WHAT IS PCOS?

Updated 12th September 2022

Polycystic ovary syndrome, or PCOS as the condition is often called, is a disorder of the women's endocrine system. In this condition, the ovaries produce an abnormal amount of the male sex hormones, or androgens, that are usually present in small quantities in women. It is a disorder that affects at least 7% of adult women.

The polycystic ovary syndrome is named after the characteristic numerous, tiny, fluid-filled sacs (known as cysts) that form along the outer edge of the ovary. However, some women with PCOS may not have cysts, while some without the syndrome do.

PCOS is called a syndrome or group of symptoms that affect the ovaries and ovulation. Its three main features are:

1. Cysts in the ovaries.
2. High levels of androgens.
3. Irregular or skipped periods.

An ovary releases a mature egg during ovulation, which is later fertilized by a male sperm. If the egg remains unfertilized, it is expelled from the body during your period.

In some cases, the body does not produce enough hormones needed to ovulate. When ovulation does not occur, the ovaries can then develop the cysts which make androgens. The fluid-filled cysts in PCOS also contain immature eggs, called follicles, which fail to release eggs regularly.

In women with PCOS, high levels of androgens can often lead to many of the symptoms of PCOS. The resultant hormonal imbalance also causes the body to skip menstrual periods and makes it harder to get pregnant.

PCOS treatment is usually done with medication. Early diagnosis and treatment may lower the risk of long-term complications.

Read on to take a closer look at the likely causes of PCOS, the symptoms, and its possible effects on a woman’s body.

What Causes PCOS?

The exact cause of PCOS is not yet clearly understood. Insulin resistance is one of the primary causative imbalances in most, if not all, cases of PCOS. There are, however, several other factors that can play a role in the development of the disorder. The causes of PCOS include:

Insulin Resistance

Insulin is a pancreatic hormone that lowers blood sugar levels by allowing the cells to use it. While their bodies can produce the hormone, Insulin resistance in women with PCOS affects its effective bodily utilization. This leads to a rise in blood sugar levels, which can cause your body to produce more insulin.

Insulin helps to regulate ovarian function, and the ovaries respond to excess insulin by producing androgens. This can cause trouble with ovulation and the menstrual cycle.

Insulin resistance co-occurs with PCOS in up to 70 percent of women. A major cause of insulin resistance is obesity, and both conditions can increase the risk of type 2 diabetes. Additionally, obesity can be exacerbated by poor dietary choices and physical inactivity.

Excess Androgen

The presence of excess androgen interferes with ovulation. This means that eggs do not develop regularly and are not released from the follicles even if they do.

Heredity

Studies show that PCOS runs in families, and you might be more likely to have PCOS if your sister or mother also has it.

Several genes have been identified as contributors to the development of the disease. These genes are involved in various levels of the steroid and androgen hormone synthesis pathways in the body.

Low-grade Inflammation

Low-grade inflammation is a chronic response to injuries, diseases, foreign invaders, etc. that constantly produces a steady, low level of inflammation throughout the body.

Increased levels of inflammation are common in women with PCOS. Studies have also linked excess inflammation to higher androgen levels.

Stress can also contribute to chronic inflammation and possibly cause PCOS.

Others

Infections and toxins may also play a role in the development of PCOS. Some hypotheses also include exposure to androgen in fetal life.

Who Are At Risk Of PCOS?

There are several risk factors for PCOS in adult women.

Any form of diabetes, type 1, 2, and diabetes developing in pregnancy (gestational diabetes) increases the chances of PCOS.

Obesity and insulin resistance are also linked with an increased likelihood of developing PCOS.

History of PCOS in the family (mothers, sisters) is also crucial. According to a study, daughters are nearly eight times as likely to have PCOS if their mothers had it.

Chronic disease in the mother or father that creates an unfavorable condition in the womb may also increase your risk of developing PCOS.

Studies have suggested that pregnant women with elevated blood pressure are likely to give birth to daughters with PCOS. Women also had a slightly higher risk if their mothers smoked during pregnancy. If the fathers had a stroke or heart disease, the daughters also had a higher risk of PCOS: twice and thrice the risk, respectively.

Symptoms of PCOS

PCOS is a hormonal problem occurring during the reproductive years. It wreaks havoc on a woman's menstrual cycle. As a result, you may have periods that last many days, have them infrequently and irregularly, or not have them at all.

Insulin resistance can present as dark, velvety patches of skin on the lower part of the neck, armpits, under the breasts, or groin. Weight gain and a bigger appetite may be other signs.

Excess androgen can result in oily skin and acne. It can also cause hirsutism and excess male-type hair growth usually on the face, chest, back, or buttocks. Some women can also experience headaches triggered by hormonal changes.

Other symptoms include:

• Male pattern thinning of hair and head hair loss.
• Weight gain (especially around the belly)
• Difficulty in getting pregnant.
• Skin tags (small pieces of excess skin in the underarms or on the neck).

Can I Have PCOS But Not Have Any Symptoms?

All symptoms may not present in all women with PCOS, and each symptom can vary from mild to severe. The signs and symptoms are typically more severe in people with obesity.

More than half of women may not have any symptoms. Some only discover they have PCOS after they’ve had trouble getting pregnant or gained a lot of weight for unknown reasons.

PCOS And Pregnancy

Higher-than-normal levels of androgen in a woman's body can affect fertility and other aspects of health.

Infertility or subfertility (reduced fertility) is a common problem for women with PCOS. This may be due to the imbalance of hormones or the ovaries infrequently releasing eggs.

Many women with PCOS do become pregnant, with or without medical assistance. But you will be at risk for more complications during pregnancy, labor, and delivery, such as gestational diabetes, pregnancy-induced high blood pressure, larger baby, miscarriage, or premature delivery.

With proper monitoring, the majority of PCOS symptoms during pregnancy can be treated. Due to complications that may arise during labor and delivery, women with PCOS are more likely to deliver via cesarean.

When To See Your Doctor?

Speak with your health care provider if you have:

• Irregular or infrequent periods.
• Missed your periods, but you are not pregnant.
• Unexplained weight gain.
• Trouble getting pregnant (for more than 12 months).
• Signs of excess androgen (such as hair growth on your face and body).
• Symptoms of diabetes, such as excessive hunger or thirst, unexplained weight loss, or blurred vision.

How Is PCOS Diagnosed?

There is no single test to specifically diagnose polycystic ovary syndrome (PCOS).

During your appointment, your healthcare provider will ask you about your symptoms and medical history. They will also perform a complete physical examination, including checking for signs of excess hair growth, acne, and insulin resistance.

The doctor may then recommend a pelvic exam to check the health of your reproductive organs both inside and outside your body.

Other tests that are required are:

Ultrasound

This test utilizes sound waves to produce images of structures within the body. Ultrasound is especially used to look at the size of the ovaries and see if they have cysts. It can also check the thickness of the lining of your uterus (endometrium)

During the test, a wand-like device (or a transducer) is placed in your vagina.

Blood Tests

These can detect high levels of androgens and other hormones. Your health care provider may also check your blood glucose, cholesterol, and triglyceride levels.

Additionally, tests that measure levels of C-reactive protein (CRP) and white blood cells, which can indicate the level of inflammation in your body, may also be performed.

Further Tests

If diagnosed with PCOS, your doctor may recommend more tests for complications which can include:

• Regular checks of glucose tolerance, blood pressure, cholesterol, and triglyceride levels
• Screening for obstructive sleep apnea
• Screening for depression and anxiety

PCOS Treatment

Treatment of PCOS targets the symptoms since the primary cause remains unknown.

Lifestyle Modifications

If you are overweight or obese and have PCOS, exercise and calorie-restrictive diets are the best interventions for weight loss. Your condition might improve even with modest weight reduction. Losing weight may also increase the effectiveness of medications and can help with infertility.

Limit carbohydrates as high-carbohydrate diets might elevate insulin levels. Staying active with exercise helps lower blood sugar levels. Weight loss can lower insulin and androgen levels.

It is best to work with your health care provider and a registered dietitian to determine the most appropriate weight-loss plan for you.

Medications

Your doctor may recommend the following medications depending on your concerns.

Drugs To Regulate Periods

Birth control pills that contain both estrogen and progestin regulate estrogen and decrease androgen production. Progestin therapy alone can regulate your periods and protect against endometrial cancer. In addition, if you wish to avoid pregnancy, the progestin-only minipill or progestin-containing intrauterine device is a better choice.

Alternatively, birth control hormones can come in a patch or vaginal ring.

Drugs To Induce Ovulation

An oral anti-estrogen medication, Clomiphene, is taken during the first part of your menstrual cycle to induce ovulation.

Letrozole (Femara) can work to stimulate the ovaries.

Drugs To Regulate Insulin Levels

Metformin (Fortamet, Glucophage) is a type 2 diabetes medication that also treats PCOS by improving insulin levels.

If you have prediabetes, metformin can slow the progression to type 2 diabetes and help with weight loss. Additionally, if you don't become pregnant using clomiphene, your provider might recommend adding metformin to help you ovulate.

Drugs To Control Acne And Excessive Hair Growth

Eflornithine (Vaniqa) cream is a drug prescribed for slowing facial hair growth.

Birth control pills can decrease androgen production, which causes acne and excessive hair growth.

Spironolactone (Aldactone) blocks the effects of androgen on the skin. As the medication can cause birth defects, it is not recommended if you are pregnant or planning to become pregnant. Effective birth control is also needed while taking this medication.

There are several options, including pills and topical creams or gels, for acne. Your doctor will recommend the best-suited option for you.

Other procedures

Surgical options (like ovarian drilling) can be used to improve fertility if other treatments don’t work. The procedure makes tiny holes in the ovary with a thin heated needle or laser to restore normal ovulation.

Laser hair removal and electrolysis can eliminate unwanted hair on your face and body.

The former is a medical procedure that uses a concentrated beam of light to remove unwanted hair. The latter uses a small needle inserted into each hair follicle. It sends out a pulse of electric current that damages and then destroys the follicle.

Multiple sessions of laser hair removal or electrolysis may be required. Plucking, shaving, or using creams that dissolve unwanted hair are other options.

Long-term Complications Of PCOS

Endometrial Cancer

Multiple studies have shown an increased risk of cancer of the endometrium in patients with PCOS later in life. Women with absent or very irregular periods (fewer than 3 or 4 periods a year) for many years have a higher-than-average risk.

From the teen years through menopause, all women experience a monthly buildup of the endometrial lining in the uterus. This happens as the body prepares for the potential of a fertilized egg. In the absence of pregnancy, the lining is normally shed through menstruation.

In women with PCOS, the monthly buildup of the endometrial lining is not sufficiently shed due to infrequent or nonexistent menstrual periods. The lining then continues to build up (a condition known as endometrial hyperplasia) which can eventually increase the risk of endometrial cancer.

Diabetes

We now know that insulin resistance may cause your body to produce excess androgens. As a result, the cells in your organs and other tissues do not absorb blood sugar very well. Consequently, too much sugar moves through your bloodstream, causing diabetes.

Lipid Abnormalities

Increased androgens can lead to an unfavorable lipid profile in women with PCOS. The blood lipid profile may show a lower rate of the "good" cholesterol or high-density lipoproteins (HDL) and a higher rate of the "bad" cholesterol or low-density lipoproteins (LDL).

This imbalance increases the risk of cardiovascular disease.

Cardiovascular Problems

Several factors contribute to the risk of cardiovascular disease in women with PCOS, such as dysregulated lipid profile, overweight, and poorly controlled blood sugar.

Metabolic Syndrome

Metabolic syndrome is a cluster of conditions, including high blood sugar, high blood pressure, and unhealthy cholesterol or triglyceride levels that significantly increase your risk of cardiovascular diseases, diabetes, and stroke.

Obstructive Sleep Apnea

Obstructive sleep apnea is a condition that causes repeated pauses in breathing during the night, which interrupts sleep.

The high androgen levels in PCOS seem to play a role in the development of sleep apnea. Increased body weight also contributes to this risk.

Depression, Anxiety, And Eating Disorders

Many women with PCOS eventually experience depression and anxiety due to hormonal changes and symptoms like unwanted hair growth.

FAQs

Does PCOS Ever Go Away?

Sometimes, menopause can make your PCOS go away, but not always. At times, the hormonal imbalance does not change as you age and can continue into menopause.

What's The Difference Between PCOS And PCOD?

Polycystic ovarian syndrome or PCOS was previously known as polycystic ovary disease or PCOD. They are essentially the same condition.

Can Men Have PCOS?

PCOS-type manifestations are not limited to women. Men can also suffer from insulin resistance, obesity, cardiovascular diseases, and diabetes mellitus despite not having ovaries. Besides hormonal and metabolic abnormalities, the clinical characteristics are early-onset baldness, excessive hair growth anywhere on the body, or acne.

Can I Prevent PCOS?

Proven ways to prevent PCOS remain undiscovered. You can, however, make changes to your diet and lifestyle to reduce your symptoms. For instance, exercising regularly, managing your weight, and eating a healthy and nutritious diet can help you avoid the effects of PCOS.

Conclusion

Polycystic Ovary Syndrome, or PCOS, is a common condition that affects ovarian functioning. The three hallmark facets are irregular periods, excess androgen, and polycystic ovaries - the presence of any two can diagnose the condition. While there is no cure yet for the condition, the symptoms of PCOS can be treated.

Talk to your healthcare provider if you think you have PCOS.

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References:

• Ndefo, Uche Anadu et al. “Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches.” P & T : a peer-reviewed journal for formulary management vol. 38,6 (2013): 336-55.
• Rasquin Leon LI, Anastasopoulou C, Mayrin JV. Polycystic Ovarian Disease. [Updated 2022 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459251/
• Marshall, John C, and Andrea Dunaif. “Should all women with PCOS be treated for insulin resistance?.” Fertility and sterility vol. 97,1 (2012): 18-22. doi:10.1016/j.fertnstert.2011.11.036
• González, Frank. "Inflammation in Polycystic Ovary Syndrome: Underpinning of insulin resistance and ovarian dysfunction." Steroids, vol. 77, no. 4, 2012, p. 300, https://doi.org/10.1016/j.steroids.2011.12.003.
•  Kurzrock, Razelle, and Philip R Cohen. “Polycystic ovary syndrome in men: Stein-Leventhal syndrome revisited.” Medical hypotheses vol. 68,3 (2007): 480-3. doi:10.1016/j.mehy.2006.03.057

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