By Dr Lizle Oosthuizen, MBChB (UCT), FCOG (SA), Mmed (UCT)
Polycystic ovarian syndrome (PCOS) is a common medical condition in women. Some of the latest data estimates 8-13% of women are affected, with 70% of affected women remaining undiagnosed. With a broad range of symptoms, this condition is both misunderstood by patients and doctors alike, so let us get into some questions a lot of patients have about the condition!
What is PCOS?
Polycystic ovarian syndrome is more complex than many people think, and it can cause more symptoms than just irregular periods. PCOS may present in a few ways, including irregular or absent periods, signs of increased testosterone (acne, excess body hair), and/or characteristic appearing ovaries on ultrasound. It is NOT a condition of multiple cysts on the ovaries – many patients panic they have cysts; this is a misnomer and simply a part of the name.
What are the symptoms of PCOS?
It is important to note that there are many ways in which PCOS presents, and not all women will have these symptoms. More importantly, not all women will go on to develop these symptoms. A diagnosis of PCOS does not mean a woman will definitely struggle with fertility, hair growth or weight loss.
Symptoms include irregular periods or the absence of a period, acne, and excess hair growth. PCOS can also be associated with a metabolic syndrome that may include difficulty losing weight, insulin resistance or Type II Diabetes, and raised cholesterol.
Women may have difficulty conceiving as many women with PCOS have what we call an ‘anovulatory’ cycle (i.e. they do not ovulate each month). This, besides causing irregular bleeding, also makes it harder to fall pregnant – if you don’t ovulate, there is no eggs for the sperm to fertilize.
What causes PCOS?
We don’t fully understand this yet. There is often a trend in a family to have PCOS, so we think there is a genetic aspect, but there is ongoing research into the exact cause. We do know weight loss can improve the symptoms. Similarly, some patients may only develop symptoms after a period of weight gain.
Can the onset PCOS be prevented?
Currently, we can’t prevent the development of PCOS. Maintaining a healthy lifestyle and a healthy weight does help in the management of PCOS, so avoiding gaining weight may prevent some of the symptoms and complications. Minimizing your refined sugar intake can also be helpful in managing any insulin resistance you may develop.
How is PCOS diagnosed?
PCOS is diagnosed by having two out of three of the following criteria:
- irregular or absent periods;
- clinical (acne/increased hair) or biochemical (blood test proven) signs of increased androgens (androgens include hormones like testosterone); and
- the appearance of the typical polycystic ovary on ultrasound.
We have to be sure that the problem is in fact polycystic ovaries as many things can masquerade as it. We do a panel of blood tests, but these are not to “diagnose” PCOS, rather to identify associated problems (such as insulin resistance or high cholesterol) and to exclude other conditions that can present just like PCOS.
Can PCOS be cured or only managed?
It can be managed. As the symptoms are what bother women, we can manage these and therefore it can appear to fix the problem. The symptoms can also improve with diet and weight loss, but if a patients gains a significant amount of weight, the symptoms will probably reappear.
How can you treat PCOS?
Treatment is multifactorial and addresses the metabolic side, the future health concerns and the current symptoms.
Irregular cycles can be managed with multiple strategies. Commonly we prescribe an oral contraceptive pill to regulate the cycle in patients who do not currently want to be pregnant.
We can also use progesterone in a cyclical pattern (a few days of the month) to cause a withdrawal bleed once a month. This “return of a regular cycle” is often misunderstood as a way to ovulate – this is not true; it is simply causing a regular bleed.
We also sometimes use a Mirena intrauterine device. This is best in women not planning on falling pregnant soon or currently desiring contraception. Although it usually takes away the period, it does this by thinning the lining of the uterus and preventing a bleed. It is very different to not having a period on your own.
The reason we want to have a regular period OR a medically induced “absence of a period” is the future risks of PCOS. If a woman does not have frequent periods, she is at risk of developing cancer of the uterus lining when she is in her 40s and 50s.
The theory is that because the lining is not bled away every month, it has a higher chance of eventually undergoing a cancerous, or precancerous change. Most women who take a contraceptive that takes away a period will then panic – this a very different situation. When we medically take away a period using a contraceptive, the lining is not building up every month, and so there is actually a lower risk of uterine cancer.
We can treat the high testosterone-like hormones too. If a patient is on a contraceptive pill, usually these androgen levels will drop. If the patient has complaints such as acne or excessive or unwanted hair growth, we can use specific contraceptive pills (such as Diane or Ginette) which contains a special type of progesterone to act against the androgen levels.
We have multiple other medications we can also use to reduce androgen levels, but these need to be monitored closely by your doctor and should be used with contraception. If you are pregnant and taking strong anti-testosterone drugs, you may prevent a male fetus from developing normally. The best approach to excessive or unwanted body hair will always be laser treatment, as although we can prevent further hair growth and slightly reduce what is already there, we can’t completely undo the hair growth.
High insulin levels and Type II Diabetes can be managed with medication and lifestyle changes. Fertility treatment is also offered to couples trying and struggling to conceive.
Can you make lifestyle changes to manage PCOS?
Yes, you can! Weight loss and exercise are very important. A loss of 5-10% of body weight can make a dramatic difference to symptoms and even result in a regular cycle. A diet low in refined carbohydrates should be followed. Many dieticians are well trained in the best approach to diet in PCOS. Heart health is very important and a healthy lifestyle with exercise will also help to keep the heart healthy.
What can happen if you do not treat PCOS?
Worst case scenarios are uterine cancer later in life, heart disease, diabetes, and raised cholesterol. Quality of life is a major concern and the risk of anxiety and depression as a result of the physical manifestations of PCOS and difficulty conceiving also need to be considered. It is important to consider the effect on body image, self-confidence, sexual relationships as well as your emotional relationship.
How does PCOS affect fertility?
In PCOS, irregular periods are often caused by the lack of reliable ovulation. Ovulation is the process of releasing the egg and should occur once per cycle. If you are not ovulating, there is no egg for the sperm to fertilize.
We have multiple medications we can prescribe to assist with inducing ovulation. This is not something that should be asked for from your doctor without correct monitoring. The medication needs to be monitored with ultrasounds in every cycle it is used. Some women may not respond at all to a certain dose, some may over respond and be at risk of a multiple pregnancy (such as triplets or quads!).
Many patients expect their doctor to write a prescription for them for six months. However, fertility is more complex than this and just because you don’t ovulate, doesn’t mean there isn’t another issue with falling pregnant that should be dealt with. Drugs like Clomid, Femara and injectable medications should be prescribed by a fertility specialist. Your fertility doctor will also be able to advise you when other strategies need to be tried.
Is PCOS becoming more common?
Recent work on improving guidelines and diagnostic criteria have meant that we are better at diagnosing it. Women are also more empowered and informed, and they are asking their doctors to look for the condition. Ultrasound machines are more available and better in quality, making diagnosis more reliable.
One aspect to consider is the fact that our society has never been more overweight. As our health is declining, more women who would have been controlled PCOS patients are probably tipping into the syndrome.
The most important message I always want readers to take home about PCOS is that if you are experiencing these symptoms, then alert your doctor to them so that you can be properly investigated. Help is available and we are able manage to improve the symptoms and quality of life of patients with PCOS, so don’t be afraid to ask for help!