This weeks feature article is dedicated to Polycystic Ovary Syndrome (PCOS), a condition that I am learning about and currently being “treated for” (head to my article about my recent health update to learn more).
What Is It?
Polycystic Ovary Syndrome (PCOS) is a set of syndromes that occurs in females when there is a presence of increased androgens – these are male hormones and I spoke about them in a bit more detail in this article. It is a common condition that falls both under gynaecology and endocrinology – the department specific for hormones.
It is considered a spectrum disorder, meaning that one patient with PCOS could have all of the symptoms, whereas another one could only have a couple. It can be diagnosed a by a couple of different methods and there is currently no cure for it.
One of the most common features associated with PCOS is infertility.
Signs and Symptoms
Patients with PCOS commonly present with menstrual symptoms, and this can range from amenorrhea (no periods for 3 consecutive months or more), oligomenorrhea (less than 9 periods a year) and simply irregular periods that are consistently late. Periods after often a lot longer than the usual 28-35 day cycle.
In line with menstrual symptoms, patients with PCOS will experience a lack of ovulation or ovulating late in their cycle, often due to the long length of their cycle. Some patients will find ovulation is inconsistent. Problems with ovulation, particularly chronic anovulation (lack of ovulation) leads to difficulty getting pregnant.
Even with a lack of ovulation, some patients who have PCOS or may be in the process of being diagnosed will still have very light periods or very short ones that only last a couple of days.
The ovaries may also contain more egg follicles that normal, and may be seen to be polycystic under ultrasound. However, this is something that not all PCOS patients have despite having every other symptoms. These cysts are not the same as other ovarian cysts that I have written about before – they are actually immature follicles which have come about to the hormonal imbalances disturbing the ovaries normal function.
Symptoms that arise from the excessive androgen hormones include acne, male pattern hair growth (e.g. hair on the buttocks, stomach, facial region and chest) as well as excessive hair loss and/or hair thinning. The tendency to have an increase in male hormones can lead to some patients developing very heavy and prolonged periods – the exact opposite of what is described above. This clearly demonstrates the wide spectrum of the disease.
Other symptoms that patients might present with are increase in weight and problems with insulin resistance. Whilst not directly related to diabetes, patients with insulin resistance may have symptoms such as increased hunger, tiredness and a poorer ability to concentrate.
PCOS is termed as a heterogeneous medical condition. This means that it is a disease of multiple causes with no clear defined cause. There are multiple factors;
- Genetics – there is some evidence that PCOS runs in families, and although there is no hard evidence of this, it is likely that if your mother, sister or aunt has PCOS, you are at an increased risk (the exact percentage is unknown).
- Metabolics – PCOS is sometimes look at as a “metabolic disorder”, which simply means that there is an abnormal reaction among cells, chemicals and hormones which alter the normal metabolic (e.g. insulin) function. Some of these abnormal reactions can be reversed through medication, which diminishes some PCOS symptoms.
- Hormonal imbalance – the abnormal balance of female to male hormones in the body leads to the above symptoms, although it is not known why these hormonal imbalances or changes occur. It is thought to be linked to blood sugar levels, as an increase in blood sugar levels and resistance to insulin does play a role in hormone regulation. However, there are other thoughts that suggest the hormonal imbalance starts within the ovary itself or the hypothalamus, the region of the brain that controls hormones.
- Chronic inflammation – whilst there is not a lot of information available on this particular theory, it is thought that an environment that is constantly or chronically inflamed (e.g. from Endometriosis and Adenomyosis) might impact on the ability to ovulate effectively.
From That, How Does It Occur?
When the ovaries are stimulated by excessive levels of androgen hormones, PCOS starts to develop. The irregularity or absence of ovulation has an impact on the ovary function, prevent egg follicles to develop properly, leaving them to appear as small and multiple cysts.
This, in combination with problems with insulin resistance, means that the brain produces some hormones more than others and effects the way hormones interact.
The most common diagnostic tool is pelvic and transvaginal ultrasound, as it enables the gynaecologist or sonographer to clearly see the ovaries and check how many follicles are present, and if there is an appearance of polycystic ovaries. It is highly likely that both ovaries will appear polycystic. One of the criteria I have been educated on suggests that an ovary requires 12 or more follicles to be classed as polycystic, but remember that only 15% of PCOS patients will have this appearance.
Other diagnostic tools include blood tests to identify hormone imbalances, as well as those to look at blood sugar and insulin levels. It is also possible to see polycystic ovaries during a laparoscopy, but this is not a confirmed method of establishing a diagnosis. Also, some specialist gynaecologists are able to diagnose purely from history taking, as they will be able to assess the menstrual cycle pattern of the patient in detail, alongside any features of acne, male pattern hair growth and increasing body weight. Some patients may also be asked to complete a certain amount of ovulating testing using home tests, in order to establish whether there is any ovulation taking place at all or it is simply late. This can help guide management options, particularly if infertility is present.
As mentioned previously, PCOS has no cure, and it’s management focuses on relieving symptoms and aiding ovulation to allow for pregnancy. The main goals of management are;
- Restoring fertility
- Treatment of acne and male pattern hair growth
- Improving weight
- Lowering insulin resistance levels
- Lowering blood sugar levels
- Restoring regular menstruation
Because PCOS is a spectrum disorder, each patient will have a preference over the above goals. Common management options are;
- Improving diet to aid weight loss, as patients whose weight comes under normal limits will have an improvement in ovulation and menstrual regulation, aiding fertility and hormonal imbalances.
- Focusing on a low GI (glycaemic index) diet to control blood sugar and insulin levels. This will enable better hormone regulation and ovulation, aiding fertility.
- Hormonal birth control to provide a more regular cycle for the body to “mimic”, but also help with hormonal imbalances. Hormonal birth control has a scale of those which contain the most female hormones, and those that contain higher male hormones. Regulating hormones with this method will often improve things such as acne and male pattern hair growth.
- Prescription medication can also be used to improve acne and male pattern hair growth if it is a main concern for the patient.
- The use of metformin, which is traditionally used in patients with type 2 diabetes, can be used in patients with PCOS to aid blood sugar and insulin levels, and thus address hormonal imbalances. Metformin can often help with regulating ovulation, but not necessarily starting ovulation if a women has not ovulated for a long time.
- IVF drugs can be utilised where appropriate to “kick start” ovulation. A common drug in the UK is Clomid, which I’ve actually heard may cause patients to ovulate from both ovaries at the same time (hence why it is very useful in treating infertility).
- There is a surgical option known as ovarian drilling, which is used for the fertility problems associated with PCOS. It is done under general anaesthesia, and the ovaries are “drilled” to remove any tissue that is causing an increase in androgen production. There is some evidence that it successfully improves hormonal imbalances, thus improving ovarian function.
- There is a variety of alternative treatments available to research that uses more natural approaches to help regulate hormones and ease symptoms, as well as aid fertility. As with all alternative treatments, you may find they effect each person differently.
There is some evidence to suggest that patients with PCOS are at an increased risk of developing other conditions. I guess as with any condition you are diagnosed with, take them with a pinch of salt and always ask your specialist for further advice if you are worried;
- Type 2 diabetes
- High blood pressure
- Depression and anxiety
- Cholesterol disorders
- Weight gain
- Some cancers (please ask your specialist about this rather than googling it – I find using Dr. Google can make things a lot worse!)
As you may have read in my most recent update article that I linked at the top, I am currently being treated for what my gynaecologist suspects is PCOS. How did I get that from going to an appointment that was predominantly for my Endometriosis and Adenomyosis pain? Well…
Since coming out of the medical menopause about 10 months ago now, I’ve noticed that my cycle has been becoming increasingly long – sometimes as long as over 40 days. My periods are also very irregular. I realised this because I used a period tracking app called Flutter (it’s amazing by the way, and was designed by those who suffer from Endometriosis, for Endometriosis patients. Check it out here), and I started using an app because this is the first time since my periods begun that I have not been on any hormonal birth control, so I wanted to keep an eye on what is going on. Clearly, things aren’t going to plan – sometimes my periods would be Hell on earth whereas a couple of times they were like a dream, light and short.
Alongside my AWOL menstrual cycle, I started to breakout really badly around my chin, and I’m not just talking little pimples – I’m talking those pesky, giant and sore under skin spots that are so painful, and they were coming up in groups. I also had hair on my stomach creeping up and my upper lip.
I just decided to mention these symptoms to my gynaecologist. She knew about the crazy cycles that I was having, but because the first time I had seen her I’d only been out of the menopause for a couple of months, we assumed it would settle. However, it’s persistence led to her conclusion of PCOS.
My internal ultrasound didn’t identify that I was that polycystic on my ovaries, but I had 12 follicles so I was a bit borderline. However, it was her that reassured me PCOS was a spectrum disorder so just because my ovaries didn’t look as bad as others she’d seen, she was convinced all the same.
I am currently on a low GI diet as advised by my gynaecologist and I am having to do 2 months worth of ovulation testing. I can’t really say what I expect from my ovulation because I have never tracked it, but a couple of cysts I have had previously may suggest that it isn’t consistent, but we’ll wait and see. The results of these ovulation tests will determine my next course of treatment – if its assistance then it’ll likely be metformin I’ll be prescribed, whereas if it’s full-on needing to get going again, I’ll be given Clomid even though we aren’t actively trying for a baby right now.
It’s weird because with every diagnosis I have had (except the bladder, that was bloody obvious, and the M.E., that was just unfortunate), I’ve realised I have probably had problems for a long-time. With my Endometriosis, my periods were horrific since they first started – I used to bleed so much I would have to come home from school regularly to change my clothes and the pain would lead me feel like I was going to pass out. With my Adenomyosis, I was experiencing flooding that was like a waterfall and such intense contraction-like pain they would stop me in my tracks. With this PCOS, for the years where I had just started my period and then put on birth control, my period was irregular and chin acne was rife. It’s funny how everything seems to make sense when someone else is looking at it, or the answer is given to you.
I don’t really know what to expect with PCOS. I mean, from a fertility point of view it is pretty frightening – I suffer with 3 conditions that impact my fertility. Does this mean my chances of conceiving naturally are getting smaller and smaller? I’ve got no idea, but I’m not focused on that right now. All I know is that this gynaecologist is brilliant for listening to me and spotting when something wasn’t right.