Polycystic Ovarian Syndrome (PCOS)

Polycystic ovarian syndrome (PCOS) is a set of symptoms that occurs when you don’t ovulate regularly due to high androgens (hormones responsible for male-type characteristics).  It is normal for women to have some androgens, which are necessary for oestrogen production, libido and keeping bones strong.  However, during PCOS, excess amounts of androgens result in undesirable symptoms such as acne, male-pattern hair growth (hirsutism) and scalp hair loss.  They also interfere with ovulation, making the menstrual cycle irregular and causing difficulty with fertility.

If you’ve been diagnosed with PCOS you may have an image in your head that your ovaries are being attacked by cysts.  They are not.  The cystic appearance of ovaries during PCOS is caused by many tiny eggs trying to develop at the same time, instead of just one.  The hormonal feedback loop needed for ovulation malfunctions and none of the developing eggs reach the maturity needed to be released.  As a result you may not get your period for long stretches of time or you may have an irregular cycle.

Symptoms of PCOS

Other than irregular or infrequent periods, the major signs and symptoms of PCOS include:

  • Hirsutism: male-pattern hair growth, particularly on the belly, chin, upper lip, chest, back upper arms & inner thighs
  • Hair loss: thinning hair or male-pattern scalp hair loss
  • Acne
  • Anxiety and stress
  • Depression
  • Sugar cravings
  • Difficulty losing weight
  • Skin pigmentation (acanthosis nigricans): areas of thicker, darker skin with a velvety texture that tend to occur in body folds such as the neck and groin.
  • Trouble conceiving
  • Severe premenstrual syndrome (PMS)

Symptoms and severity vary from person to person and you may not have all of the symptoms mentioned above.

Do I have PCOS?

You need to see your doctor for assessment to find out if you have PCOS.  Diagnosis is based on the Rotterdam Criteria, which states that you must have at least two of the following:

  1. Irregular or anovulatory cycles.  This means your period does not come in a regular 21-35 day cycle or you do not ovulate on a monthly basis.
  2. Evidence of high androgens.  This includes clinical signs such hirsutism, acne and hair loss, or high blood levels of androgens.
  3. Polycystic ovaries on ultrasound.  Twelve or more cysts are seen on each ovary during a pelvic ultrasound.  As noted earlier, the ‘cysts’ are actually follicles that contain underdeveloped eggs .  If you have 12 or more underdeveloped follicles, it usually means that an egg will not be released that cycle; instead egg growth will be arrested and all the follicles will recede.  But all is not lost.  Your ovaries get a fresh go at ovulating the next month.  This is why they don’t remain cystic in appearance all the time, and the first two criteria alone are adequate for diagnosis.

Your doctor should also exclude other endocrine disorders before giving you a diagnosis of PCOS.  These include adrenal hyperplasia, hyperprolactinaemia, Cushing’s syndrome, thyroid disease, ovarian, pituitary or adrenal tumors, premature ovarian failure, hypothalamic amenorrhoea and ovarian hyperthecosis.

What causes PCOS?

Insulin resistance

Insulin is a hormone released by our pancreas in response to sugar (glucose) in our blood stream.  Insulin acts like a key to the door of our cells, allowing them to take the glucose in and use it as energy.  If you have insulin resistance it’s like the key doesn’t open the door very effectively and the glucose can’t get inside the cell.  Therefore, your pancreas sends out more insulin to try and get the job done.  The excess insulin in the bloodstream then stimulates your ovaries to make more androgens.

Weight

Being overweight worsens insulin resistance, exacerbating the above picture and the symptoms of PCOS.  Insulin resistance also causes excess sugar to be stored as fat rather than being used for energy and makes us crave sugar because your body thinks it is starving.  Hence the difficulty losing weight that many women with PCOS experience.  However, it should be noted that skinny women can have insulin resistance and PCOS too.

Heredity

It is thought that both insulin resistance and PCOS may have a genetic link.  Daughters of women with PCOS have a 50% chance of developing the syndrome.

What do I do now?

Once you have a diagnosis of PCOS you can choose how you want to deal with it.

Medical treatment

The standard medical treatment is the combined oral contraceptive pill.  This makes us have a regular monthly bleed (if we choose not to skip it) and blocks the effects of androgens with synthetic oestrogen and progesterone.  It does not fix the problem and when you stop taking the pill the symptoms come back.

This is problematic, particularly when one wants to conceive (the usual reason for coming off the pill) and may not be ovulating regularly.  The underlying cause still needs to be dealt with.  At this point treatment options usually involve metformin (an anti-diabetic drug for controlling blood sugar) and clomiphene citrate (a drug that stimulates ovulation).  If hirsutism is not controlled with the pill, anti-androgenic drugs may be added to the treatment regime.

Naturopathic treatment

Naturopathic treatments focus around the control of blood sugar and insulin through dietary modifications, herbal medicine and nutrients that increase the sensitivity of cells to insulin.  In addition, herbal medicine may be used to balance hormones and encourage the regular function of the menstrual cycle.

Dietary modifications are based around avoiding sugar and refined carbohydrates while including protein with every meal and an abundance of green leafy vegetables. Commonly used herbs and nutrients for insulin resistance include Goat’s rue (Galega officinalis), cinnamon, chromium, magnesium and inositol.  Herbs for hormonal balance include licorice, peony, tribulus and black cohosh.

Long term risks

The poor blood sugar control that goes hand in hand with PCOS can have consequences if left untreated.  Women with PCOS have greater risk of developing type 2 diabetes and cardiovascular disease.

Women with PCOS who experience infrequent periods (<6-8 per year) have an increased risk of endometrial cancer.

Women with PCOS have an increased risk of high blood pressure, pre-eclampsia and gestational diabetes during pregnancy and should be screened for these frequently in pregnancy.

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