PCOS = Polycystic Ovarian Syndrome
What is PCOS?
PCOS is a disorder of the endocrine (or hormonal) system that we currently still have a poor understanding of. We know that it causes a cluster of characteristic symptoms including irregular periods, acne, excess hair & excess weight.
Who gets PCOS?
PCOS affects 12-21% of cis-women of reproductive age. It is estimated that up to 70% of women with the disorder remain undiagnosed.
How is PCOS diagnosed?
Diagnosis is based on the presence of 2 out of 3 KEY features, provided certain other hormonal conditions have been ruled out.
Feature 1: Irregular (or no) periods, or periods lacking ovulation Feature 2: Signs of excess androgens (‘male hormones’ - see coming post), e.g. acne, excess hair, high androgens on blood tests Feature 3: Polycystic ovaries on ultrasound scan
Cyst can be a scary word, & to have LOTS of them 😬 … but a cyst is just a medical term for a sac of fluid (no you’re a cyst). In PCOS, ‘cysts’ are due to eggs not being released over time. The normal follicles that would normally be released each month keep growing, forming multiple ‘cysts’. Follicular cysts do not cause harm in of themselves.
Other features of PCOS (that are common but not part of the diagnostic criteria): > infertility (as a result of irregular ovulation) > increased propensity for excessive weight gain > increased risk of diabetes (independent from any risk from excess weight) > increased risk of mental health disorder
Tests for PCOS?
Ultrasound scan: not required if features 1 & 2 present but often performed; usually a vaginal pelvic US unless not sexually active; not useful for diagnosis in the first 8 yrs after first period as often normal to have polycystic ovaries Blood tests: for hormone levels, to rule out other causes of irregular periods such as thyroid & to assess for diabetes & cardiac risk
Tests for PCOS cannot be done while on hormonal contraception (need to stop for 3 months for the tests to be meaningful).
How is PCOS treated?
Because we still don't know the underlying cause of PCOS, avail. treatments target PCOS features only. Just like everyone else, healthy diet & regular exercise are key to staying healthy but are also vital in the management of many PCOS features. PCOS has a significant impacts on physical & mental health /wellbeing & carries with it increased risks of chronic diseases including cardiovascular disease, diabetes, depression, eating disorders & other psychosexual dysfunction. There is also a slight (but still low) increased risk of endometrial cancer. Care of patients with PCOS requires long term primary care with a good GP as well as multidisciplinary support where indicated e.g. psychologists, dieticians, exercise physiologists. Women with PCOS are often eligible for a care plan & team care arrangement with their GP to help with access to these allied health professionals for comprehensive health care. See your GP :-) Treatment options:
1. Irregular periods: > lifestyle interventions such as exercise/ healthy diet for 5-10% weight loss (if appropriate) > the pill > metformin
2. Infertility: > healthy lifestyle interventions > medications for ovulation induction e.g. metformin, clomiphene, letrozole > assisted reproductive technologies/ surgery, e.g. IVF > early family initiation (where appropriate/ possible) to improve conception chances
3. Hirsutism (excess hair) > laser (or other) hair removal > the pill (can take 6-9 months for effect) > anti-androgen therapy (needs to be used with contraception) > can combine pill with anti-androgen therapy
4. Cardiometabolic (heart/ diabetes) risk > healthy lifestyle interventions > optimise other risk factors, e.g. quit smoking > metformin to reduce diabetes risk
5. Excess weight > healthy lifestyle interventions > metformin > surgery 6. Psychological issues: > healthy lifestyle interventions > psychotherapy where appropriate > medications e.g. anti-depressants if appropriate
Hormones in PCOS
1. Hyperandrogenism (high androgens) Androgens are “male” hormones but they are produced in both women & men just in differing amounts. The two main types are testosterone & androstenedione. In POCS, these are elevated above the normal (cis) female levels. It causes symptoms such as excess hair & acne and probably the multiple cysts in the ovaries.
2. Neuroendocrine abnormalities Reproductive hormones in women are controlled in a feed back loop involving gonadotropin releasing hormone (GnRH) from the brain, lutenising & follicle stimulating hormones (LH & FSH) from the pituitary gland & oestrogen & progesterone from the ovaries (still with me?). In PCOS, due to changes in pulses of GNRH from hypothalamus in the brain, there is an imbalance in the normal ratio of LH to FSH which may underlie the androgen excess. What we don’t know is the cause of the faster GnRH pulses in women with PCOS.
3. Insulin resistance & diabetes Women with PCOS have higher degrees of insulin resistance that women without PCOS when matched for BMI/ fat stores. That is women with PCOS are more prone to diabetes which is separate to the risk from any excess weight. The cause of this increased risk in PCOS is not known. Higher levels of insulin also worsen the high androgens & the ovarian cysts.
4. Antimullarian hormone This is a hormone involved in the development of the male sexual reproductive tract in the embryo & it is also produced normally in the ovaries during reproductive yrs. It is often elevated in women with PCOS & may be used in the future as part of diagnosis. There is also a suggestion from mice studies that exposure to higher than normal AMH in utero may lead to PCOS.
So in summary, there are several interlinked hormonal imbalances in PCOS & we mostly know how these lead to PCOS features but we are still in the dark as to the root cause of the hormonal imbalances & way more investigation is required before we can target anything more than the outcomes of these imbalances.
International evidence-based guidelines for the assessment & management of PCOS 2018.