This is a very common hormonal condition that affects 3-8% of the female population. As you may already know, PCOS stands for Polycystic Ovarian Syndrome; but it is a misnomer and it is time to change that!
The term “Cyst” understandably conjures an image of a benign or malignant growth (greater than 2 cm). The term “Cystic” in “Polycystic Ovarian Syndrome” is medically incorrect; does not convey accurate medical information; and creates undue anxiety for patients. For PCOS patients, there are generally numerous follicles visible by ultrasound of the ovaries. These are NOT cysts. A follicle is a normal ovarian fluid filled structure that holds an immature egg when it is 2 to 10 mm; and holds a maturing egg when it is 11 to 20 mm. We are talking millimeters; very small. The noteworthy feature by ultrasound for patients with this disorder is that there are 2 to 4 times the normal amount of follicles; consistent with the disordered egg maturation process; but all consistent with a favorable ovarian reserve.
Polyfollicular ovarian morphology (PFOM or PFOS) is a better term. We can take that one step further and have 2 subsets: PFOS-MD (With Metabolic dysfunction) and PFOS-HM (with hyper androgenic manifestations), as suggested by Dr. Rosenwaks. Alternatively, we could use the term Reproductive Metabolic Syndrome, as suggested by Dr. Teede. This later term, Reproductive Metabolic Syndrome serves to focus our attention on the task at hand: to improve metabolism.
Abnormal lab findings for PCOS/PFOS/ Reproductive Metabolic Syndrome:
Elevated insulin levels stimulate the ovary to make androgens which interfere with normal egg maturation and ovulation. Hence, the irregular and infrequent periods that occur for patients with this disorder. Twin studies reveal an70% heritability of PCOS. For patients with irregular cycles, the work up, done with Dr. Moomjy, must exclude: thyroid disease, elevated prolactin, and adult-onset congenital adrenal hyperplasia; and must confirm normal ovarian reserve.
Causes/Factors of PCOS:
The primary factor for this condition is an over production of androgen hormones by the ovary and/or by the adrenal. What is an androgen (you may ask)? Androgens are hormones made by men and women. Androgens start the process of puberty. For women, androgens circulate in much smaller amounts than in men. In women, androgens are converted to estrogens. In men, androgens at much higher concentrations are responsible for facial and body hair and sexual development. A slight increase of androgens for women can cause undesirable symptoms. Such an excess of androgens is stimulated by elevated insulin levels in more than half of the affected women. Alterations of the insulin hormone that make it less effective will cause the body to secrete more insulin to effect metabolism. The higher insulin level causes the ovary to produce more androgens that interfere with the process of ovulation. Ultimately, the higher androgens are converted to estrogens by the fat cells, that also interfere with ovulation at the level of the pituitary.
Symptoms:
For the Clinical diagnosis, most specialists will look for at least 2 of the following:
- Clinical or serum evidence of elevated androgens (other hormonal diseases excluded)
- Prolonged, irregular, or rare ovulation as in the setting of normal ovarian reserve
- Polycystic/polyfollicular appearance of ovaries on ultrasound. The picture on ultrasound has been called “String of Pearls” as the immature follicles crowd around the periphery of the ovary, like a string of pearls.
While adolescents may have irregular cycles after the first period; cycles are expected to be normally regular by the second year of menarche (menarche=first period). If irregular cycles persist in the later teenage years, this should be addressed by a physician, such as Dr. Moomjy.
Environmental factors are important in the expression of the involved genes, and presentation and progression of the disease. Environmental factors include weight gain, level of exercise, degree of sedentary lifestyle, and dietary choices (carbs vs protein, and total caloric intake).
Longer term general health concerns:
- Increased risk of endometrial cancer related to lower lifetime progesterone, which is related to less ovulatory cycles.
- Increased risk of diabetes in pregnancy
- Increased lifetime risk of diabetes (test with fasting and 2 hour GTT or Hb A1c)
- Increased risk of obesity, and with that, increased risk of elevated blood pressure, and heart disease
- Increased obstructive sleep apnea
Treatment:
- Exercise, like a part time job! Keep to a schedule, choose exercises/activities that are appealing to you.
- Calorie restriction diet, identify stress eating and address that.
- For those patients with insulin resistance, Metformin is an insulin sensitizing agent, that, in conjunction with diet and exercise, may facilitate weight loss, cycle regularity, and lower androgens.
- Work with a reproductive endocrinologist, such as Dr. Moomjy. It is clearly possible to control this PCOS, PFOS, Reproductive Metabolic Syndrome, and have a healthy life.
As weight loss occurs, there may be an improvement in ovulation and regular cycles, and stability or improvement of acne and abnormal hair growth. Hormonal contraception reduces androgen production from the ovaries; raises the binding protein for androgens to make them less effective; and reduces androgenic effects upon skin cells. Hormonal contraception matures the uterine lining and sheds it monthly to prevent abnormal bleeding and to reduce the lifetime risk of uterine cancer.
Antiandrogens that may be used in conjunction with hormonal contraception include spironolactone or finasteride. Hormonal contraception with or without anti-androgens will reduce or control the appearance of new abnormal hairs. Abnormal hairs present prior to diagnosis will need to be addressed with laser hair removal or electrolysis.
If you are trying to conceive, confirm ovulation with a well-timed progesterone level. Consider ovulation induction medications, if not ovulating.
Consider psychological support given the higher risks of anxiety, depression, and eating disorders.
Support groups to consider:
Pcoschallenge Veritypcos
PCOS Awareness Association
Consider a nutritionist and/or personal trainer as needed.
It may take a team to conquer PCOS, PFOS, Reproductive Metabolic Syndrome; and Dr. Moomjy is here to help you be successful.
References:
Teede H., Gibson-Helm M., Norman R.J., Boyle J. “Polycystic ovary syndrome: perceptions and attitudes of women and primary health care physicians on features of PCOS and renaming the syndrome, “ J Clin Endocrinol Metab 2014; 99: E107-E111.
Rosenwaks, Z, “Polycystic ovary syndrome, an enigmatic syndrome begging for a name change,” Fertility & Sterility, Nov 2017, pp 748-749
