Let's Talk About PCOS

 

Polycystic Ovarian Syndrome (PCOS) is a health condition in which a woman’s hormones are imbalanced. This hormonal imbalance causes women to have irregular menstrual cycles or skip their periods altogether and can make it harder for them to conceive. PCOS is a condition that affects women during their reproductive years (ages 15 to 44). Between 2 to 27 percent of women in this age group suffer from PCOS. This makes it one of the most common hormonal disorders in this age group. It often begins soon after the first menstrual period around the age of 11 or 12. It can also develop during the 20s or 30s.

 

What Exactly Happens in PCOS

The ovaries are responsible for producing the Female Sex Hormones (Estrogen & Progesterone). These hormones help to regulate the normal development of eggs in the ovaries during each menstrual cycle. The ovaries also produce a small amount of Male Hormones known as Androgens.

The release of an egg by one of the ovaries each month is defined as Ovulation. The Follicle Stimulating Hormone (FSH) and the Luteinizing Hormone (LH) are responsible for regulating Ovulation. The FSH stimulates the ovary to produce a follicle - a sac that contains an egg. The LH then triggers the ovary to release a mature egg.

 

When the ovaries produce more Androgens, the imbalance leads to the Polycystic Ovary Syndrome. PCOS is a syndrome or group of symptoms that affects the ovaries and the process of ovulation. As a result of the hormonal imbalance, the eggs in the ovary follicles are never mature enough to be released. Instead, several small, fluid - filled sacs or cysts are formed in the ovaries, each one containing an immature egg, hence the name Polycystic Ovaries.

 The lack of ovulation alters the levels of Estrogen, Progesterone, FSH and LH. The Estrogen and Progesterone levels are lower than usual, while the Androgen levels are higher than usual. The over - production of Androgens disrupts the menstrual cycle. Hence, women with PCOS get fewer periods than usual.

 

Causes of PCOS

The exact causes are not known but production of higher - than - normal levels of Male Hormones or Androgens is largely responsible for PCOS. Other factors that have been linked to over - production of Androgens are -

●       Hereditary Factors - In some cases, Genes are also responsible for PCOS. Thus, the chances of having PCOS are higher if other women in the family suffer from it.

●       Insulin Resistance - Insulin is a hormone produced by the Pancreas which enables the body to utilise the sugar obtained from the food eaten, for energy. Insulin Resistance is a condition in which the cells are unable to use the Insulin properly. When the cells become resistant to the action of Insulin, the blood sugar levels can rise, thus increasing the body’s demand for Insulin. In order to meet the increased demand, the pancreas produces more Insulin. Extra Insulin then triggers the ovaries to produce more male hormones which further causes difficulties with Ovulation. Obesity is a major cause of Insulin Resistance. Both Obesity and Insulin Resistance can increase the risk for Type 2 Diabetes.

●       Inflammation - This term is used to refer to the production of certain substances by the White Blood Cells (WBCs) to fight infections. Low Grade Inflammation can stimulate the Polycystic Ovaries to produce more Androgens, which can further lead to several other complications.

 

PCOS - Symptoms & Complications

The most common symptoms of PCOS are -

●       Irregular Periods - Lack of Ovulation prevents the uterine lining from shedding every month. Therefore, some women with PCOS get fewer than eight periods in a year.

●       Heavy Bleeding - The uterine lining builds up over a longer period of time. Thus, the periods can be heavier than usual.

●       Hirsutism - More than 70 percent of women with PCOS have hair on their face, back, belly, and chest Excess hair growth is called Hirsutism.

●       Acne - Male Hormones can make the skin oilier than usual and cause breakouts on areas like the face, chest and upper back.

●       Weight Gain - Up to 80 percent of women with PCOS experience weight gain especially around the belly.

●       Male Pattern Baldness - This refers to the thinning of hair on the scalp.

●       Darkening of the Skin - Dark patches of skin can be seen on the neck, in the groin and under the breasts.

●       Headaches - Hormonal changes can trigger headaches in some women.

 

Having higher than normal Androgen levels can lead to severe complications -

 ●       Infertility - Ovulation is necessary for a woman to conceive. Women who do not ovulate regularly, as a result of PCOS, do not release as many eggs and this makes it extremely difficult for them to get pregnant. Thus, PCOS is one of the leading causes of infertility in women.

●       Metabolic Syndrome - Up to 80 percent of women with PCOS struggle with managing their weight. Obesity and Hypothyroidism can further aggravate the existing symptoms. Metabolic Syndrome refers to a cluster of conditions including High Blood Pressure, High Blood Sugar and abnormal Cholesterol or Triglyceride levels that significantly increase the risk for Cardiovascular Diseases.

●       Sleep Apnea - This condition leads to irregular breathing during the night. Sleep Apnea is more common in women who are obese, especially if they also have PCOS.

●       Endometrial Cancer - Normally, the uterus prepares itself for pregnancy every month. The uterine lining gets thickened at the time of ovulation. When a woman bleeds, the unfertilized egg is ejected out of the body, along with thickened uterine lining. However, if, as a result of PCOS, a woman does not ovulate every month, the lining keeps building up. A thickened uterine lining can increase the risk for endometrial cancer.

●       Depression - Both Hormonal Changes as well as Symptoms like Unwanted Hair Growth can negatively affect the mental health of a woman. Many women suffering from PCOS end up experiencing Depression and Anxiety, especially due to the social stigma and lack of awareness.

●       Nonalcoholic Steatohepatitis - This refers to severe liver inflammation which is caused by fat accumulation in the liver.

 

Understanding the Complex Nature of PCOS - Although PCOS is a fairly common disorder, many women are forced to suffer in silence, due to lack of knowledge and the social stigma attached to the issue. Delayed diagnosis can aggravate the symptoms. PCOS manifests itself in the form of several conditions such as Hyperandrogenism (Hirsutism, Acne, Alopecia), Menstrual Disturbance, Infertility, Obesity, Type II Diabetes Mellitus, Hypertension, Cardiovascular Diseases and Endometrial Carcinoma. Therefore, no single diagnostic criterion is sufficient for clinical diagnosis.

 PCOS remains largely under diagnosed. As a result, the patients are not treated effectively. Therefore, it is essential to spread awareness about PCOS in order to ensure timely diagnosis as well as for social acceptance. Furthermore, the management of PCOS may require various departments of reproductive and hormonal sciences to work in collaboration with each other.

 Even with a new understanding of PCOS, doctors and health care practitioners remained perplexed precisely due to the variety of complex symptoms that have been observed in different women. However, in 2003, the Rotterdam Criteria was created which stipulated that a woman with PCOS only needed to have two of the three conditions mentioned below in order to be diagnosed:

 

●       Delayed Ovulation

●       Excess Androgen Hormones

●       Polycystic Ovaries

 

This enabled the demarcation of four different types of Polycystic Ovarian Syndromes, thus allowing women with completely different symptoms to be diagnosed with the same condition.

 

Diagnosis of PCOS - PCOS is a diagnosis of exclusion. This means that all the other possible disorders that mimic the PCOS phenotype must be ruled out first. Other imbalances such as Hypothyroidism, Hyperprolactinemia, Hypothalamic Amenorrhea and Non Classical Congenital Adrenal Hyperplasia, that involve similar symptoms, must be ruled out before exploring the causes that lead to the symptoms of PCOS. Once these possibilities have been ruled out, the probable causes that might have led to the symptoms of PCOS, are explored:

 

●       Anovulation - The first cause is Anovulation which refers to delayed or absent ovulation or menses. This is defined as fewer than ten menstrual cycles in a year, or cycles that last around 35 days in length (as opposed to the average 28 day cycle)

 ●       Hyperandrogenism - The second cause is Hyperandrogenism, or excess Androgen Hormones. These hormones include Testosterone, DHEA and Androstenedione. They are responsible for the occurrence of Male Sex Characteristics. An excess of Androgens in women can cause Male Pattern Hair Loss and Hirsutism (hair growth on the face, chest, and neck, and moderate to severe acne on the jawline or back)

 ●       Polycystic Ovaries - The third cause is the actual presence of Polycystic Ovaries in the ultrasound. This can be misleading, as many women who do not suffer from PCOS have experienced ovarian cysts, and many women who suffer from PCOS do not have ovarian cysts. In this case, the type of ovarian cyst offers an important distinction. Common non PCOS cysts are actually fluid filled sacs that dissolve on their own. PCOS type cysts are nothing but the underdeveloped follicles. In a healthy ovary, follicles are the sacs that hold the eggs. The follicles mature gradually, until an egg is ready to be released at the time of Ovulation. High levels of Testosterone and Insulin, associated with PCOS, can cause these follicles to stop growing and eventually accumulate in the ovaries. In the ultrasound, these follicles look like a string of pearls.

 

In order to meet the definition of a Polycystic Ovary, twelve or more follicles must be present in at least one of the two ovaries, and should have an ovarian volume of ten centimeters or more. Other factors, such as age, must also be considered during diagnosis as age drastically affects the follicle count.

 

Treatment of PCOS: Common Medical Treatments - Birth Control Pills and other medicines can help regulate the menstrual cycle and treat PCOS symptoms like Acne and Hirsutism

●       Birth Control - Taking Estrogen and Progestin daily can help restore Hormonal Balance, regulate Ovulation, relieve symptoms such as Hirsutism, and protect against Endometrial Cancer. These Hormonal Supplements are available in the form of a Pill, Patch, or Vaginal Ring.

●       Metformin - Metformin (Glucophage, Fortamet) is a drug that is used to treat Type 2 Diabetes. It also treats PCOS by improving Insulin levels.

●       Clomiphene - Clomiphene (Clomid) is a Fertility Drug that can help women with PCOS to get pregnant.

●       Hair Removal Medicines - Eflornithine (Vaniqa) Cream is a prescription drug that helps to deal with Hirsutism. Laser Hair Removal and Electrolysis can get help to get rid of unwanted hair on the face and body.

●       Surgical Methods - Ovarian Drilling is a procedure through which tiny holes are made in the ovary using laser or a thin needle, to restore Ovulation.

 

Non Medical Treatment & Management of PCOS - Lifestyle Modification and Insulin Sensitizers form the backbone of the treatment, especially for rectifying the Metabolic Derangements. PCOS can be effectively managed through the following tips:

●       Strategic Caloric Intake - Meal Timings have a significant impact on the Glucose, Insulin and Testosterone levels. Keeping the Insulin levels in check could potentially help with infertility issues. Women with PCOS, who consumed the largest meal of their day at breakfast, for 12 weeks, witnessed a significant improvement in their Insulin and Glucose levels as well as a 50 percent decrease their Testosterone levels, compared to the women who consumed calorie - dense meals for dinner. An effective diet should consist of a 980 - calorie breakfast, a 640 - calorie lunch and a 190 - calorie dinner.

 

●       Decrease AGEs (Animal Based Products & Processed Foods) - Women with PCOS have been found to have higher levels of Advanced Glycation End Products (AGEs) in their blood. AGEs are compounds that are formed when Glucose gets combined with Proteins. It is believed that AGEs contribute significantly to certain Degenerative Diseases and Ageing. Hence, reducing and regulating dietary AGEs can help lower the Insulin levels, and thus combat infertility.

 

●       Load up on Omega 3s - Fish oil is known to have several health benefits. Studies have indicated that Omega 3 Supplements can help lower the Androgen levels in women with PCOS.

 

●       Exercise Regularly - Regular exercise is essential for Weight Loss and Weight Management. It helps combat Obesity by burning calories and building muscle mass, which in turn, helps to deal with Insulin Resistance. Exercise can also be effective for managing Cholesterol levels.

 

●       Alcohol and Tobacco Consumption - Alcohol is high in calories and can lead to weight gain. The toxins from Tobacco can lead to High Cholesterol. Therefore, Alcohol and Tobacco should be avoided at all costs.

 Social Stigma & Mental Health attached to PCOS

In India, PCOS is commonly referred to as a "Lifestyle Disease". The urge to treat PCOS stems from the Indian Society's fear of a woman not being able to have children in the future, and has little to do with other symptoms. Dealing with PCOS can be extremely debilitating - both physically and mentally, especially in a patriarchal society that considers reproduction as a moral imperative and glorifies fertility as an indicator of femininity. Therefore, PCOS is as much about social stigmas around the female body and femininity, as it is about its physiological manifestations. It is extremely important for a woman suffering from PCOS, to surround herself with people who are willing to listen and understand. PCOS can be harrowing at times and hence, it is important to consult a doctor who is knowledgeable and considerate enough to guide the patient through this difficult journey.

By- Shreya Chaudhry