This week’s post highlights the most common, although somewhat unknown, women’s health diagnosis. Polycystic ovarian syndrome affects anywhere from 1 in 10 to 1 in 20 women in the United States alone, and many more worldwide. It is an endocrine disorder, meaning it is a problem with hormone regulation.
What is it?
PCOS occurs when there are too many androgen hormones which result in changes in the woman’s body. Androgens are male hormones, although women normally have them in small amounts too. The increase in androgens leads to the formation of cysts in the ovaries which results in abnormal periods. It also has a wide variety of other effects throughout the body including acne, oily skin, and increased hair growth (in places where men usually only get hair such as the face, chest, etc).
Currently, no one knows exactly why women get PCOS but there is a genetic link, meaning you are more likely to get it if a close female relative has it. Women can develop different types of cysts, some of which are normal and others which are problematic such as PCOS and endometrial cysts. PCOS is likely underdiagnosed as many women may not know that what they are experiencing is abnormal and many doctors do not know how to diagnose or look for it. That’s why you need to be your own best advocate!
Many women with PCOS also have problems with insulin resistance, meaning their cells don’t respond to insulin. This results in high levels of insulin in their blood (hyperinsulinemia), an increased risk of obesity, and makes it harder to lose weight. Insulin resistance also slows down ovulation and increases the formation of androgen, which keeps the cycle of PCOS going.
Symptoms of PCOS vary from woman to woman but may include:
- Infertility (not able to get pregnant) because of not ovulating. In fact, PCOS is the most common cause of female infertility.
- Infrequent, absent, and/or irregular menstrual periods
- Hirsutism (increased hair growth on the face, chest, stomach, back, thumbs, or toes)
- Cysts on the ovaries
- Acne, oily skin, or dandruff
- Weight gain or obesity
- Male-pattern baldness or thinning hair
- Patches of skin on the neck, arms, breasts, or thighs that are thick and dark brown or black
- Skin tags (small, excess flaps of skin)
- Pelvic pain
- Anxiety or depression
- Sleep apnea (when you stop breathing for short periods)
Ideally, diagnosis should start with screening girls after they begin their periods. One study found that up to 36% of teenage girls had PCOS. Early diagnosis is important because women with PCOS are more likely to develop diabetes, heart disease, and endometrial cancer. The health impacts of PCOS, without any of those other diseases, should be addressed as early on as possible to improve women’s health and quality of life.
Unfortunately, diagnosis of PCOS is difficult because 1) women present differently and 2) there is no one test or measure for diagnosis. A PCOS diagnosis is made by ruling out all the other possible conditions which could cause the patient’s symptoms. Over the years there have been 3 classification systems developed for diagnosing PCOS. The latest diagnostic criteria, created by the Androgen Excess Society in 2006 state that in order to be diagnosed with PCOS you must have:
1. Ovulatory and menstrual dysfunction. Assessed by you tracking/reporting your history.
2. Hyperandrogenemia - High levels of androgens in your blood. Assessed with a blood test.
3. Clinical features of hyperandrogenism - high levels of androgens. Typically the increased hair growth/acne.
4. Polycystic ovaries. Assessed by ultrasound viewing (the same kind used to see a baby) usually through the vagina.
This criteria emphasize the increase in androgens as a key component of PCOS. Women can have menstrual dysfunction and/or polycystic ovaries on ultrasound but NO increase in androgens and thus do not have PCOS. However, there is currently not enough research to say what level of androgens can be diagnostic of PCOS. Even though it didn’t make it to this updated criteria, insulin resistance is also usually tested when a woman is suspected to have PCOS.
Implications of PCOS
A woman diagnosed with PCOS is also at an increased risk for infertility, dysfunctional bleeding, endometrial carcinoma (cancer), obesity, type 2 diabetes mellitus, dyslipidemia (high cholesterol), high blood pressure, and possibly cardiovascular disease. Women with PCOS are 3-7x more likely to develop diabetes compared to women without PCOS due to insulin resistance. Women with PCOS are also more likely to miscarry, as high levels of insulin in the blood prevent the creation of two key factors needed to maintain a pregnancy.
Treatment varies based on your symptoms and whether or not you want to get pregnant. The most advocated for change is diet and exercise. Even a 5-10% decrease in body weight can help to regulate your periods, reduce insulin resistance, reduce excess hair growth, and improve fertility. I suspect the reason for all these changes is that diet and exercise control insulin which helps to break the cycle of PCOS.
One of the most common treatments is oral contraceptives because it regulates your period and can reduce the effects of excess androgens. For more information about birth control pills, check out this post. Another commonly used medication is metformin, to regulate insulin. There are also medications which make your body more sensitive to insulin. As with any medication, there are side effects which range from minor to troublesome. Talk to your doctor about the possible side effects and what you are experiencing.
There are a few surgical procedures which are reserved for women who have failed other types of treatment and who are trying to get pregnant. The goal of these surgeries is to break down the excess cystic tissue. It’s unclear exactly why these surgeries work but there are a couple minimally invasive techniques available.
For women who are trying to get pregnant and who have not had success with diet/exercise and other medications, there is also in-vitro fertilization (IVF) and in-vitro maturation (IVM). With IVF, the sperm and egg are manually combined in a dish and then placed into the uterus. For more information about the process of IVF you can read this article.
If you suspect that you may have PCOS, speak with your healthcare provider about it. Find a provider who has worked with other patient's with PCOS. This is especially important if you are trying to become pregnant.
See below for an awesome infographic about the basics of PCOS!
Pathology: Implications for the Physical Therapist. 3rd edition, by Goodman and Fuller.
Best methods for identification and treatment of PCOS. Minerva Ginecologica 2010. Available at https://www.researchgate.net/profile/Paolo_Artini/publication/41578798_Best_methods_for_identification_and_treatment_of_PCOS/links/02e7e5243fb7f2ea9c000000.pdf
US Department of Health and Human Services, Office of Women's Health: PCOS FAQ. Last updated 2010. Available at: http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html