Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome (PCOS)

What is Polycystic Ovarian Syndrome (PCOS)?

Polycystic ovarian syndrome, also known as PCOS, typically affects women during their reproductive years. This condition is a common endocrine system disorder causing enlarged ovaries (or ovarian cysts, often with multiple cysts present, hence the name ‘polycystic’) that each contain follicles (small accumulations of fluid). Typically, these can be seen during an ultrasound scan.

With this condition, sex hormones (androgens, such as testosterone) in a woman’s body are out of balance, causing follicles to develop. These hormones, as well as oestrogen and progesterone cause the ovaries to enlarge, forming benign masses (follicles). The fluid-filled follicles in the ovaries don’t break open, and thus affect the ability of mature eggs to be released. Instead, the eggs band together and form tiny cysts or fluid-filled follicles which resemble a string of pearls when viewed on an ultrasound .

One hormone change affects another, and another. As a condition, the effects of this cause an imbalance in a woman’s menstrual cycle (interfering with the growth and release of eggs from the ovaries), her fertility, physical appearance and even cardiac function.

A woman with polycystic ovarian syndrome will often experience extended or sporadic (sometimes absent) menstrual periods (a monthly cycle whereby a woman’s ovaries release eggs during ovulation to prepare the uterus for pregnancy), hair growth (abnormal body hair and facial hair, medically termed hirsutism ), acne, and even excessive weight gain (obesity) as a result of enlarged ovaries.

It is not entirely clear why this happens, but PCOS can be successfully treated when picked up early, reducing the risk of long-term complications, such as heart disease and even diabetes (type 2) which can happen with excessive weight gain.

PCOS is a fairly common hormonal condition for many woman of childbearing age around the world, affecting between 5 and 10% of the global female population, and is a frequent cause of infertility.

Illustration showing a normal versus polycystic ovary

What causes PCOS?

It is still to be determined what the exact cause of PCOS really is. One thing that all medical professionals can agree on in all instances of PCOS, is that a hormonal imbalance is the main influence in the body that causes the disorder.

A woman with PCOS typically has an overproduction of the male sex hormones, androgens in her body. While women’s bodies normally produce these hormones, women with PCOS have an excess amount of it in the body. As a result, the overproduced hormone affects the natural development and release of eggs during ovulation.

Another contributing factor is an excess production of insulin in the body. Insulin is another hormone, naturally produced in the pancreas that helps convert sugar (glucose) and starch to energy, while also regulating cell functionality and growth.

When there is insufficient insulin in the body, or the body cannot utilise it effectively (i.e. the body becomes insulin resistant), blood sugar levels increase and this can lead to a host of complications and the development of conditions such as cardiovascular disease and diabetes.

Elevated insulin levels, in turn lead to higher levels of androgen hormones like testosterone in women which are responsible for the irregular periods, increased hair growth and acne associated with PCOS.

Other common factors include:

  • Genetics: It has been noted that many women with the condition have a mother or sister with similar imbalances too. Extensive research is being conducted to find a possible link between certain genes in families, especially in mothers and sisters of women with PCOS. There does appear to be a higher probability of the condition developing if close female family members have the disorder.
  • Low-grade inflammation: The body produces white blood cells as a natural means to fight off infection or fever. Typically, women with PCOS experience low-grade inflammation (a neuroendocrine or immune system response to adverse or damaging stimuli) in the body which leads to the overproduction of androgen hormones, and in turn stimulates polycystic ovaries.

Illustration showing a follicular cyst on an ovary

How does PCOS affect the body?

PCOS affects a woman’s body in these three key ways:

  • Excess androgen production: High levels of androgen hormones cause excess facial hair or abnormal hair growth on the body, as well as acne and androgenic alopecia (male-pattern baldness).
  • Irregular or imbalanced menstrual cycles: Ovulation doesn’t happen in predictable patterns and menstrual cycles can be irregular (sometimes with intervals longer than 35 days, or with prolonged and heavy bleeding), infrequent (fewer than 8 periods in a year) or absent altogether for 4 consecutive months (or longer) – this is known as amenorrhoea.
  • Polycystic ovaries: Enlarged and fluid-filled follicles or sacs on the ovaries.

Common signs and symptoms of PCOS

PCOS typically begins to show signs once a young woman begins to menstruate for the first time (during puberty when hormonal changes typically start). It is normal for a young girl / woman to experience irregular menstrual periods (heavy or irregular bleeding). The severity of this irregularity and other symptoms varies from one female to another. Other PCOS symptoms a young female will experience along with irregular menstrual cycles include:

  • Young woman with acne prone skinA deeper voice
  • Hirsutism - Excess hair on the face, as well as the chest area, stomach, toes and thumbs
  • Hair loss
  • A small or decreased breast development size
  • Acne and oily skin
  • Pain in the pelvic area 
  • Unexplained weight gain
  • Depression and mood swings
  • Infertility or repeat miscarriages
  • Hyperinsulinemia (too much insulin in the body) or insulin resistance
  • Skin tags 
  • Obstructive sleep apnoea (breathing problems during sleep)

It is not unusual for concurrent health concerns to develop along with excessive weight gain due to PCOS. These can include problems with hypertension, high cholesterol and diabetes. It is not advisable to take a wait-and-see approach when it comes to experiencing PCOS symptoms. Symptoms typically worsen with weight gain and an imbalance in levels of insulin in the body, causing complications. This is why it is important to seek medical attention for effective treatment, especially if you note excessive weight gain, abnormal hair growth or hair loss, severe acne and irregular menstrual cycles.

Young woman with hair loss

When should a woman seek immediate medical care?

  • If a woman experiences severe vaginal bleeding (bleeding is soaking through tampons or pads every hour for more than 2 hours)
  • A woman has any signs of diabetes (frequent urination, increased thirst, fatigue, unexplained weight loss, blurred vision, an unexplained increase in appetite, or a tingling / numbness in the feet and hands.)
  • Increased mood swings or depression as a result of emotional problems related to physical symptoms, such as obesity and abnormal hair growth or hair loss.

Whom should a woman see?

If a woman experiences any symptoms she may suspect to be related to PCOS, the following health professionals can all diagnose and treat the disorder:

  • General practitioner (GP) or family physician
  • Gynaecologist or obstetrician
  • Internist
  • Endocrinologist (including reproductive endocrinologists)
  • Physician assistants and nurse practitioners

Female endocrinologist testing woman patient at her consulting office

Diagnosing and treating PCOS

How is PCOS diagnosed?

To diagnose polycystic ovarian syndrome (PCOS), a doctor will take you through the following steps:

  • Medical history: A doctor will ask specific questions relating to a woman's overall symptoms (What are you experiencing? How long ago did you notice your symptoms? How often are you experiencing your symptoms? How severe are your symptoms?) to gather as much specific information as possible. He or she will discuss areas such as weight (Have you gained weight? How much have you gained?), the condition of hair and skin, as well as the nature of menstrual cycles (When was your last period? How frequent are your periods? Do you bleed heavily?). He or she may also ask if a woman is currently trying to get pregnant and experiencing any trouble. A doctor will need to know what medications and supplements are being taken, as well as get a good idea about eating and exercise habits. A woman may be asked to share specific details abouther family medical history (as much as she knows). Specific questions around this may include any known hormonal issues in the family (Has your mother or a sister been diagnosed with PCOS?) or diabetes. It is important to be as honest as possible, even though much of what is being experienced in terms of symptoms is highly personal, which can be very uncomfortable. Honesty will help the doctor to test appropriately and make the most accurate diagnosis in order to treat in the most effective way.
  • Physical exam: A doctor will then want to conduct some physical checks to help either diagnose or rule out potential causes. He or she will look at the thyroid gland, the overall condition of your hair and skin (including the chest or breast area and abdomen), as well as assess your BMI (body mass index). Your doctor will check your blood pressure and then request a pelvic exam. This will help the doctor determine if there are any abnormalities with your ovaries (particularly if they are enlarged).
  • Ultrasound: A doctor may then request a pelvic ultrasound to look at a visual of your ovaries and determine whether there are any follicles. An ultrasound won’t necessarily confirm PCOS as some women do not have follicles on their ovaries, but have other symptoms related to the disorder. An ultrasound will create real-time images of your reproductive system to assess any areas of concern or help to pick up any abnormalities which will be tell-tale signs of a malfunction in the body. If there are any growths spotted at this stage, a doctor may recommend a pelvic laparoscopy. This is a minimally invasive surgical procedure that allows your doctor to make a very small incision in the lower abdomen area. A tiny camera will then be inserted to get a better view of any potential growths of cysts. If it is determined that there are growths or cysts, more tools will be inserted to retrieve a small tissue sample (biopsy) to send away to the lab for further examination or testing.

Young woman having an ultrasound scan

What tests are involved?

A doctor may recommend several blood tests to examine the following:

  • Thyroid function: A blood sample may be used to assess how much thyroid hormones (thyroid-stimulating hormone / TSH) in the body produces and whether there are any signs of an overactive or underactive thyroid.
  • Blood sugar levels: A sample of blood will be used for a fasting glucose test to measure sugar levels. A doctor may also wish to check insulin levels and assess glucose tolerance levels to see if there any signs of abnormal function (such as insulin resistance). If there are any signs of possible diabetes as a result of PCOS, this test is more than likely to be recommended.
  • Cholesterol levels: A lipid level test will assess the amount of cholesterol and triglycerides in your blood. If there are strong signs that a woman’s blood pressure, cholesterol and triglycerides need to be checked frequently or if she is at higher risk of heart disease, atherosclerosis (hardening of the arteries), heart attack or stroke as a result of PCOS, a doctor may like to perform this test.
  • Sex hormone levels – Androgen, oestrogen, progesterone and testosterone.
  • Adrenal gland hormone levels: Problems with DHEA-S or 17-hydroxyprogesterone can lead to PCOS-like symptoms.
  • Prolactin (PRL) levels: A protein hormone that enables women to produce milk. These levels can also play a role in infertility or disrupted menstrual cycles.
  • hCG (Human chorionic gonadotropin): If a woman is sexually active, a doctor may wish to test if she is already pregnant before conducting further tests or prescribing a treatment plan.

Treatment for PCOS

Once diagnosed, a treatment plan is going to be one of focussed control. At present, there is no cure for PCOS. A doctor will make recommendations that will best manage the symptoms of the condition so as to reduce the risk or prevent possible complications, as well as make a woman as comfortable as possible to live her best life.

Treatment does tend to vary from one person to another, and largely depends on specific symptoms. Recommendations a doctor will make will involve the following:

  • Vegetarian rice salad with tofu and brown riceLifestyle: Diet and exercise habits will form a large part of the changes that will need to be adapted to for overall health and wellbeing. A healthy eating plan (that includes fruits, vegetables, whole grains and low-fat dairy) that is low-calorie or low in carbohydrates and regular exercise activity is highly recommended, especially those who are overweight. Carbohydrates shouldn’t be completely restricted. A woman may want to seek assistance from a dietician who can recommend carbohydrates which are high in fibre (whole-grain breads, whole-wheat pasta, whole-grain cereals, brown rice, beans, barley and bulgur wheat) as part of the diet plan. In this way food is digested slowly, and gradually stabilises your blood sugar levels. Maintaining this is also essential, in order to control a healthy weight, as well as help stabilise a menstrual cycle and balance out hormone levels. A good rule of thumb when it comes to exercise is to try and get in about 150 minutes’ worth of activity each week. A doctor will recommend that a woman does not smoke as this promotes higher levels of androgen in the system.
  • Pregnancy planning / birth control: A doctor will discuss options available when it comes to pregnancy. If a woman is not yet (or not at all) interested in starting a family, a doctor may prescribe oral contraceptive pills (birth control pills). These are known to help regulate a woman’s menstrual cycle, lower male hormone levels in the body and also treat acne. An alternative to birth control pills is the patch or vaginal ring which also contains oestrogen and progestin hormones. Both options are also effective for reducing the likelihood of falling pregnant. If a woman is wanting to get pregnant and have a baby, a doctor may prescribe fertility medications (hormone therapy) to stimulate ovulation, helping the body along. Any hormone medications taken to stimulate ovulation will usually be accompanied by regular ultrasounds and consults with a reproductive specialist to keep a close eye on your progress and reduce the risk of any complications.
  • Medications: Treatment in the form of medication will involve those that aid in reducing male sex hormone levels (this is known as anti-androgen medication). This will reduce excess hair growth and acne. If blood glucose and testosterone levels are high, diabetes medications may be prescribed to help stabilise this in the body. If a woman is working to lose weight through good nutrition and exercise, and is struggling to shed the kilos (or pounds), a doctor may prescribe medication to help stimulate ovulation in the meantime. Usually, reducing weight will help stabilise hormone levels and stimulate ovulation. Hormone therapy (which can include birth control pills) can also be effective in correcting menstrual cycle concerns. Oral contraceptives are also good with controlling hormones that can lead to a build-up resulting in uterine (or endometrial) cancer. Pills that contain both oestrogen and progesterone help to regulate menstrual cycles, decrease androgen production and thus correct abnormal bleeding.
  • Surgery: One option is ovarian drilling. This procedure may be recommended if a doctor feels it necessary to destroy part of the ovary with a laser or electrocautery (which involves ‘puncturing’ the ovary with a small needle that has an electric current or by using an electrode) as a short-term solution that may help stimulate ovulation and reduce male sex hormone levels. If a woman has been unsuccessful in losing a sufficient amount of weight and has had a poor response to medication, this procedure may be recommended. Another surgical option is an ovarian wedge resection. This procedure effectively removes part of the ovary in an attempt to promote normal ovulation and regulate a woman’s menstrual cycles. As an option, this procedure is rarely recommended as there is a risk of damaging the ovary and causing scar tissue. A doctor will discuss the benefits and risks of all surgical options, and these are generally only recommended if all other treatment options have not been successful. One such risk is scar tissue which can cause pain or fertility concerns later down the line. Some benefits may be temporary and not last the rest of a woman’s lifetime. A woman should ask as many questions as she needs to in order to be well informed about any recommended procedure before consenting to it. The more a woman knows, the better she will be able to understand her body and how to alleviate present symptoms and reduce the risk of future complications.

A doctor will advise regular check-ups so as to monitor the body’s overall condition and reduce the risk of developing further health complications such as high blood pressure, cholesterol and heart disease.

What are the most common complications of PCOS?

One of the main factors that can lead to more serious health concerns in those with PCOS is weight. If a woman with PCOS really struggles with her weight, other health concerns can arise, making her a high-risk patient. Common complications associated with excess weight or obesity include:

  • High blood pressure (hypertension) or pregnancy-induced high blood pressure
  • Diabetes (type 2)
  • Gestational diabetes
  • Elevated triglycerides / low high-density lipoprotein (HDL) cholesterol
  • Metabolic syndrome
  • Infertility
  • Abnormal uterine bleeding
  • Uterine / endometrial cancer
  • Endometrial hyperplasia (if a build-up and clearing off of the uterine lining during a period doesn’t happen each month, a precancer of the uterine lining occurs)
  • Non-alcoholic steatohepatitis (severe liver inflammation)
  • Sleep apnoea
  • Anxiety or depression
  • Heart attack (coronary artery disease)
  • Breast cancer

Complication risks in pregnancy

A pregnancy will be considered high-risk in a PCOS sufferer and the woman in question will be referred to a specialist with experience in these cases. The expectant woman will need to be carefully monitored throughout her pregnancy so as to reduce her risk of:

  • Gestational diabetes
  • Miscarriage
  • Premature delivery of the baby
  • Having a larger or smaller than normal baby

Are there ways to prevent PCOS?

An endocrine system disorder, PCOS cannot be prevented. Early diagnosis, effective treatment and lifestyle changes can help to lower a woman’s risk of developing any long-term health complications. This disorder is not yet curable, and is merely managed according to a woman’s symptoms throughout her life.

Facial laser hair removal

What can you do to manage excessive / abnormal hair growth?

For a woman, excessive hair growth in areas of her body that aren’t normal can be upsetting and uncomfortable. It can make a woman feel very self-conscious about her appearance and affect her self-confidence.

For a woman with PCOS, the best option in dealing with this symptom is to understand what is happening in her body so that she can better deal with its effects. When androgen hormone levels are high, hair growth in abnormal areas (the chest, stomach, toes and face) occurs. Medications will help to regulate hormones and decrease these levels of androgen.

A woman can still make removing unwanted hair part of her beauty regimen (and choose a method that works for her budget) in the following ways:

  • Electrolysis: Permanent hair removal process by means of an electric current that is applied to the hair root.
  • Laser hair removal: A process using a laser beam which destroys hair follicles.
    • Depilatories: A chemical hair removal product is applied to the skin in order to remove unwanted hair.
  • Waxing: Semi-permanent hair removal which pulls hair follicles out by the root.
  • Bleaching, tweezing and shaving

How will diet changes really affect PCOS symptoms?

One of the biggest changes a woman diagnosed with PCOS will make is an adjustment to her diet. What she puts into her body is of vital importance and has a direct impact on her body and in turn, the nature of her symptoms.

A healthy and nutritious diet will need to be a lifelong commitment. Aside from hair growth, weight gain in excessive amounts can also deeply affect a woman’s self-esteem and make her very self-conscious about her appearance. As well as the physical aspects of this, excessive weight, and even obesity can have a debilitating effect on a woman emotionally.

A woman can kill two birds with one stone (in a sense) by working with a dietician or nutritionist to develop the best diet plan for her overall health, reduce her size (and thereby the increased risk of other health complications) and improve her emotional and mental wellbeing.

The best place to start is to learn about how what one eats affects the body (and by extension the disorder). With abnormalities in hormone levels, insulin levels are higher than normal. This affects the function of cells in the body be able to process glucose (sugar) into energy which sustains a person throughout the day.

Without enough insulin in the body, blood sugar levels increase. A woman may also become insulin resistant as a result of an imbalance and become unable to process the amount the pancreas does produce effectively enough. As a result, the body attempts to regulate itself and maintain blood sugar levels at a normal rate by pumping out higher levels of insulin. Insulin resistance affects a woman’s weight and makes it more difficult for her to lose a sufficient amount.

The result of high insulin levels also directly affect a woman’s ovaries, causing an excess production of male sex hormones (androgens) such as testosterone.

To combat high insulin levels and abnormal or excessive hormone levels a woman with PCOS should look to add the following foodstuffs to her diet on a regular basis:

  • Ripe and juicy fresh picked blueberries closeupHigh-fibre foods such as broccoli, cauliflower, lentils, beans, red leaf lettuce, brussels sprouts, green and red peppers, berries, almonds, squash, pastas or pasta noodles (with lentil or bean flour), pumpkin and sweet potatoes.
  • Lean protein such as fish, tofu and chicken.
  • Anti-inflammatory foods such as tomatoes, kale, turmeric, spinach, olive oil, almonds, walnuts, blueberries, strawberries, spices and fatty fish, such as sardines and salmon that is high in omega-3 fatty acids.

As with introducing more high-fibre, lean proteins and anti-inflammatory foods, there are others which a woman can be more mindful of limiting or cutting out altogether from her diet. These foods will aggravate insulin resistance and lead to inflammation in the body which will worsen symptoms of PCOS. These foodstuffs include:

  • Refined carbohydrates such as white bread, muffins, sugary desserts, pastries, white potatoes, pasta noodles (which contain durum flour, durum wheat flour and semolina) and other foods made with white flour (i.e. cakes etc.)
  • Sugary foodstuffs that include sucrose, dextrose and fructose corn syrup, as well as juices (with added sugar) and sodas (Coke, Pepsi, and other carbonated drinks).
  • Inflammatory foods such as red meat, processed meats, French fries (chips) and margarine.

A change in diet will definitely be beneficial for a woman with PCOS. Once a woman’s settles into a new eating pattern, her overall health and mood will improve. It’s important to remember that just about every food that will exacerbate a woman’s physical condition and PCOS symptoms, generally has a healthier counterpart. There is no real need to feel that your diet is restricted. You’re just opting for healthier alternatives.

What is the outlook for a woman with PCOS wanting a baby?

An imbalance in the body and a disrupted menstrual cycle doesn’t necessarily mean that you will not be able to conceive and carry a baby. Hormonal therapies have been effective in inducing a more regular menstrual cycle and thus regulating the system to accommodate the changes that pregnancy brings with it.

How effective therapies are does vary from one woman to the next, and are variable among women with PCOS undergoing assistance with fertility specialists. In some cases, it merely comes down to weight. Some women may be able to achieve improved ovulation patterns with moderate levels of exercise, effectively reducing their weight and maintaining it.

Others require a little help in the form of medication and assisted reproductive technologies (fertility options) to help with conception. Age and other health concerns are a huge factor in the success rate of these kinds of treatments, but if ovulation stimulation is successful a high percentage of woman can conceive.

Pregnant woman sitting on bed and touching her belly at home

What should a woman be mindful of when it comes to PCOS and pregnancy?

PCOS is typically diagnosed and treated during a woman’s childbearing years. A woman wanting to have her own children need not feel that her condition will mean the end of her dream of becoming a mother. Women with PCOS can still have healthy pregnancies and babies. A woman will, however, fall into a high-risk pregnancy category and be carefully monitored. This is to ensure the safety of both mother and child as there are risks for certain complications during the 9-month gestation term, labour and delivery of the baby.

It is important that a woman with PCOS understand that her pregnancy will not be without risk of complications. Pregnancy-safe exercise and diet will also play a huge role in having a healthier experience and baby, as well as managing PCOS symptoms. Discuss everything with your doctor to ensure the best possible outcomes.

It may also be a little difficult for a woman to fall pregnant in the first place due to hormonal imbalances. Other physical aspects that may compromise a woman’s ability to fall pregnant relate to her weight. Obese women may need a helping hand with the use of reproductive technology. This can still be challenging and a small percentage have successful pregnancies. If you have been trying to conceive naturally for more than a year and find that you are struggling, speak to your doctor for advice and assistance. Your doctor will be able to give you all the information you need regarding the options available to you and also discuss strategies that may help to increase your chances of conceiving.

Risks and complications for women with PCOS wanting to get pregnant include insulin resistance, high cholesterol, hypertension (high blood pressure), heart disease, type 2 diabetes, gestational diabetes, stroke, sleep apnoea, uterine / endometrial cancer, preeclampsia (also known as toxaemia, this is a pregnancy complication characterised by high blood pressure), delivering a larger than normal sized baby (a caesarean may be necessary), a smaller than normal sized baby, and miscarriage.

A baby who is larger than normal in size also runs the risk of injury during delivery and may experience shoulder dystocia (when the shoulder gets stuck during birth). This is why a large baby will usually be delivered via caesarean and not natural birth.

Other risks for the baby include premature birth, meconium aspiration (or neonatal aspiration of meconium – a baby experiences respiratory distress when meconium, which comprises of substances such as amniotic fluid, bile, mucus and water accumulated in the womb, is breathed into the lungs during birth) and a lower Apgar score (the measure of a new-born baby’s physical condition that details heart rate, muscle tone, respiratory function, response to stimulation and skin colouration).

Another risk relates to female babies who have a higher chance of having PCOS (born from a mother with the disorder) themselves once they reach puberty and start menstrual periods.

Hormonal fluctuations during pregnancy will affect pregnancy and continue once a baby is born and a new mother begins breast-feeding. It may take some time for a woman to feel “normal” during pregnancy and breast-feeding, and settle into the changes both will bring physically and emotionally.

It is generally safe for a woman with PCOS to successfully breastfeed, but will depend on any medication prescribed to be taken as well. Insulin medication to help control blood sugar levels may not be problematic. Check with your doctor and discuss options that will best benefit you and your baby. Certain medications may be discontinued during pregnancy and breast-feeding, but overall if well monitored, your PCOS symptoms will not necessarily get in the way of a healthy pregnancy and baby.

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