PCOS is short for the polycystic ovarian syndrome, a hormonal disorder that affects women. This article tells all you need to know about it.
Polycystic ovarian syndrome (PCOS) is a complex hormonal disorder that affects women of childbearing age (between 15 and 44). As its name implies, the disease affects the ovaries, which are the female reproductive organs responsible for producing the hormones necessary to regulate the menstrual cycle. Polycystic ovary syndrome is a common cause of irregular menstrual periods and the most common cause of treatable infertility in women. Surprisingly, some studies suggest that over 70% that suffer from PCOS don’t know it yet.
PCOS is one of the most common endocrine disorders around. In the United States, it affects approximately 5% to 11% of women between the ages of 15 to 44. Numbers in Europe are a little bit lower than in America (around 8%). Still, they represent a significant proportion of childbearing age women. The age of onset is usually during adolescence (16 is the most common age ). However, most patients don’t notice or don’t get concerned by symptoms until much later, thus delaying treatment. Many patients discover they suffer from the disease when suddenly gaining weight or realizing they have difficulties conceiving.
What happens in PCOS?
Ovaries are female reproductive organs that, in normal conditions, release an egg each month to be fertilized by male sperm. The process in which the ovaries release an egg is called ovulation. Ovulation depends on the availability of two hormones produced by the pituitary gland. These hormones are the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH). Polycystic ovarian syndrome disrupts this whole process.
The distinguishing characteristic of the disease is the presence of several small sacks filled with a fluid called cysts. The name polycystic means that there are many cysts. Thus polycystic ovarian syndrome refers to many ovarian cysts. These cysts are immature eggs that never were able to develop enough to trigger ovulation.
In polycystic ovary syndrome, there is a decrease in FSH and LH’s blood levels and an increase in the production of male hormones called androgens. This hormonal imbalance also disrupts the menstrual cycle; women with PCOS have fewer menstrual periods than the rest.
What is the leading cause of PCOS?
Modern medicine doesn’t exactly know what causes polycystic ovary syndrome. There doesn’t appear to be a single specific cause. PCOS is, more likely, the result of the interaction of multiple different factors. The evidence that supports that there is a genetic component behind the disease has gained strength in the last few years.
Studies of families with PCOS reveal that there appears to be some form of disease inheritance. Some studies have isolated specific genes that appear to be related to the inheritance of polycystic ovarian syndrome. However, the evidence is not conclusive in any of the studies.
Other studies show a significant association between type 2 Diabetes Mellitus and the development of polycystic ovary syndrome. Other metabolic abnormalities like insulin resistance and metabolic syndrome also have an essential link with PCOS. There is also a genetic link between obesity and PCOS. The FTO gene (proven to predispose towards obesity) is also correlated with a higher risk of developing polycystic ovary syndrome.
What are the four types of PCOS?
Some authors propose distinguishing four different types of polycystic ovary syndrome. However, this classification has not been broadly accepted by the medical community in general. It goes as follows:
- Insulin-resistant PCOS: This is the most common type of PCOS and is due to insulin resistance. It is heavily associated with risk factors such as smoking, high sugar, and trans-fat consumption.
- Pill-induced PCOS: This is the second most frequent type of PCOS. According to some authors is the result of consuming birth control pills for a very long time.
- Inflammatory PCOS: It is the result of inflammation due to excessive stress and environmental toxins.
- Hidden PCOS: This is mostly due to thyroid disease.
Although this classification does exist, most experts see PCOS as a single multifactorial entity with no specific cause.
What are the signs of PCOS?
Polycystic ovary syndrome can present with many different signs and symptoms consequence of the hormonal imbalance the disease causes. Common symptoms include:
- Irregular menstrual cycle
- Unwanted hair growth in unusual places (hirsutism)
What are the menstrual abnormalities in PCOS?
Women with PCOS normally experience nine or fewer menstrual periods each year. The menstrual cycle in PCOS women tends to be irregular. Each menstrual period occurs in intervals that vary from 35 days to 6 months. These patients also suffer from irregular menstrual bleeding. Each menstrual period in PCOS tends to be more painful and uncomfortable than in the rest of the population.
What is a PCOS belly?
Many PCOS patients have a characteristic abdomen with a lot of fat around the waist. Fortunately, with appropriate diet and exercise, most patients can overcome this problem.
What is hyperandrogenism?
Androgens are male hormones that promote the development of masculine physical attributes like muscle growth and excessive facial hair growth. In PCOS women, androgen excess manifests as hirsutism, excess hair growth in a male distribution pattern.
More than 60% of women that suffer from polycystic ovarian syndrome experience unusual hair growth in their face, belly, back, and chest. Simultaneously, these women can also experience male pattern baldness, which means hair loss in the scalp.
Hirsutism is the main symptom of hyperandrogenism. However, very severe PCOS cases may also present with increased muscle mass, voice deepening, and an increase in the size of the clitoris. This is called hyperthecosis and is only present in extreme cases.
What is metabolic syndrome?
Metabolic syndrome is a multifactorial disease that arises from insulin resistance and obesity and has several risks for developing heart disease and metabolic diseases like diabetes mellitus. More than 50% of women with PCOS are clinically obese and have characteristics of metabolic syndrome such as:
- A waist circumference greater than 35% (abdominal obesity)
- High blood sugar (indicative of insulin resistance)
- High cholesterol and high blood triglycerides
- Black spots distributed in certain parts of the body (acanthosis nigricans)
- Elevated blood pressure
Women with PSCOS have an increased risk for atherosclerosis and, therefore, an increased chance of suffering a heart attack or a stroke throughout their lifetime. Also, between 5% to 10% of women with polycystic ovary syndrome will suffer from type two diabetes mellitus. Over 35% of women with PCOS suffer from insulin resistance or glucose intolerance by the time they reach the age of 40.
Does PCOS cause sleep apnea?
Although polycystic ovarian syndrome is not a direct cause of obstructive sleep apnea, research reveals that an essential percentage of women that suffer from PCOS also suffer from sleep apnea. Sleep apnea is when breathing stops involuntarily for a brief time during sleep, snoring is the most characteristic sign. These patients do not get repairing sleep and often suffer from daytime somnolence (sleepiness), poor performance at work, depression, and frequent and severe headaches. Sleep apnea is also an independent risk factor for developing high blood pressure and cardiovascular disease.
What are the complications of PCOS?
- Endometrial hyperplasia: It is a condition in which the lining that covers the inside of the uterus becomes increasingly thicker because the number of cells inside it increases. The main symptom of endometrial hyperplasia is abnormal bleeding through external genitals outside the menstrual period, heavier than usual menstrual bleeding, and irregular menstrual cycles. The main issue with menstrual bleeding is that it increases the risk for endometrial cancer.
- Endometrial cancer: PCOS increases the risk for endometrial cancer because of the prolonged exposure of the endometrium to estrogen due to anovulation (fewer menstrual cycles). Furthermore, PCOS is often correlated with other disorders that also increase the risk of developing endometrial cancer, such as diabetes mellitus, infertility, and never giving birth (nulliparity). One study done in Taiwan between 1998 and 2013 showed that for every 100.000 patients with PCOS, approximately 226 would develop endometrial cancer at some point. Other studies reveal that women with PCOS are almost three times more likely to suffer from endometrial cancer than women that do not suffer from the condition.
Should you see a specialist for PCOS?
If you suffer from symptoms suggestive of PCOS, your first step should be going to your family physician. He or she will assess the situation a refer you to the appropriate specialist. In some cases, PCOS management may require a multidisciplinary approach. These are the medical specialties involved in the management of PCOS.
- Endocrinology: Involved in treating a wide variety of hormonal disorders.
- Gynecologist: Involved in the treatment ay pathology of the female reproductive apparatus.
- Fertility specialists: Involved in the treatment of anovulation.
How do doctors diagnose PCOS?
When facing a patient with symptoms suggestive of the polycystic ovarian syndrome, the first step is to rule out other possible explanations for the symptoms. Some many other diseases and conditions can also cause menstrual cycle irregularities and hyperandrogenism. Many of these conditions are more complicated and dangerous than PCOS. Some of these diseases include:
- Congenital adrenal hyperplasia
- Cushing syndrome
- Thyroid disease
- Ovarian tumors
- Turner syndrome
- Adrenal tumors
- Pituitary tumors
To rule out these conditions and diagnosing polycystic ovary syndrome, most gynecological associations recommend performing the following basic testing in all patients with signs and symptoms suggestive of PCOS:
- Thyroid hormone levels
- Serum prolactin levels
- Serum androgen levels
- Free cortisol levels
- Serum creatinine
- Growth hormone levels
- A pregnancy test
Which lab results suggestive of PCOS?
PCOS patients usually have elevated male hormone levels. The standard indicator for hyperandrogenism has high free testosterone levels. Another androgenic hormone called Androstenedione is also typically elevated in women with PCOS. High levels of other androgens like dehydroepiandrosterone sulfate are more suggestive of other pathologies like congenital adrenal hyperplasia. PCOS patients should report normal FSH levels and elevated LH levels. The LH to FSH proportion is typically higher than 3 in these patients.
Because the frequency of insulin resistance and diabetes mellitus in polycystic ovarian syndrome is high, most doctors choose to make a full metabolic panel in patients with PCOS. These tests include a 75 mg glucose tolerance test, fasting glucose, total cholesterol, and triglycerides.
What imaging tests are useful in polycystic ovarian syndrome?
Doctors can observe the presence of cysts in the ovaries using ultrasonography. Operators can visualize the ovaries through normal abdominal ultrasound. However, a transvaginal ultrasound is the modality of choice for PCOS diagnosis. Most doctors wait for the lab results before deciding to perform ultrasonography.
CT-SCAN and MRI images are only for patients suspected to have a tumor. Still, in very obese women in which the ovaries are not identifiable through transvaginal ultrasonography, MRI represents a valid diagnostic alternative.
What is the treatment for polycystic ovary syndrome?
Medical therapy for PCOS intends to treat the hormonal imbalance to alleviate menstrual irregularities, excessive hair growth, metabolic abnormalities (insulin resistance), and lack of ovulation.
The first line of therapy in PCOS consists of using oral contraceptives (birth control pills). The use of low dose contraceptives inhibits the production of androgenic hormones and induces regular menstrual periods. Oral contraceptives not only restore regular menses but also decrease the risk of endometrial hyperplasia and endometrial cancer. The birth control pills of choice for PCOS treatment are those that contain a combination of estrogen and progestin. Estrogen and progestin are also available in the form of patches and vaginal rings. The downside is that oral contraceptives can cause other metabolic abnormalities and increase deep vein thrombosis risk.
In some patients, the use of oral contraceptives is not enough to alleviate hyperandrogenism symptoms. The patients require additional pharmacologic treatment with an androgen blocking agent like spironolactone or finasteride. There are also topical treatments (creams) specific for getting rid of abnormal hair in hyperandrogenism. Eflornithine is a prescription drug that interferes with an enzyme necessary for hair growth in the skin. It does not have a depilatory effect but reduces hair growth. Most patients begin seeing improvements after 4 to 8 weeks.
Many times, treating PCOS also involves dealing with metabolic problems like insulin resistance and diabetes mellitus. Metformin is the initial treatment of choice for diabetes mellitus. It can even be used in PCOS women without diabetes but with important risk factors for developing cardiovascular disease. Also, certain recent studies show that metformin can also reduce androgen levels.
How do you ovulate with PCOS?
Although PCOS produces anovulation and infertility, with appropriate treatment, women that suffer from the condition can still have children. PCOS women that have unsuccessfully tried to conceive for more than two months should visit a fertility specialist. Your fertility doctor will probably start ovulation induction therapy, which involves a course of injections that stimulate the ovaries to produce and release eggs. The first line of therapy for anovulation treatment is currently a drug called clomiphene; the alternative is letrozole. Some studies show that taking metformin before initiating ovulation induction therapy leads to an increased chance of success.
If pharmacologic treatment fails, the next alternative is laparoscopic ovarian surgery. The procedure involves doing a small incision in the abdomen (less than an inch) and introduce a tiny camera and special surgical equipment through it. The surgeon will then start laser-drilling the ovary. Focal damage in the ovary will restore normal ovulation cycles. However, surgery’s effects may not last forever, and many patients will start experiencing anovulation again after some time. The surgery results in successful ovulation in approximately 50% of women in which clomiphene treatment fails. Laparoscopic surgery is a relatively simple procedure.
Most patients can expect to go home 24-48 hours after the procedure is finished. Yet, like any other surgery, there are certain risks involved. Some of these risks involve:
- Infection of the incision
- Hemorrhage (bleeding)
- Accidental injury to internal organs or blood vessels
- Scarring inside the body
- Adverse reaction to anesthesia
Are our lifestyle and diet important in PCOS management?
More than pharmacological treatment, lifestyle management and diet modifications are the real cornerstone of PCOS treatment. Lifestyle changes are the first line of treatment for women and adolescent girls with PCOS, even before estrogen and progestin pills. Many studies show that lifestyle modifications like losing weight, doing more than 150 minutes of exercise a week, and eating a healthier diet is more effective for reducing the risk of diabetes than medication. Furthermore, these modifications are also useful in restoring ovulatory cycles, reducing hyperandrogenism symptoms, and increasing the chance of getting pregnant.
Which exercise is best for PCOS?
Cardio is the best option for losing weight and managing PCOS symptoms. Moderate aerobic exercise like jogging, power walking, hiking, swimming, and playing sports like tennis, soccer, or basketball can help women with PCOS if done regularly. However, to see results, you must do at least 30 minutes of exercise at least 3 to 5 times a week.
Do you have symptoms of this condition?
This tool is a PCOS Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for the disease. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of the polycystic ovarian syndrome. Using the tool is free and would only take a few minutes.