Polycystic Ovarian Syndrome (PCOS)
If I had to choose a favorite “disease process" to manage, polycystic ovarian syndrome (PCOS) would be on my top 5 list. I know that sounds crazy, but in my training, I was always drawn to dysfunctions of endocrinology, but this syndrome is a bit more than that. It’s complex and can lead to cascade of factors that can affect so many different parts of the body, and what’s even more crazy, the problem is not even caused by the ovary! You could have your ovaries removed and still have polycystic ovary syndrome or PCOS. Heck, I’m going to go one step further. You can be a man and still have PCOS!
One out of 10 women have PCOS. It was first discribed in the 1930's. When PCOS was first “discussed,” doctors knew that this collection of symptoms happened in women with larger than average ovaries. For example, an average ovary may be 3 -3.5cm. A PCOS ovary will be about 4.5cm. It’s not huge and neither are the cysts. There are multiple cysts present but all are about 1cm or less, thus the name polycystic ovary.
Ladies with PCOS were often identified at the time of their inability to become pregnant. The symptoms that go along with this syndrome are weight gain, infrequent or no periods, difficulty getting pregnant, acne, and male pattern hair loss and hair growth. Many women don’t have all of these, at least not at first.
What we now know about PCOS is that it is genetic. It is actually a disorder of insulin resistance. There are teenagers that have this and don't know it because it hasn’t yet manifested completely, and there are 50+ year olds that have this and don’t know it. They never got the diagnosis early in their life because the syndrome was not completely understood.
What else is involved in PCOS? Women with PCOS have a higher fat mass around the visceral organs than women who do not have it. Even “skinny” PCOS patients have a higher fat mass. This fat mass leads to the insulin resistance. This leads to glucose issues. Glucose levels rise in the body, eventually to diabetic ranges over time. This leads to more fat and causes hormonal alterations that cause high androgens (testosterone) and hinders ovulation. It also leads to chronic inflammation over time. This inflammation disrupts other important body functions. Patients then develop high blood pressure, cholesterol issues and, eventually heart and blood vessel disease, thus increasing the risk for heart attack and stroke. This is the cardiometabolic disease of PCOS and why I said earlier that men can have PCOS. (BTW: insulin resistance, chronic inflammation, and cardiometabolic issues in men causes issues with testosterone levels and erectile dysfunction.)
The hormones are also affected by the insulin resistance. PCOS ladies have estrogen but not enough progesterone. The progesterone is made after ovulation. No ovulation; no progesterone. Estrogen without progesterone causes the lining of the uterus to over grow and then over time can lead to cancer of the uterus.
How is PCOS diagnosed? The strict criteria at this time is to have 2 of the following 3 signs/symptoms:
1. Multiple cysts on the ovaries. There is a pattern they form on the ovary that looks like a string of pearls on the ultrasound.
2. Androgen excess. This may be elevated testosterone levels or signs of elevated testosterone like male pattern hair loss or hair growth.
3. Infrequent or no periods.
What do you do about it? There is not a quick fix or a cure for this. PCOS is a life long diagnosis that requires management. The very first thing any physician will tell you is that you need to reduce the fat mass. “UH, diet! Everything is about diet!” to quote a patient once. Look, I get it. I understand how something that should be so easy can be so difficult! However, let’s look at this.
We know that in order to break insulin resistance, lower carb diets work great. Few carbohydrates around will not stimulate a large need for insulin and will also prevent high glucose levels. You can do this with a ketogenic diet if you do not have a contraindication to that type of diet, or you can do that with a protein rich, low carb diet (be careful; protein can convert to carbs if you eat too much). I have seen patients do a low carb diet or a ketogenic diet, and within a few months, even with a 5-10% weight reduction, have their periods back or become pregnant, with NO medications!
Weight reduction is good for insulin resistance too. Studies have shown that it doesn’t matter how you lose the weight. The recommendation is to lose it like you’ll live it. So, if keto is your thing, great! However, if Weight Watchers, Whole 30, a completely plant based diet is what you love and you thrive on one of those, then do that. You have to eat this way the rest of your life. You’re gonna need to like it. Again, just a 5-15% reduction in weight will do wonders for a large number of women!
Ya’ll know I’m now a nut for the gut. I am a HUGE believer in optimizing gut bacteria and function for improvement of overall health. PCOS is no different. The very least one could do is to follow a “no sugar, no flour” diet. That would be the first and easiest thing to do. After that, see if eliminating other foods make you feel better. If you really pay attention to what you feel like and what your body does 30-60 minutes after eating certain foods, you’ll know if it’s a food to keep in your diet. Some symptoms that will alert you that have a food sensitivity may be sinus congestion, foggy head, fatigue, itching, irritability, euphoria followed by a crash, etc.
There are three supplements that every woman with PCOS should be on.
1. Fish oils – I would recommend an omega 3. These help to reduce inflammation in the body, improve insulin sensitivity, and improve mood. Women with PCOS have higher rates of depression than women who do not have PCOS.
2. Inositol – This helps to reduce insulin resistance
3. Vitamin D3 – For a PCOS patient, you want your blood vitamin D levels to be 110-120. Again, vitamin D improves insulin sensitivity, inflammation, and mood.
Other supplements that may be helpful:
1. Saw Palmetto, Stinging Nettle, EGCG from green tea – You may recognize these as supplements that men use to prevent hair loss or to help an enlarged prostate. These supplements can help reduce the amounts of testosterone you have from being converted to dihydrotestosterone (DHT). DHT causes the unwanted hair growth and hair loss.
2. Adrenal support supplements – Supplements like Ashwagandha, cordyceps, or Asian ginseng help support the adrenal gland and can help normalize cortisol production. This can help with increased abdominal fat, sleep, energy, and mood.
Some women may need medications.
1. Metformin is great at helping insulin resistance. I have seen women’s cycles resume or pregnancy occur with its use alone.
2. Spironolactone helps with the facial hair growth.
3. Birth control pills can help regulate the cycle if a woman is not trying to get pregnant. This will also decrease the risk for uterine cancer. However, this may not be the best choice for a woman with high blood pressure, cholesterol/triglyceride issues, and/or diabetes.
4. For women with cardiometabolic symptoms, progestin or progesterone therapy can be used. I prefer progesterone therapy if the patient can and is willing to pay for it. A Mirena IUD can be used too. It has a progestin releasing sleeve that delivers the progestin directly to the lining of the uterus and decreases her risk of uterus cancer without affecting too many of the other functions in the body. It can help with the heavy bleeding they get after going so long with no period, and if they happen to need birth control, it’s great for that too.
5. Clomid is used for infertility. Some women are resistant to clomid and need to do IVF. I do want to note that if a patient does IVF, studies have shown they are more successful if they have been on a diet that decreases insulin resistance and inflammation in the body. The placenta (think of it as a collection of blood vessels) can form better, grow better and be healthier when it can form in an environment that is no longer conducive to cardiovascular disease. This reduces the risk for pre-eclampsia, growth restricted babies, birth defects, pregnancy loss/miscarriage, and stillbirth.
If you have PCOS, these are some things you can do to minimize its affects on your life. Remember, there is no magic pill. If you think you have PCOS, speak to your GYN about it. Blood work and an ultrasound can be done. The interesting thing about this syndrome it that you can be tested for it in your 20’s and it not show it, then be tested for it in your 30’s and the findings now support the diagnosis. For me, if I see a woman whose history and physical is very suggestive of PCOS, I will go ahead and begin to manage her like a PCOS patient. Early intervention with her food choices and the addition of important supplements will help her future fertility and health. She will gain education and options early in the process for lifelong management and prevention of serious complications later in life.
Disclaimer: While I am a doctor, I am not your doctor. The information in this blog post is for information and entertainment and not intended as medical advice!