Polycystic Ovarian syndrome (PCOS) is a hormonal problem typically affecting women of reproductive age. The word ‘syndrome’ means there are several signs and symptoms that exist together that form this condition. These include:
- Infrequent or no ovulation (release of an egg), presenting as infrequent or no periods respectively.
- Signs of excess male hormone (commonly testosterone). This causes excess facial and body hair (hirsutism), acne, hair thinning or hair loss.
- Polycystic ovaries defined as the presence of 12 or more follicles (measuring 2-9 mm in diameter on a scan) in one or both ovaries and/or increased ovarian volume (greater than 10cm3).
To make the diagnosis of PCOS, you need 2 out of the 3 above signs and symptoms. You do not actually have ‘cysts’ if you have PCOS. You have fluid-filled sacs called ‘follicles’ that surround the eggs. So, admittedly, the term ‘cysts’ is a misnomer! In PCOS, eggs don’t always develop or get released from the sacs, which can lead to missed or irregular periods. As a result, PCOS can be associated with difficulties in getting pregnant.
It’s important to be aware that about 20% of women will have lots of follicles on the ovaries, or polycystic ovaries. This does not mean you have polycystic ovarian syndrome. Remember, you need 2 out of the 3 signs and symptoms mentioned above to have the syndrome.
Furthermore, you can only make a diagnosis of PCOS once other causes of irregular cycles has been excluded such as thyroid dysfunction, or high prolactin levels.
So, what causes PCOS?
The exact cause of PCOS is still not fully understood. We do know that there are certain hormonal and chemical changes that take place in the body. One of the most important is insulin resistance.
What does insulin resistance mean? Tissues of the body need energy. One of the main sources of energy is glucose (a type of sugar) which comes from the food you eat. A hormone called insulin produced by the pancreas opens the gate to cells of your tissues to shuffle glucose in so that it can be used for energy. Glucose is also stored as ‘glycogen’ in the liver and muscle cells (ready for periods of fasting, when glycogen can be broken down to release glucose). Insulin is also a ‘chief fat-builder’, converting glucose to fat within the liver and fatty tissues (adipose tissue). Increased fat storage contributes to weight gain.
With insulin resistance, the cells of the body don’t respond to insulin that well, so the cells don’t let glucose through the gate that easily. But your cells need glucose for energy, so your pancreas churns out more and more insulin, to try and get glucose into cells. As long as your pancreas can make enough insulin to overcome your cells’ weak response to insulin, your blood glucose levels will stay in the healthy range, and the cells get enough glucose for energy.
If insulin resistance persists, and insulin pumps remain turned on, over time the blood glucose level rises causing your blood sugar levels to be higher than normal, a condition called pre-diabetes. Over-time this can lead to full blown diabetes where the blood sugar levels are very high. We don’t fully understand what causes insulin resistance, but it is strongly associated with overweight/obesity, and lack of physical exercise. Other long term problems of PCOS include high cholesterol, high blood pressure, and sleep apnoea.
High levels of insulin also cause the ovaries to make too much testosterone. A high level of insulin and testosterone cause problems with ovulation, hence, period problems and reduced fertility. It is the Increased testosterone levels in the blood that also cause excess hair growth on the body, thinning of the scalp hair, and acne.
A hormone called Luteinising hormone (LH) is produced by a gland in the brain. This hormone stimulates the ovaries to produce an egg. Alongside insulin, it also helps to produce testosterone. In women with PCOS, we find higher levels of LH which means that the ovaries are more likely to produce higher levels of testosterone.
There may be genetic factors associated with the development of PCOS, but these are not fully understood. We do know that PCOS can run in families.
Excess insulin can also lead to a condition called ‘acanthosis nigricans’. Here there are patches of darker skin mainly affecting folds of the neck, armpits, groin, and underneath female breasts. Excess insulin causes the skin cells to increase in number. Skin cells have pigment (or natural colour) in them called melanin. Now, if skin cells increase in number, there is more melanin. This increase in melanin produces a patch of skin that’s darker than the skin surrounding it.
When to suspect that you may have PCOS?
- If you have signs of raised testosterone levels such as acne, abnormal hair growth (hirsutism), and hair loss.
- If you have irregular infrequent periods or no periods at all
- A family history of PCOS
- Other symptoms associated with Insulin resistance such as struggling to lose weight or being overweight, and acanthosis nigricans.
What happens next if I am diagnosed with PCOS?
Great question. The way PCOS is dealt with, really depends on your priorities or the main issues for you at that time. For some it may be trouble conceiving and so would need to be referred early to a fertility service, for some it may be establishing regular periods and still for others, it may be treating troublesome acne, or excess hair growth, or weight loss. There is no ‘magic bullet’ cure for PCOS since we have already established that we don’t know the exact cause for the condition, and there are likely to be several factors (including hormonal, and biochemical) interacting in quite a complex manner to cause symptoms of the condition. Rather, it is about managing the symptoms, and improving quality of life.
Interventions for PCOS
The single most important intervention is lifestyle modification through weight loss. But weight loss can be difficult to achieve with PCOS. The key is a combination of dietary modification with calorie restriction and exercising more:
Reduce your intake of foods that have a high glycaemic index, i.e., foods that trigger the biggest surge in blood sugar levels. These tend to be carbohydrates. Carbohydrates (or ‘carbs’) are simply long chains of sugar molecules. These tend to include foods made from refined flour (such as bread, cereals, pastas); starches such as rice, potatoes, and corn, and liquid carbs such as soda, beer, and fruit juice. They flood the bloodstream with glucose and stimulate the release of insulin, which then stores excess calories as fat. So, the more sugar we eat, the more we tell our bodies to transfer them to fat. In the liver this leads to ‘fatty liver’. Fat is also stored elsewhere in the body contributing to central obesity, hence your commonly coined terms: ‘love handles’, ‘muffin tops, and ‘beer bellies’. Worst of all, it leads to visceral fat, which refers to fat that hugs vital organs.
Weight loss helps to reduce insulin resistance. This has a knock-on effect of reducing the levels of testosterone. This then improves the chance of you ovulating, which improves period problems and fertility issues. Reducing levels of testosterone may also help to reduce excess hair growth and acne. The increased risks of long-term problems such as diabetes, are also reduced. Even moderate weight loss of 5–10% of your body weight can be enough to improve fertility and chemical/hormonal abnormalities. It’s recommended to increase your physical activity by 5% each week until you’re getting between 2.5-4 hours of exercise per week.
Metformin
This is a medicine that is commonly used to treat people with type 2 diabetes. It makes the body’s cells more sensitive to insulin, so overcoming insulin resistance, resulting in an overall reduction in the body’s level of insulin and preventing the cascade of hormonal and biochemical processes that are associated with PCOS. There have been several studies looking at the use of Metformin in women with PCOS and the majority have shown that Metformin can make periods more regular and improve fertility in women with PCOS. The use of Metformin may also make weight loss easier. Finally, it may also help reduce excessive hair growth although this may take several months. Metformin works best in conjunction with weight loss interventions. Side effects can include nausea, vomiting, diarrhoea, abdominal pain, and non-specific gastrointestinal disturbance.
Acne and Hirsutism
The treatments used for acne in women with PCOS are no different to the usual treatments for acne. Hormonal treatments such as the Combined Contraceptive methods contain low doses of oestrogen and different types of progestogens, which can improve features associated with excess testosterone. It’s important to mention that not everyone with PCOS will be eligible to use Combined Contraception. This is because women with PCOS can struggle with overweight and the use of Combined Contraception in a woman with a BMI over 30 increases the risk of blood clots. Physical methods of hair removal such as shaving, waxing, electrolysis, laser treatments may be needed for excess hair growth (hirsutism). Creams such as Eflornithine used in combination with physical methods can also be effective.
Treating period problems
Some women who have no periods, or very infrequent periods. You may not wish to have any treatment for this, but it is very important to be aware that the risk of developing cancer of the womb is increased if you have no periods for a long time. This is because the lining of the womb is building up and with this there is an increased risk of cells becoming abnormal. Over many years, these abnormal cells can become cancerous. Inducing regular bleeds will help to prevent this risk. If you are having less than one period every three months or abnormal vaginal bleeding, there are a few treatment options:
- A cyclical progestogen, such as medroxyprogesterone 10 mg daily for 14 days every 1–3 months
- A low-dose COCP
- The levonorgestrel-releasing intrauterine device or hormonal coil.
You may also be referred for a scan to assess the thickness of the lining of your womb.
Fertility
As previously mentioned, one of the main features of PCOS is ovulation disorders. A woman with PCOS can experience infrequent ovulation (presenting as Infrequent periods also called ‘oligomenorrhoea’) or no ovulation at all (presenting as no periods or ‘amenorrhoea’). In fact, PCOS accounts for approximately 80–90% of cases of infertility related to lack of ovulation. If you are not ovulating, this reduces the chances of you getting pregnant. However, it’s important to be aware that you can still ovulate now and again and this can result in a pregnancy if you are having sex, so you still need contraception if you do not want to get pregnant!
If you do want to get pregnant and are struggling to conceive, remember, weight loss can significantly improve your chances of conception in combination with fertility treatments. You will need to be referred by your doctor to a fertility clinic to discuss your options for treatment.
Visit us ….
- You can book a 2Me Clinic PCOS package if you feel that you may have PCOS
- You will have a 30-minute consultation with one of our female doctors
- A PCOS blood profile will be performed during the consultation. Results are available within 48 hours
- Referral for a pelvic ultrasound scan can also be arranged
- Our Nutritionist, Muriel, is available to support you through your journey, providing nutritional guidance on optimal food choices and calorie restriction
- As part of our holistic approach, we work with a Psychotherapist supporting your mental health, as well as an Acupuncturist
References:
- Management of Polycystic Ovarian Syndrome in Adults and Adolescents: National Institute for Health and Care Excellence (NICE) Guidelines, July 2023
- Polycystic Ovarian Syndrome Patient UK May 2023
- Essential Endocrinology: C. G. D Brooks and N. J. Marshall; Blackwell Science Ltd 2001
- Long-term consequences of Polycystic Ovarian Syndrome: Royal College of Obstetrics and Gynaecology (RCOG) Green-top guidelines No. 33, November 2014
