Our guest blog this week is from Lisa Marasco, MA, IBCLC, FILCA, a board certified lactation consultant both in private practice and for WIC and a contributing editor to Core Curriculum for Lactation Consultant Practice. She is also co-author of Making More Milk.
What is PCOS?
PCOS is the leading cause of infertility in women, and it affects 5-10% of all women in the U.S. It is typically characterized by high levels of male hormones (androgens) and insulin resistance, and many women also have multiple ovarian cysts (polycystic ovaries). Erratic or no menstrual cycles are common. Half of all women with PCOS struggle with obesity, but the other half do not and are often overlooked because of it. The Rotterdam criteria of 2003 suggests that the syndrome of PCOS is diagnosable when a woman has two of the three following symptoms: Physical or laboratory evidence of high androgens; irregular or no ovulation/menstrual cycles; polycystic ovaries. Though insulin resistance is common, it is not a part of the diagnostic criteria.
How can PCOS affect breastfeeding?
When a woman who has struggled with infertility finally manages to have a baby, everyone breathes a sigh of relief. The assumption is that once this hurdle is cleared, it should be clear sailing thereafter. It comes as a shock for some women, then, when breastfeeding does not proceed smoothly. Only recently have we realized that the hormonal imbalances that contribute to infertility may also affect lactation.
Recent research is noticing that abnormally high levels of one or more androgens increase the risk of lactation problems (presumably milk supply). While androgens such as testosterone are normal and necessary in women, too many can cause problems such as stunting breast growth or suppressing lactation outright. Some women with PCOS do not experience normal breast development during puberty, ending up with small, underdeveloped breasts or large, pendulous breasts that have less than the normal amount of glandular tissue inside. Others appear to have breasts with normal glandular tissue but that do not respond normally to pregnancy hormones, which should cause additional growth in preparation for making lots of milk for baby. Part of the vicious cycle of PCOS is that high androgens can fuel insulin resistance and hyperinsulinemia, which in turn can fuel more androgens. A further complication is that androgens have three possible sources: the ovaries, the adrenal glands and fatty tissue, and current treatments are not equally effective on each type.
While we don’t have all the answers to these dilemmas yet, a logical strategy is to try and bring these androgens into a more normal range. Drugs such as metformin reduce hyperinsulinemia, which in turn can help reduce ovarian testosterone. This drug has helped a number of women to start cycling regularly, and has also helped some women to make more milk as well. Metformin was originally developed from the herb goat’s rue, which is known for its antidiabetic properties as well as its reputed ability to stimulate milk production and breast gland development. This makes goat’s rue particularly appropriate for women with PCOS who are struggling with low milk supply. Some women have even chosen, with their health care provider’s approval, to take some goat’s rue during the last trimester of pregnancy to boost glandular development before baby comes, though there is no research on the safety of this use.
While there are a few other anti-androgen or hormone-balancing herbs that may also help improve low milk supply in mothers with PCOS (saw palmetto, chastetree berry, fennel) , we presently have less experience with them. The best strategy for PCOS moms with low milk supply is find out what hormones are out of balance and then do your best to bring them closer into balance. Lots of breastfeeding or pumping stimulation is absolutely necessary; all the drugs or herbs in the world will not make a difference if there is no “action” going on at the breast! With these things in place, galactogogues such as goat’s rue may help increase milk supply. Patience is important as changes take time, though most women will begin to notice some difference in the first few days to weeks. Most importantly, if you are doing a lot of work to increase milk production, be sure to take plenty of time to just enjoy your baby and motherhood. Women who stress out too much about what is not perfect may unintentionally make things worse as chronic stress can affect the milk ejection reflex. The bottom line is that you do your best and make peace with the results. Your baby is lucky to have a mother who has worked so hard to give him the most of the best that she possibly can!