I've stopped thinking of the etiology of the low production in terms of PCOS. 
 Call it a semantic issue, but I focus more on whether or not the woman shows 
signs of insulin resistance, ONE sign of which can be irregular periods 
coupled with a possible "diagnosis" of PCOS.  But I've had several women who 
wouldn't meet the criteria necessarily for PCOS, but do show subtle signs of insulin 
resistance.  It's gotten to the point where I cringe when people take away 
from the whole PCOS thing just the minute bit of information that involves the 
name tag; I hate hearing "Well, if you're PCOS you have to be careful."  
(Believe it or not, some LC's here teach that in pre-natal breastfeeding classes!  
Talk about too little knowledge being dangerous...)  Half the time I feel like 
some of the LC's don't even recognize what it is ABOUT the PCOS that may be 
responsible for the impaired supply--it's like the *term* is the etiology.  Very 
annoying.

Example:  Let's say you see a woman on day 8.  Milk never "came in," no 
edema, no severe blood loss at birth, etc.  All that was fine.  No problems getting 
pregnant, no history of missed periods except maybe 10 years ago when she was 
21 and was a heavy runner for a year.  Back then she missed a few periods.  
But other than that, very regular.  No hairiness, breasts look okay shape-wise, 
in fact quite round.  But flaccid.  And she looks a little heavy, like she is 
sort of solidly built in real life (i.e., not just post partum), with a 
certain kind of weight distribution.  We refer to this as the "insulin-resistant 
look" in our group.  She had lots of skin tags grow during pregnancy and failed 
her first gestational diabetes test but passed the second with flying colors.  
And although you don't mention it to her, she did get pregnant first try 
right after coming off the pill which she was on for ten years (to regulate your 
periods?, you may ask, just to be sure she hadn't "forgotten" her irregular 
past), which makes you think she may be a little under-the-radar PCO.  So....what 
is this?  Is is "PCOS?"  I don' t think anyone would diagnose her with this.  
Would I be surprised if her ovaries looked polycystic?  No, I wouldn't.  But 
the point (in my opinion) is to "see" the other stuff and not focus so much on 
the PCOS per se.  It's like you miss the trees through the forest, to reverse 
a metaphor.

Of course, there could be other things at work--elevated androgens, thyroid 
problems, etc.--  other things that coincide with or dovetail with PCOS and 
make understanding lactation failure very difficult.  I'm in no way suggesting 
that it is just the insulin.  BUT, in my experience, if you go around only 
looking for PCOS, or salient, patent signs of it, you may be missing a lot. 

Heather Kelly, MA, IBCLC
NY, NY
    

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