PolyCystic Ovarian Syndrome PCOS is a complex condition. The exact cause of PCOS is unknown however, it involves hormones imbalance and multiple ovarian cysts, irregular menses, and infertility. In some cases, PCOS can be compounded by diabetes, hypertension and other metabolic conditions. PCOS has been shown to effect approximately 10% of women of childbearing age with symptoms of menstrual abnormalities, poly cystic ovaries, and excess androgen (male sex hormone). PCOS should be diagnosed by ensuring there are no other underlying endocrine issues. There are several associated disease processes that seem to be related to PCOS. These related disease processes are Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.
Anatomically, numerous cysts are found on the ovaries. These are usually diagnosed by ultrasound, blood levels of hormones, and symptoms described above.
Bariatric Surgery and PolyCystic Ovarian Syndrome PCOS
Bariatric Surgery can improve PCOS in those individuals with Type 2 Diabetes Mellitus. Further information on weight loss surgery and its effect on PCOS here.
There is a continuous desire for a “less invasive”, “easier” procedure for the treatment of obesity and its associated co-morbidities. We have been very clear when discussing the benefits and long term outcome of the procedures. Let’s remind ourselves that “less invasive” does not mean a better option. In almost all cases a less invasive weight loss surgery means less weight loss, lower incidence of resolution of co-morbidities, and in some cases higher complications rate. Have we forgotten the adjustable gastric banding that was advocated to be the cure all for all obesity? All we hear now are the complications, the long term sequel of the reflux, hiatal hernia, irreversible esophageal injury, in addition to inadequate weight loss or weight regain.
Unfortunately, the same is to be said about the Sleeve Gastrectomy. We have said, as supported by the scientific literature, that the long term outcome of the sleeve gastrectomy is not as good as that of the Duodenal Switch procedure. This is true for the amount of weight loss as well as the resolution of the co-morbidities. We see quite a few patients who have gained their weight back after sleeve, never lost enough weight, and/or did not achieve resolution of their co-morbidities, such as diabetes, and are having their procedure revised to Duodenal Switch procedure.
Along with the same argument, this is why I caution patients when having the SIPS or SADI procedures. There is a chance that when the long term data for SIPS/SADI is available there may be some benefits procedure. However, as it stands at this point in time, these procedures are not the same as the Duodenal Switch procedure. So in short, less invasive, easier isn’t better.
New guidelines and recommendation are coming out of the second Diabetes Surgery Summit in the Fall of 2015. One major change is Metabolic or Weight Loss Surgery for the treatment of Diabetes. With all the advances made in newer classes of medication for treatment of diabetes, the majority of patients who are being treated fail to get to achieve the desired results of lowered blood glucose level. This is in contrast where weight loss surgical procedures such as Duodenal Switch can results in >95% cure rate of type II diabetes.
The American Diabetes Association has made the recommendation for weight loss surgical procedures be considered as a treatment option for type II diabetes.
Summarizing their criteria “According to the new Guidelines, metabolic surgery should be recommended to treat type 2 diabetes in patients with Class III obesity (BMI greater than or equal to 40 kg/m2), as well as in those with Class II obesity (BMI between 35 and 39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and medical therapy. It should also be considered for patients with type 2 diabetes who have a BMI between 30 and 34.9 kg/m2 if hyperglycemia is inadequately controlled, the authors agreed. The Consensus S
tatement also recognizes that BMI thresholds in Asian patients, who develop type 2 diabetes at lower BMI than other populations, should be lowered 2.5 kg/m2 for each of these categories. ”
This is a remarkable change in thought and policy on diabetic treatment and long term strategies that can only improve patient outcomes. Stabilization and blood glucose hemostasis can only improve patient health, health care utilization and health care costs.
Diabetes should be considered as a family of diseases sharing a common name. They are different diseases because the cause, pathophysiology, and the treatment options are different for each diseases. This is not to say that there are not commonalities between them.
- Type I (Insulin deficiency, Juvenile onset)
- Type II (Insulin Resistance, Adult onset)
- Latent Autoimmune diabetes (LADA)
Type I diabetic patients requires insulin for control of their blood sugar. Insulin deficiency is the underlying problem with type I diabetes. The causes of type I diabetes are many and some are poorly understood. It is presumed that viral infections, genetics, infections, chronic pancreatitis and autoimmune conditions may all be potential causes of type I diabetes.
Type II diabetes is an insulin resistance state. This means that the patients’ body may be making adequate level of insulin however, for a number of reasons, the insulin is not able to normalize the blood sugars. Some Type II diabetic patients may also require insulin during advanced stages, but in most cases the initial treatment is oral medications.
|Diabetes Type||Blood Sugar||Blood Insulin|
|Type II||High||High(early disease state)|
The table above summarizes the laboratory findings in a patient who is diagnosed with diabetes. The measured insulin can be distinguished in the labs as being injected or patients own.
LADA is probably a subtype of Type I, with a delayed presentation. It behaves like Type I, with insulin deficiency, yet it is adult onset.
Gestational is more of a high blood glucose state during the pregnancy.
The goal of medical treatment for diabetes has been to normalize the blood sugars. There are no medical treatments regimens that correct any of the underlying causes of the Type I, or Type II.
In the case of Type I, the underlying case is Insulin deficiency. The definitive treatments may include Pancreatic transplantation, and intelligent Insulin pumps.
Surgical treatment of Type II, by some know and unknown mechanisms, corrects the underlying resistance to the insulin.
Weight loss surgical procedures have been shown to “cure” Type II”. The “remission” or “cure” rate of diabetes is really different between surgical procedures. Duodenal switch operation has been shown to have the highest remission-cure rate of all surgical procedures for the Type II diabetes. The references are available on our website. By definition, Type I can not be corrected-cured with weight loss surgery, since the underlying problem is insulin deficiency. What we have experienced however is that the Insulin requirements significantly decreases and blood glucose control is much easier after weight loss surgery.
There have been a number of articles reporting high relapse rate of Type II in gastric bypass patients. This is why I have always advocated that the patients with metabolic conditions, including diabetes should only consider the duodenal switch as their only surgical option.
The one study of 4434 patients, 68.2% of those patients who had Type II had remission within 5 years after the gastric bypass procedure. 35% of those patients, however, had a redevelopment of Type II after 5 years. “When the patients that never remitted and those that relapsed were added together, more than half of the patients (56%) did not have durable remission of diabetes.” (Obes Surg 2012 Nov 18:doi 10.1007/s11695-012-0802-1).
An article published in May 2010, reported 24% recurrence or worsening of the diabetes in patients who have had gastric bypass operation. (SOARD Volume 6, issue 3, May 201 249-253).