Polycystic Ovary Syndrome (PCOS)

What Causes PCOS?

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting up to 10% of women. The ovaries produce excess hormones, particularly androgens like testosterone, causing hormonal imbalances in the body. This imbalance disrupts ovulation, causing irregular or absent periods. As a result, PCOS is one of the most common causes of female infertility.

Is PCOS Genetic or Hereditary?

Evidence suggests PCOS runs in families, but the exact genetic mechanisms are still being researched.

PCOS Symptoms

PCOS presents with a wide range of hormonal and physical symptoms, including:

• Acne: The face, back and chest are commonly affected.
• Fatigue: PCOS-related fatigue stems from a combination of factors, including hormonal imbalances, insulin resistance and disrupted sleep, all of which contribute to feeling sluggish and tired. Women with PCOS have a higher chance of having sleep apnea, too, which can cause significant fatigue during the day.
  
• Hair loss or thinning: Hormonal imbalances cause hair thinning or loss. It’s most often observed as a male-pattern baldness in women.
• Infertility: The hormonal imbalances that disrupt ovulation make it difficult to conceive.
• Irregular or absent periods: Patients can go several months or more without having a period. When they do, it's heavy and painful.
• Pain: This can be due to ovarian cysts, heavy menstrual bleeding or chronic inflammation. If you can’t sleep due to PCOS pain, it could be linked to one of these factors, but it’s important to ask your doctor about other causes as well. Severe back pain from PCOS may also be associated with ovarian cysts and period irregularities. However, some women don’t experience any pain with PCOS.
• Skin darkening: Called acanthosis nigricans, this occurs most often in skin folds such as the armpits, groin and underneath the breasts.
• Unwanted hair growth: Known as hirsutism, hair can grow on the face, upper lip, chest or back on women due to elevated testosterone levels.
• Weight gain or difficulty losing weight: PCOS often causes insulin resistance, meaning the body struggles to use insulin properly, leading to fat storage. Hormonal changes, like increased testosterone and a slower metabolism, also make weight gain more likely and weight loss harder. Obesity is closely associated with PCOS, too, but not always.

How to Lose Weight with PCOS

For patients with PCOS who are overweight, weight reduction is the initial recommended treatment. Even 5% weight loss can improve hormone imbalances and restore regular cycles.

PCOS and proper nutrition also play a crucial role in this approach. While there are many online resources regarding PCOS diets, there isn’t strong evidence a particular diet is superior for managing the condition. Therefore, it’s recommended to follow a generally healthy, anti-inflammatory diet, like the Mediterranean diet, which is proven to be beneficial for heart health, weight loss and longevity.

Nutritious, anti-inflammatory PCOS foods to eat include berries, peppers, leafy greens, tomatoes, fatty fish and nuts. Teas with anti-inflammatory properties are good for managing PCOS symptoms as well, such as green, turmeric and ginger tea.

Increasing physical activity, even with simple activities like walking, is beneficial, too.

Beyond diet and exercise, prioritizing good sleep and managing stress, including treating any underlying depression through counseling or therapy, can positively impact PCOS. If significant weight loss isn’t achieved through these methods, a referral to a nutritionist or weight management clinic may be considered to explore options such as weight loss medications, like Ozempic, or surgery.

PCOS and Pregnancy

While it’s possible to get pregnant with PCOS, it can be more difficult and carries certain risks.

Patients with PCOS have a higher likelihood of developing gestational diabetes due to insulin resistance, gestational hypertension (high blood pressure) and preeclampsia (high blood pressure that damages the organs, most often the liver and kidneys).

These risks are monitored during pregnancy, rather than automatically classifying a patient as high-risk. Early glucose testing is recommended, and low-dose aspirin is often prescribed at the end of the first trimester to reduce the possibility of preeclampsia, especially for women with one or more risk factors.

However, the primary concern for patients with PCOS who are trying to get pregnant is irregular or absent ovulation, preventing conception. In these cases, a diagnostic workup is performed to confirm ovulation issues.

If your periods are irregular and you're not ovulating, your provider may use medication to help you ovulate. Letrozole, a drug used for breast cancer, works well for PCOS ovulation problems and is often preferred over clomid. Though off-label, letrozole’s efficacy and safety are well-supported.

Treatment typically begins with the next menstrual cycle, with the medication taken on days three through seven. After treatment, your provider tests to see if you're ovulating and changes the dose if needed.

PCOS Medications

Additionally, several medications are used to manage PCOS. What works best depends on your specific symptoms and goals. Metformin is sometimes prescribed to address insulin resistance, a common issue in PCOS. It helps regulate hormone imbalances and improve menstrual cycles.

For patients not trying to get pregnant, oral birth control pills are recommended to regulate periods, suppress cyst formation and even treat acne and excess hair growth due to their anti-androgen effects. However, birth control pills aren't right for everyone, especially those with migraines or a history of blood clots.

In such cases, alternatives like hormonal IUDs, progestin-only pills or the Depo-Provera shot should be considered. Additionally, spironolactone (used to block testosterone) can be used to specifically target high androgen levels in PCOS, making it effective for managing symptoms like excessive hair growth on unwanted parts of the body and acne.

How Do You Get Diagnosed with PCOS?

To test for PCOS, your provider looks for two out of three things based on the Rotterdam criteria: irregular periods, signs of high testosterone and polycystic ovaries on an ultrasound.

Irregular menstrual cycles, persisting for a year or more, usually mean you're not ovulating. High testosterone, a sign of excess androgen activity, appears as abnormal hair growth and can be confirmed with PCOS blood tests showing testosterone levels above 45-60 ng/dL.

The third piece of PCOS diagnostic criteria involves seeing polycystic ovaries on the sonogram during a pelvic ultrasound.

When to See a Doctor about PCOS

While there isn’t a cure for PCOS, and it won’t go away on its own, the condition can be managed with lifestyle adjustments and medication.
Even though PCOS isn’t dangerous, it can increase your risk of other health conditions. These comorbidities include:

• Cardiovascular disease
• Endometrial hyperplasia (when lining of uterus is abnormally thick) and cancer
• High blood pressure
• Type 2 diabetes

If you're experiencing symptoms like irregular periods, unusual hair growth, unexplained weight gain or infertility, talk to your provider. Early diagnosis and a tailored treatment plan can significantly improve your quality of life, reduce the risk of long-term health complications and empower you to effectively manage PCOS.