PCOS, 1 in 4!

By: Erica Ferraro

PCOS surpasses even the commonality of endo, affecting a staggering 20% of the female population worldwide. Astonishingly, such an important and prevalent topic is not addressed during the early education of young girls when they first learn about menstruation.

The Condition

PCOS, an abbreviation for polycystic ovarian syndrome (pronounced either as P-C-O-S or Pee-Kos), is a hormonal disorder that impacts women in their childbearing years. Its hallmark distinction from endo is the irregularity of menstrual cycles.

“Polycystic ovarian syndrome is a poorly named condition in that it does not mean that your ovaries have cysts. It means that your ovaries may be larger and have many tiny follicles located around the outer portions of your ovaries” – Natalie Stentz, MD, Fertility Specialist

PCOS is characterized by irregular or skipped periods, whereas endo is associated with regular but painful periods. Both conditions significantly affect female infertility and may coexist concurrently. It is not uncommon to encounter women who grapple with both conditions simultaneously. Individuals with PCOS may experience infrequent menstrual cycles or prolonged periods lasting several days. Additionally, they may exhibit higher levels of androgen, a hormone found in excess within their bodies. With PCOS, multiple tiny fluid-filled sacs known as cysts develop along the outer edge of the ovaries. These cysts contain immature eggs, which unfortunately fail to release regularly. The precise cause of PCOS remains unknown. However, early diagnosis, treatment, and proactive weight management can reduce the risk of long-term complications, such as type 2 diabetes and heart disease. PCOS can be diagnosed through blood work, an ultrasound, and a pelvic exam at your OB/GYN or fertility clinic.

The Symptoms

The onset of PCOS symptoms commonly emerge around the initial menstrual period, although in some cases, symptoms may manifest later after a time of regular menstruation.

The symptoms of PCOS vary. A diagnosis is established when at least two of the following indicators are present:

• Irregular Menstruation: Infrequent or irregular menstrual cycles are a common indication of PCOS. Likewise, periods extending beyond the typical duration are also characteristic—for instance, having fewer than nine periods within a year or exceeding 35 days between periods. Difficulties in achieving pregnancy may also arise.
• Excessive Androgen Levels: Elevated levels of the hormone androgen can lead to the development of unwanted facial and body hair, referred to as hirsutism. In some cases, severe acne and male-pattern baldness may also manifest.
• Polycystic Ovaries: Enlarged ovaries with multiple follicles containing immature eggs may be observed, and their functionality may be compromised.
  • Notably, the severity of PCOS signs and symptoms tends to be more pronounced among individuals who are affected by obesity.

Underlying Factors

The precise cause of PCOS remains unknown, but several factors are believed to contribute to its development:

• Insulin Resistance: Insulin, a hormone produced by the pancreas, facilitates the utilization of sugar, the primary energy source for cells. When cells become resistant to insulin’s actions, blood sugar levels may rise, prompting the body to produce more insulin to lower them. Excessive insulin production can stimulate the overproduction of androgens, the male hormones. This disruption in hormone balance can interfere with the ovulation process, which involves the release of eggs from the ovaries. Dark, velvety patches of skin in areas such as the neck, armpits, groin or under the breasts, along with increased appetite and weight gain, can indicate signs of insulin resistance.
• Low-Grade Inflammation: White blood cells release substances as a response to infection or injury, leading to a condition known as low-grade inflammation. Research suggests that PCOS patients experience a chronic, low-grade inflammation that prompts the polycystic ovaries to produce excessive androgens. This inflammatory state can contribute to complications involving the heart and blood vessels.
• Hereditary Factors: Studies indicate a potential link between specific genes and the development of PCOS. A family history of PCOS may influence an individual’s susceptibility to the condition.
• Excess Androgen: The ovaries may produce elevated levels of androgen hormones. This hormonal irregularity disrupts regular ovulation, resulting in irregular egg development and the failure of eggs to release from the ovarian follicles. 

Potential Complications

• Infertility: Difficulty in conceiving or achieving pregnancy is a common complication of PCOS. The irregular ovulation patterns and hormone imbalances associated with the condition can hinder the release of eggs necessary for fertilization.
• Gestational Diabetes and Pregnancy-Induced Hypertension: Women with PCOS have an increased risk of developing gestational diabetes during pregnancy, which is characterized by elevated blood sugar levels. Additionally, pregnancy-induced high blood pressure can occur, posing potential risks to both the mother and baby.
• Miscarriage or Premature Birth: PCOS has been linked to a higher incidence of miscarriages and premature births, further highlighting the complexities of fertility and reproductive health in affected individuals.
• Nonalcoholic Steatohepatitis (NASH): NASH is a severe liver inflammation caused by fat accumulation in the liver. PCOS can contribute to the development of NASH, posing additional health concerns.
• Metabolic Syndrome: PCOS is associated with an increased risk of developing metabolic syndrome, a cluster of conditions such as high blood pressure, elevated blood sugar levels, and unhealthy cholesterol or triglyceride levels. Metabolic syndrome significantly heightens the risk of cardiovascular diseases affecting the heart and blood vessels.
• Type 2 Diabetes or Prediabetes: Insulin resistance, a common feature of PCOS, can lead to the development of type 2 diabetes or prediabetes. These conditions impact the body’s ability to regulate blood sugar levels effectively.
• Sleep Apnea: PCOS has been linked to an increased risk of sleep apnea, a sleep disorder characterized by interrupted breathing patterns during sleep. This can lead to daytime fatigue and other related health complications.
• Mental Health Challenges: PCOS can contribute to mental health issues such as depression, anxiety, and eating disorders. The complex interplay between hormonal irregularities, physical symptoms, and emotional well-being can impact the overall quality of life for individuals with PCOS.
• Uterine Lining Cancer (Endometrial Cancer): The hormonal irregularities associated with PCOS can increase the risk of developing cancer in the uterine lining.

Treatment Approaches

The management of PCOS revolves around addressing the specific concerns that trouble you, which could include infertility, excessive hair growth, acne, or obesity. Treatment methods may involve a combination of lifestyle adjustments and medication.

Lifestyle Adjustments

Your healthcare provider may suggest weight loss through a low-calorie diet and moderate exercise. Even a modest reduction in body weight, such as losing 5%, can improve your condition. Weight loss may enhance the effectiveness of prescribed medications for PCOS and aid in addressing infertility. Collaborating with a registered dietitian and your healthcare provider can help determine the most suitable weight-loss plan for you.

Medication:

To regulate your menstrual cycles, your healthcare provider might recommend:

• Combination birth control pills: These pills contain both estrogen and progestin, which can reduce androgen production, regulate estrogen levels, and mitigate risks associated with endometrial cancer. They can also address irregular bleeding, excessive hair growth, and acne.
• Progestin therapy: Taking progestin for 10 to 14 days every 1 to 2 months can help regulate your periods and provide protection against endometrial cancer. However, progestin therapy does not improve androgen levels or act as a contraceptive. If you wish to avoid pregnancy, alternative options like the progestin-only minipill or progestin-containing intrauterine device are more suitable.

To stimulate ovulation and enhance your chances of becoming pregnant, your healthcare provider might recommend:

• Clomiphene (Clomid): This oral anti-estrogen medication is typically taken during the early phase of your menstrual cycle.
• Letrozole (Femara): Originally used in breast cancer treatment, this medication can stimulate the ovaries.
• Metformin: When taken orally, metformin, primarily prescribed for type 2 diabetes, can improve insulin resistance and lower insulin levels. If clomiphene alone does not result in pregnancy, your provider might suggest combining it with metformin. Metformin can also slow the progression from prediabetes to type 2 diabetes and assist in weight loss.
• Gonadotropins: These hormone medications are administered through injections and can be utilized if other methods prove ineffective.

In cases where excessive hair growth or acne is a concern, your healthcare provider might recommend:

• Birth control pills: These pills can decrease androgen production, addressing excessive hair growth and acne.
• Spironolactone (Aldactone): This medication blocks the effects of androgen on the skin, reducing excessive hair growth and acne. However, spironolactone can cause congenital disabilities, so effective birth control methods are necessary while taking this medication. It is not recommended during pregnancy or if pregnancy is planned.
• Eflornithine (Vaniqa): This cream slows down facial hair growth.
• Hair removal techniques: Electrolysis and laser hair removal are permanent options. Electrolysis involves inserting a tiny needle into each hair follicle and sending an electric current to damage and destroy it. Laser hair removal employs concentrated light to remove unwanted hair. Shaving, plucking, or using hair-removal creams are temporary alternatives, but hair may grow back thicker.
• Acne treatments: Various medications, including oral pills and topical creams or gels, can help improve acne. Discuss suitable options with your healthcare provider.

“PCOS, although a common fertility issue, really can cause a slew of other health issues, hence why a delay in diagnosis and treatment should be avoided. This  can be explored with a primary care physician, even before seeing an RE, as hormonal irregularities, along with cholesterol, blood pressure, and BMI are regularly monitored as part of treatment for this condition.” Sarrah Bair MSN, FNP-C, Family Medicine and Women’s Health

The bottom line is this: PCOS is a common female health condition, is a leading cause of infertility and, many times, the need for pregnancy intervention through assisted reproductive technologies. Whether you are trying to conceive or not, discussing symptoms with your doctor is never a bad idea.

If you resonate with any of the above, you are not alone. This is a prevalent condition that impacts many women worldwide.