Understanding Polycystic Ovary Syndrome (PCOS)

PRIMARY SYMPTOMS

Until we’re postmenopausal, most women get their period every twenty-eight days or so, and it typically lasts anywhere from four to seven days. But women with polycystic ovary syndrome (PCOS)—a common hormonal problem that affects up to one in ten women—may skip their period or experience longer periods. Other symptoms of PCOS include acne, excess hair growth (hirsutism), weight gain, pelvic pain, irregular periods, depression, ovarian cysts, and infertility (Bozdag, Mumusoglu, Zengin, Karabulut, & Yildiz, 2016). Given the symptoms and how common PCOS is among women, it is fairly under-studied. But there is a meaningful collection of research on lifestyle changes, medications, treatments, clinical trials, and other interesting studies that can help us navigate PCOS.

How Many Women Have PCOS?

Polycystic ovary syndrome (PCOS) affects one in ten women, but many aren’t aware that they are affected by it.

HORMONE IMBALANCE AND OVARIAN CYSTS AND FOLLICLES

Women have two ovaries with two crucial reproductive jobs. Our ovaries release eggs during our menstrual cycle and they also produce three major hormones—estrogen, progesterone, and testosterone—as well as a few other hormones, like inhibin and relaxin. The “female” hormones estrogen and progesterone are necessary for the menstrual cycle. The “male” androgen hormones, like testosterone, are also needed at low levels in women, although the reasons why are not entirely clear. One theory is that testosterone is related to female sexual desire and lubrication (Davis & Wahlin-Jacobsen, 2015). Women with PCOS often have higher than normal levels of testosterone and low levels of estrogen, creating a hormone imbalance that interferes with ovulation and can manifest as ovarian cysts (Housman & Reynolds, 2014).

Ovarian cysts are very common. They’re typically small, unnoticeable fluid-filled sacs that don’t cause problems; many of us have had or will have one in our lifetime, usually without knowing it. Cysts become an issue if they grow to be large and painful or if multiple cysts grow on the outer edge of the ovaries, as is often the case in PCOS. It’s also possible for women to have ovarian cysts due to other conditions, such as endometriosis. But what distinguishes PCOS from other conditions is the hormonal imbalance. Another technicality is that women with PCOS actually have ovarian follicles, not ovarian cysts. Which means: Follicles and cysts look exactly the same on ultrasound, and while the names are used interchangeably, follicles contain an immature egg, but cysts do not. Since women with PCOS have trouble releasing an egg each month due to hormone imbalances, these follicles tend to build up on the ovary over time. This is sometimes described as looking like a “string of pearls” on the ultrasound (Housman & Reynolds, 2014).

Potential Causes and Related Health Concerns

The exact cause of PCOS is not known. It runs in families, so it is likely caused by a combination of genetics and environmental factors. One factor that has been heavily researched is insulin resistance.

INSULIN RESISTANCE, WEIGHT, AND DIABETES

Women with PCOS have a high prevalence of insulin resistance, regardless of their weight. They also have a higher risk for other diseases, such as diabetes and cardiovascular problems, especially if they are overweight (Bil et al., 2016; Jeanes & Reeves, 2017).

How Does Insulin Work?

Insulin helps our body regulate the amount of sugar in our blood. In the case of insulin resistance, the body’s cells don’t respond to insulin very well, which causes your blood sugar level to rise. And your body compensates by making more and more insulin.

This can eventually progress to diabetes. Scientists aren’t sure whether PCOS causes insulin resistance or insulin resistance causes PCOS (more on this later in our research section).What we do know is that insulin resistance can cause issues such as type 2 diabetes, metabolic syndrome, and cardiovascular disease if not managed properly. It’s also been linked to increased cancer risk (Orgel & Mittelman, 2013).

The risk of type 2 diabetes may be up to four times greater and diagnosed an average of four years earlier among women with PCOS compared to other women (Rubin, Glintborg, Nybo, Abrahamsen, & Andersen, 2017). In addition, women with PCOS are more likely to be obese, with one meta-analysis estimating the risk of obesity is almost three times higher among women with PCOS (Lim, Davies, Norman, & Moran, 2012). The weight gain with PCOS can be stubborn due to the underlying hormonal issues. Insulin resistance and diabetes are huge risk factors for heart disease if not properly managed.

For women with PCOS, figuring out how to balance insulin levels through lifestyle changes is incredibly important for managing PCOS symptoms and for preventing potentially more serious issues down the road.

FERTILITY AND PCOS

In addition to irregular periods and ovulation issues, infertility is relatively common in women with PCOS, which can be heartbreaking for those who want to become pregnant. There are many medications and technologies available today (and more likely coming) for women who struggle with fertility issues. Losing weight, if you’re overweight, can be a first step to help with ovulation and fertility (Morgante, Massaro, Di Sabatino, Cappelli, & De Leo, 2018). Fertility medications such as clomiphene citrate (aka Clomid) increase hormones to support ovulation. They can be taken alone or in combination with metformin (ASRM, 2017; Morley, Tang, Yasmin, Norman, & Balen, 2017); read more under the conventional treatments section. Other, more aggressive treatment options you may want to discuss with your doctor include assisted techniques such as in vitro fertilization (IVF), bariatric surgery for weight loss, or laparoscopic ovarian surgery (Balen et al., 2016; Butterworth, Deguara, & Borg, 2016). If you have been diagnosed with PCOS and plan to become pregnant, discuss fertility screening and treatment options with your doctor.

MENTAL HEALTH AND PCOS