Polycystic Ovarian Syndrome, or PCOS as it is known, is a common problem among women of reproductive age. The name of the syndrome comes from the fact that most women affected by it have enlarged and multicystic ovaries. Try as we may, doctors and scientists cannot seem to change the name of this syndrome, even though it is now felt to usually result from a metabolic disorder, not an ovarian abnormality. It is one of the most common causes of female infertility, as well as the most likely cause of irregular menstrual bleeding in non-perimenopausal women. It is now believed to be a strong indicator of risk for diabetes and heart disease, as well as uterine cancer and possibly breast cancer.
PCOS is best described as the chronic absence of regular ovulation (anovulation) in the presence of increased androgens or “male” hormones. Women who are affected often have very irregular periods, commonly skipping for months at a time, and symptoms of androgen excess such as acne or facial hair. Obesity or being overweight is also common, but not always seen in women with this disorder. Often, a central pattern of fat distribution is seen (mainly in the abdomen), with waist to hip ratios greater than 0.72. The diagnosis can only be made if other causes of anovulation have been ruled out.
Any woman who is skipping her periods and/or having heavy irregular bleeding should be considered at risk. Assuming a woman has the symptoms of irregular periods and acne or increased facial hair, the best way to diagnose PCOS is to rule out other causes of abnormal bleeding. Many women are first evaluated for PCOS after they have tried unsuccessfully to conceive. Blood tests, such as testosterone levels, thyroid hormone levels, abnormal prolactin levels (a substance that supports breast milk production), and blood assessment of adrenal gland function are helpful. Your physician will be looking for signs of metabolic problems such as abnormal cholesterol profiles and high blood pressure. Pelvic ultrasound may be helpful, but the isolated finding of cystic ovaries can be normal for many women without PCOS. This being said, if lab features and physical findings are suggestive of PCOS, many affected women will have ovaries that have multiple small cysts visible on ultrasound. The classic finding is one in which the cysts are distributed around the perimeter of the ovary like a “string of pearls.” These multiple cysts are the result of too much androgen hormone (male hormone) keeping the follicles, or eggs, from reaching full maturity.
There is much written about treatment for PCOS and drug companies have answered the demand for treatment with many options. This is helpful, but the mainstay of treatment begins with you.
The first rule is: CHANGE YOUR DIET. If you are affected by PCOS, you probably have some problems with carbohydrate metabolism, even if all of your blood sugar and insulin levels are measured as normal. Avoid all processed starches and minimize sugar. A good rule of thumb is to avoid the “white stuff.” White flour, pasta, rice potatoes, bread and sugar. Learning about the glycemic index can be extremely helpful. This is a measure of how foods stimulate insulin in your body. It is now felt that insulin resistance may be the root cause of PCOS. Helpful books include: Fertility Foods, by Dr. Jeremy Groll, The South Beach Diet, and Sugarbusters! Most studies indicate that lowering insulin levels helps to correct irregular ovulation associated with PCOS, even in lean women.
The second rule is: EXERCISE REGULARLY (at least 150 minutes a week). Exercise lowers insulin levels even in the absence of weight loss. This can help lessen the risk of diabetes, which is higher for women with PCOS, as well as help correct cholesterol and other lipid abnormalities commonly seen with this disorder. This may be why exercise has been shown to lessen menstrual abnormalities of all types. Anovulatory women may start having regular periods just from initiating good eating and exercise habits. To not do so is to simply patch the problem without a real correction of your metabolism.
After the first and second rules, there are many treatments depending on whether or not you are trying to get pregnant. If not, low-dose contraceptives such as the pill or the ring can reverse many of the symptoms, lessen irregular bleeding, suppress ovarian cyst formation and suppress facial hair and acne. If you are trying to become pregnant, you may need medications to help you ovulate. Many women may benefit from the addition of drugs, such as one called Metformin, to increase insulin sensitivity. The outlook is very positive with these treatment approaches. Advances in medications to induce ovulation and regulate blood sugar are extremely important, but they are in no way as significant as the lifestyle approach to this disorder.
The underlying metabolic disorder associated with this syndrome is one of the most common causes of heart disease, diabetes, and many malignancies. PCOS is really part of a spectrum of diseases now known to lead to the most severe example known as Metabolic Syndrome. The findings with Metabolic Syndrome include at least three of the following:
- High blood pressure
- High triglycerides
- Low HDLs (the “good” cholesterol)
- Abdominal fat pattern (circumference greater than 35 inches)
- High fasting blood sugar
This syndrome is associated with premature death from a number of causes, as well as increased risk of dementia. The high insulin levels associated with this disease can act as a growth hormone on tissues such as the uterine lining and the breast, resulting in cancer of these organs. If you think you may have PCOS, ask your provider about testing you. Finally, please remember, you are in control of the most effective treatment…your lifestyle.