds, "hypoglycemia" and particularly, hyperandrogenism. The women with worst HEG seem not only have prominent vellus hair but acne, facial hair and lower abdominal hair despite being bone rack thin, whereas others will have the typical android obesity but still have the hair pattern described plus acanthosis nigricans. I screen such women immediately for adequate progesterone levels, then offer the one hour glucose tolerance test at 16-18 weeks. They are instructed about low glycemic index foods and offered the usual testing and medications of HEG becomes problematic. If the glucose test is abnormal they are offered glucose monitoring as an alternative to the 3 hour test and Glyburide when one third of the daily values are out of range. If the OGTT is normal at 18 weeks, it is repeated at 30 weeks.

Since I'm feeling exceptionally brave this morning, I'll put out one more provocative thought: poor follicular progression, suboptimal progesterone production and increased risk of preterm labor is also related to Insulin Resistance?

I'll look forward to the discussion this post stimulates, but please be kind; I've been sick recently!

W. , M.D.,FACOG

In a message dated 02/12/07 09:54:26 Central Standard Time, barronmlgmail writes:

Thanks this will certainly be helpful!--and here I am attributing authorship to you on something that hasn't been written!! Anyway, what I am recalling is that the usual dietary remedies were being questioned in the presence of insulin resistance--that giving complex carbohydrates with protein was the key??? otherwise intake of simple carbs might actually make a person who was insulin resistant feel worse. Lee

On 2/11/07, T. Goodwin < tgoodwinhsc (DOT) usc.edu> wrote:

Dear ,

I am not aware of any published material on a relationship between PCOS and NVP. This is a final draft of a recent summary of the problem of NVP published in the book "Progress in Obstetrics and Gynecology" this year.

Not too long ago there was a discussion about adjusting the diet in a woman who had nausea of pregnancy and also PCOS. Can someone give me the citation--I believe the article was written by T. Goodwin but I couldn't locate the article in a search. Thanks for your help! Lee-- Lee Barron PhD©, APRN, BC, FNPAssociate ProfessorCoordinator, Family Nurse Practitioner ProgramSaint Louis University

T. Goodwin MD

Professor and Chief, Maternal-Fetal Medicine

University of Southern California

-- Lee Barron PhD©, APRN, BC, FNPAssociate ProfessorCoordinator, Family Nurse Practitioner ProgramSaint Louis University

Turn searches into helpful donations. Make your search count.

[Guest guest]

Since I'm feeling exceptionally brave this morning, I'll put outone more provocative thought: poor follicular progression, suboptimalprogesterone production and increased risk of preterm labor is also related toInsulin Resistance? I'll look forward to the discussion this post stimulates, butplease be kind; I've been sick recently! W. , M.D.,FACOG (Dr. ): Sorry to hear that you have not been feeling well lately! However, if it has stimulated  you to post on this NFP list --- then there is asilver lining! Your last statement copied above (i.e., not the part about beingsick but about poor follicular progression) reminded me of an article in lastweek’s NEJM ---- an RCT study with 626 infertile women with PCOS were randomly distributedto a clomiphene (a follicular stimulant) + placebo group vs an insulinsensitizer (metformin) + placebo group, and a clomiphene + metformin group ---and then the investigators analyzed the pregnancy rates over 6 months of use. The clomiphene + placebo had a live birth rate of 22.5%, the metformin +placebo group 7%, and the combined group 26.8%.  The authors concluded thatfollicular stimulation (clomiphene) was superior to metformin (the insulinsensitizer) for women with PCOS trying to achieve pregnancy. See:  Clomiphene, Metformin, or Both for Infertility in thePolycystic Ovary Syndrome S. Legro,  Huiman X. Barnhart,  D. Schlaff, Bruce R. Carr,  et al. The New England Journal of Medicine. Boston: Feb 8,2007.Vol.356, Iss. 6;  pg. 551 This study would seem to support the poor follicular progressiontheory --- not sure of the other components. I recommend seeing a good nurse for your recent sickness! Be well – Be brave! J. Fehring, PhD, RNMarquette University         

[Guest guest]

Speaking as someone that has had 5 very severe HEG pregnancies, requiring IV therapy, losing more than 10% of my thin body weight to begin with. I fit Dr. 's description that thin women have more severe HEG. No medication helped me. Some just made me sleepy and I could 'sleep off' a few hours of an excruciating experience. I would wake up throwing up in my sleep- not fun, had to have a bucket near my pillow. Dr. is probably correct as I have a strong history of IR/diabetes in my family. My glucose tests during pregnancy were always normal, my cycles completely regular and normal. There must be a better clinical test developed to screen for IR. I was offered standard HEG therapy: vitamin, various antiemetics, ginger, seasickness meds, wristbands, reglan, antihistamines, etc..., but nothing helped. Rehydration with IV always gave a little relief. I was denied hyperalimentation by my physician who thought the risk was " too high " .

My children all seem to have a worse case of IR than I, as research is suggesting the starvation during pregnancy can produce offspring with worse IR.(more reason to treat this more seriously and not allow starvation states during pregnancy). The children exposed to starvation during pregnancy tend to be slim and not have any changes in triglycerides and weight issues until post adolescence. If I remember correctly, the research is suggesting that they have fewer T cells in the pancreas and more fatty liver deposits, as a result. Of course to ensure survival of starvation after birth. My very thin 18 year old has PCOS and is on metformin, my thin 15 year old has had severe migraines(stroke-like, vomiting, abdominal and head pain) since age 2-3 years old and irregular cycles. All of us now are on the low-glycemic index diet/exercise. All(4) my teens' acne has cleared on diet /exercise alone. My 15 year old has had zero migraines since the day we started the diet last year and her irregular cycles appear to have corrected, so far so good. Wish I had heard this info sooner. My 18 year old with PCOS skin has cleared, but her fertility, energy, ability to get a good night's sleep has not returned yet, and we are adjusting her dosage to hopefully correct what is a very emotional and physical condition to deal with. Because we are all thin, we have to supplement our caloric intake with this diet to not lose weight. Some suggest Ensure daily.

Wish I had this info about 10-20 years ago when I was having my children. I wonder if glyburide or metformin would have helped me? I believe Dr. is helping many women to manage a condition that is misunderstood and not taken as seriously as it should. One can give progesterone, but it doesn't correct the underlying problem. Progesterone should be seen as a temporary relief for a bigger problem. Far better to correct the underlying IR before conceiving. I am indebted to Dr. for her assistance, management and insight of this for my family.

Thank you for 'sticking your neck out'.

Darcy Hemstad, RN, BSN

on 2/15/07 1:37 PM, paddy jim baggot at pjbaggot@... wrote:

I think Dr. 's comments are interesting as usual. Here is my opinion on nausea.

These therapies are effective for me, and they should be used in combinations rather than singly.

Pyridoxine 50 TID

Phenergan 25 TID (or any phenothiazine)

Doxylamine 1/2 TID (or any antihistamnine)

Each of these has been associated with an approximately 50% reduction in birth defects, either singly or in combination.

Also helpful are

Vitamin C in combination with Vitamin K 5 mg QAM

Ginger tea.

Protein intake.

Steroids as promoted by Dr. Goodwin.

For all of the above there is scientific literature.

I think the biggest problem is that practitioners often use one treatment, which doesn't work. They then stop that, and substitute another. Rather, I would suggest combining treatments which act by different physiologic mechanisms. Especially the first three above. If one is not achieving success then treatment should be increased by either

1.) add another treatment which acts by a different mechanism (better)

2.) substitute a stronger drug for a weaker drug within the same physiologic mechanism. Thus, Zofran is a stronger antihistamine, which could substitute for doxylamine. (less preferable)

Some patients are progesterone deficient, I believe. It is helpful, but should not stand alone.

Some patients are hyperthyroid and need treatment, but don't overdo it. (fetal brain development)

More seriously ill patients may be defeicient of magnesium and or potassium.

In general, I think expensive and exotic treatments, such as high powered phenothiazines and antihistamines as less effective than the approach I have outlined above. IV medications are less preferable to ones that can go home easily.

In general I think patients should rarely be made NPO. The goal is for them to go home on oral diet as rapidly as possible. If they are not tolerating the diet, treat hyperemesis more aggressively rather than restricting diet. Restricting the diet , which runs counter to the goal.

They also need continuous supervision by one physician. Frequently changing the plan or the physician will result in unproductive chaos. As more and more physicians are unsuccessful at treating the problem, the patient beciomes known as one who is impossible to treat or has a psychological problem. This is very unfair to the patient. One should be very hesitant to ascribe a medical problem to a psychological cause merely because we can't find the medical solution. More likely, the patient's ongoing misery, resulting from an unsolved medical problem, is the cause of psychopathology.

Thus I view it as a stair step program, beginning with the first three above. If two or one are sufficient, then fine. If not, increase treatment at frequent intervals until patient is comfortable.

This is my humble anecdotal opinion.

Reply-To: nfpprofessionals

To: nfpprofessionals

Subject: Re: Nausea in pregnant woman with PCOS

Date: Thu, 15 Feb 2007 10:22:30 -0600

MIME-Version: 1.0

X-Originating-IP: 64.12.137.6

X-Sender: OBDOC2000@...

Received: from n15b.bullet.sp1.yahoo.com ([69.147.64.119]) by bay0-mc3-f6.bay0.hotmail.com with Microsoft SMTPSVC(6.0.3790.2444); Thu, 15 Feb 2007 08:23:47 -0800

Received: from [216.252.122.217] by n15.bullet.sp1.yahoo.com with NNFMP; 15 Feb 2007 16:23:37 -0000

Received: from [66.218.69.3] by t2.bullet.sp1.yahoo.com with NNFMP; 15 Feb 2007 16:23:36 -0000

Received: from [66.218.67.83] by t3.bullet.scd.yahoo.com with NNFMP; 15 Feb 2007 16:23:36 -0000

Received: (qmail 32130 invoked from network); 15 Feb 2007 16:23:34 -0000

Received: from unknown (66.218.67.35) by m37a.grp.scd.yahoo.com with QMQP; 15 Feb 2007 16:23:34 -0000

Received: from unknown (HELO imo-m25.mx.aol.com) (64.12.137.6) by mta9.grp.scd.yahoo.com with SMTP; 15 Feb 2007 16:23:34 -0000

Received: from OBDOC2000@... imo-m25.mx.aol.com (mail_out_v38_r7.6.) id r.c5b.a8763a3 (47659) for <nfpprofessionals >; Thu, 15 Feb 2007 11:22:37 -0500 (EST)

Received: from YOUR-6460E1885C.ok.cox.net (ip72-198-83-70.ok.ok.cox.net [72.198.83.70]) by air-id03.mail.aol.com (v114_r3.2) with ESMTP id MAILINID35-ba2b45d488cb138; Thu, 15 Feb 2007 11:22:36 -0500

Dear Lee, Murph, and others,

I meant to respond to this earlier since it was I who questioned the traditional remedies. As more is learned about insulin resistance, it is clear to me, anyway, that it is the single greatest risk factor in the development of adult illness; affecting androgen, estrogen, growth factor, thyroid hormone, sex hormone binding globulin and a host of other hormones and processes. We know that Human Placental Lactogen in pregnancy increases IR, as does the normal weight gain of pregnancy. While respecting the peer reviewed studies available, and the invaluable contributions of Dr. Goodwin on the subject, I simply wish to posit that restricting simple carbohydrates and maximizing protein in the diets of pregnant women seems to make sense. My own anecdotal experience has shown that women who previously needed hyperalimentation because of severe hyperemesis gravidarum who maintained such diets were able to gain weight and avoid repeated hospitalizations and IV therapy while also using the recommended medical therapies for HEG. Anecdotal evidence is meaningless, but I suspect that somewhere, someone with the same idea and the ability to write a paper will eventually do so and prove me right.

Since I have already stuck my neck out, I'll go a little further. Brown (personal correspondence) has demonstrated that it is a poor follicular phase which results in a deficient luteal phase. While Dr. Hilgers recommends progesterone supplementation for deficient luteal phases, and it also appears, for HEG, might I respectfully suggest that IR is again the culprit, interfering with follicular progression resulting in suboptimal progesterone levels. Being a purist, I treat IR to ensure adequate luteal phases and have a very low index of suspicion for women who present newly pregnant with the following histories: recurrent pregnancy loss, irregular cycles, strong family history of diabetes, babies over 9 pounds, " hypoglycemia " and particularly, hyperandrogenism. The women with worst HEG seem not only have prominent vellus hair but acne, facial hair and lower abdominal hair despite being bone rack thin, whereas others will have the typical android obesity but still have the hair pattern described plus acanthosis nigricans. I screen such women immediately for adequate progesterone levels, then offer the one hour glucose tolerance test at 16-18 weeks. They are instructed about low glycemic index foods and offered the usual testing and medications of HEG becomes problematic. If the glucose test is abnormal they are offered glucose monitoring as an alternative to the 3 hour test and Glyburide when one third of the daily values are out of range. If the OGTT is normal at 18 weeks, it is repeated at 30 weeks.

Since I'm feeling exceptionally brave this morning, I'll put out one more provocative thought: poor follicular progression, suboptimal progesterone production and increased risk of preterm labor is also related to Insulin Resistance?

I'll look forward to the discussion this post stimulates, but please be kind; I've been sick recently!

W. , M.D.,FACOG

Thanks this will certainly be helpful!--and here I am attributing authorship to you on something that hasn't been written!! Anyway, what I am recalling is that the usual dietary remedies were being questioned in the presence of insulin resistance--that giving complex carbohydrates with protein was the key??? otherwise intake of simple carbs might actually make a person who was insulin resistant feel worse.

Lee

On 2/11/07, T. Goodwin > wrote:

Dear ,

I am not aware of any published material on a relationship between PCOS and NVP. This is a final draft of a recent summary of the problem of NVP published in the book " Progress in Obstetrics and Gynecology " this year.

Not too long ago there was a discussion about adjusting the diet in a woman who had nausea of pregnancy and also PCOS. Can someone give me the citation--I believe the article was written by T. Goodwin but I couldn't locate the article in a search. Thanks for your help!

Lee

[Guest guest]

Dr.

Hilgers will address IR (such as with metformin) but not all women with PCOS

have IR…myself included. The PCOS in these cases IS the only (known)

underlying problem. I DO know that when I am not being treated for my

PCOS (i.e. given post-ovulatory progesterone for my low progesterone levels), I

have insatiable hunger which I always speculated could lead to IR through

obesity; so I’m thinking it’s possible that for some women with

PCOS, the PCOS comes FIRST and the IR follows.

Re:

Nausea in pregnant woman with PCOS

Date: Thu, 15 Feb 2007 10:22:30

-0600

MIME-Version: 1.0

X-Originating-IP: 64.12.137.6

X-Sender: OBDOC2000aol

Received: from n15b.bullet.sp1.yahoo.com

([69.147.64.119]) by bay0-mc3-f6.bay0.hotmail.com with Microsoft

SMTPSVC(6.0.3790.2444); Thu, 15 Feb 2007 08:23:47 -0800

Received: from [216.252.122.217]

by n15.bullet.sp1.yahoo.com with NNFMP; 15 Feb 2007 16:23:37 -0000

Received: from [66.218.69.3] by

t2.bullet.sp1.yahoo.com with NNFMP; 15 Feb 2007 16:23:36 -0000

Received: from [66.218.67.83] by

t3.bullet.scd.yahoo.com with NNFMP; 15 Feb 2007 16:23:36 -0000

Received: (qmail 32130 invoked

from network); 15 Feb 2007 16:23:34 -0000

Received: from unknown

(66.218.67.35) by m37a.grp.scd.yahoo.com with QMQP; 15 Feb 2007 16:23:34

-0000

Received: from unknown (HELO

imo-m25.mx.aol.com) (64.12.137.6) by mta9.grp.scd.yahoo.com with

SMTP; 15 Feb 2007 16:23:34 -0000

Received: from OBDOC2000aolby

imo-m25.mx.aol.com (mail_out_v38_r7.6.) id r.c5b.a8763a3 (47659) for

<nfpprofessionals >; Thu, 15 Feb 2007 11:22:37

-0500 (EST)

Received: from YOUR-6460E1885C.ok.cox.net

(ip72-198-83-70.ok.ok.cox.net [72.198.83.70]) by air-id03.mail.aol.com

(v114_r3.2) with ESMTP id MAILINID35-ba2b45d488cb138; Thu, 15 Feb 2007

11:22:36 -0500

Dear Lee, Murph, and others,

I meant to respond to this earlier since it was I who questioned the

traditional remedies. As more is learned about insulin resistance, it is clear

to me, anyway, that it is the single greatest risk factor in the development of

adult illness; affecting androgen, estrogen, growth factor, thyroid hormone,

sex hormone binding globulin and a host of other hormones and processes. We

know that Human Placental Lactogen in pregnancy increases IR, as does the

normal weight gain of pregnancy. While respecting the peer reviewed studies

available, and the invaluable contributions of Dr. Goodwin on the subject, I

simply wish to posit that restricting simple carbohydrates and maximizing protein

in the diets of pregnant women seems to make sense. My own anecdotal experience

has shown that women who previously needed hyperalimentation because of severe

hyperemesis gravidarum who maintained such diets were able to gain weight and

avoid repeated hospitalizations and IV therapy while also using the recommended

medical therapies for HEG. Anecdotal evidence is meaningless, but I suspect

that somewhere, someone with the same idea and the ability to write a paper

will eventually do so and prove me right.

Since I have already stuck my neck out, I'll go a little further. Brown

(personal correspondence) has demonstrated that it is a poor follicular phase

which results in a deficient luteal phase. While Dr. Hilgers recommends

progesterone supplementation for deficient luteal phases, and it also appears,

for HEG, might I respectfully suggest that IR is again the culprit, interfering

with follicular progression resulting in suboptimal progesterone levels. Being

a purist, I treat IR to ensure adequate luteal phases and have a very low index

of suspicion for women who present newly pregnant with the following histories:

recurrent pregnancy loss, irregular cycles, strong family history of diabetes,

babies over 9 pounds, " hypoglycemia " and particularly, hyperandrogenism.

The women with worst HEG seem not only have prominent vellus hair but acne,

facial hair and lower abdominal hair despite being bone rack thin, whereas

others will have the typical android obesity but still have the hair pattern

described plus acanthosis nigricans. I screen such women immediately for

adequate progesterone levels, then offer the one hour glucose tolerance test at

16-18 weeks. They are instructed about low glycemic index foods and offered the

usual testing and medications of HEG becomes problematic. If the glucose test

is abnormal they are offered glucose monitoring as an alternative to the 3 hour

test and Glyburide when one third of the daily values are out of range. If the

OGTT is normal at 18 weeks, it is repeated at 30 weeks.

Since I'm feeling exceptionally brave this morning, I'll put out one more

provocative thought: poor follicular progression, suboptimal progesterone

production and increased risk of preterm labor is also related to Insulin

Resistance?

I'll look forward to the discussion this post stimulates, but please be kind;

I've been sick recently!

W. , M.D.,FACOG

In a message dated 02/12/07 09:54:26 Central Standard Time, barronmlgmail

writes:

Thanks this will certainly be helpful!--and here I am

attributing authorship to you on something that hasn't been written!! Anyway,

what I am recalling is that the usual dietary remedies were being questioned in

the presence of insulin resistance--that giving complex carbohydrates with

protein was the key??? otherwise intake of simple carbs might actually make a

person who was insulin resistant feel worse.

Lee

On 2/11/07, T. Goodwin <

tgoodwinhsc (DOT) usc.edu <mailto:tgoodwinhsc (DOT) usc.edu> > wrote:

Dear

,

I am not aware of any published material on a relationship between PCOS and

NVP. This is a final draft of a recent summary of the problem of NVP

published in the book " Progress in Obstetrics and Gynecology "

this year.

Not too long ago there was a discussion about

adjusting the diet in a woman who had nausea of pregnancy and also PCOS. Can

someone give me the citation--I believe the article was written by T.

Goodwin but I couldn't locate the article in a search. Thanks for your help!

Lee