Polycystic ovarian syndrome (PCOS) is one of the most commonly-diagnosed hormone disorders in women. It has the potential to lead to several gynaecological issues, such as having too many cysts on the ovaries, and challenges getting pregnant.

However, there are many different approaches to managing the different aspects of PCOS: read on for more!

What is PCOS?

PCOS is estimated to affect somewhere between 6 – 10% of women of reproductive age. PCOS presents in several different ways, which can include:

– Excess’ hair

– Difficulties maintaining a healthy weight

– Irregular periods

– Difficulties conceiving

What causes PCOS?

There is no one clear cause of PCOS: it’s thought to be due to several different underlying mechanisms, including:

– Genetics, which is thought to account for about 70% of your risk of having PCOS. If your mother or sister have PCOS, your chances of having PCOS are about three times that of the average population.

– Altered actions of luteinising hormone

– Dysfunctional follicle development in your ovaries

– Insulin resistance

Risk factors for PCOS include:

– Being above a healthy weight. Although this is a little ‘chicken and egg’, in that PCOS can make it really hard to lose excess weight. It’s probably a bit of both: PCOS can contribute to obesity; women who are obese (for whatever reason) are more likely to develop PCOS.

– Any diabetes (type 1, type 2, or gestational diabetes)

– Having your first period especially young (eg. at or prior to 10yo)

– Having close relatives who also have PCOS

PCOS remains an area of active research in both gynaecology and endocrinology (the medical specialty concerned with hormones), as it’s so common, and there is so much more that needs to be discovered about it! Watch this space!

Symptoms of PCOS

PCOS can manifest itself is several different ways, which are outlined below.

‘Excess’ hair

‘Excess’ hair (or ‘hirsutism’) is a common concern for women with PCOS. Classically, this presents as any or all of:

– A receding hair line +/- frontal baldness

– ‘Too much’, thick hair on your upper lip, chin, forearms, chest, tummy, back etc

Acne

Women with PCOS may notice more acne than their peers, and potentially into the later age groups (eg. 30yo and beyond).

Irregular periods

Women with PCOS often have periods that are quite irregular, with 2 – 6 months between periods. Normally, this irregularity is established from early on, in your teen years. For many women with PCOS, their periods are irregular from the get-go, and never become regular. Other women with PCOS may have regular periods to start with, which become irregular down the track.

Subfertility

In order to get pregnant naturally (ie. without resorting to IVF), it helps if you are ovulating regularly. Women ovulate (ie. one or other ovary produce an egg) 14 days before their next period.

As noted above, women with PCOS often have irregular periods. So if you only have a period every three months, this means that you only produce an egg every three months. So your likelihood of conceiving naturally is approximately one third that of women who conceive every month.

Challenges maintaining a healthy weight

PCOS goes hand in hand with resistance to the hormone insulin. This insulin resistance stimulates your pancreas to make additional insulin, which then promotes fat storage and increases hunger. Hence, women with PCOS are often overweight / obese, and often struggle to achieve and maintain a healthy weight.

Mood disorders

It is estimated that 25 – 60% of women with PCOS develop depression and / or anxiety at the time of diagnosis.

Diagnosis of PCOS

Strictly speaking, to be diagnosed with PCOS, a woman needs to fulfil at least two of these three criteria:

– High levels of male hormones

– Too many cysts on her ovaries

– Irregular periods

The above criteria are known as the ‘Rotterdam criteria’, which will now be discussed in turn.

High male hormone levels

The technical term for high levels of male hormones is ‘hyperandrogenism’. This tends to lead to: acne; ‘excess’ hair; and male-pattern hair loss.

High male hormone levels can be diagnosed clinically, when a woman has these symptoms. Alternatively, it can be assessed using blood tests such as ‘total testosterone’, ‘free androgen index’, and ‘DHEAS’, which may all be raised in PCOS.

Polycystic ovaries

In PCOS, the ovaries often produce excess numbers of developing eggs, which then stall early in development. On ultrasound, this may be visualised as:

– 12 or more follicles in each ovary, measuring 2 – 9mm in diameter

– And / or increased ovarian volume (>10mL)

(Source: https://my.clevelandclinic.org/health/diseases/8316-polycystic-ovary-syndrome-pcos )

Irregular periods

Irregular periods (or ‘oligomenorrhoea’) is defined as having more than 35 days from the first day of one period, to the first day of the next; an alternative definition is having fewer than nine periods in a calendar year. This is really common in women with PCOS, and often occurs from their teenage years onwards.

How is PCOS treated?

When thinking about ways to manage PCOS, it’s important to consider your goal(s) of treatment. This is very patient-specific, in that different patients have different priorities. Your treatment goals may include any or all of:

– Improvement of the symptoms of excess male hormones (eg. ‘excess’ hair, acne, frontal baldness)

– Management of any underlying metabolic conditions (eg. diabetes, cardiovascular disease)

– Prevention of overgrowth of the uterine lining

– Contraception (for women not actively trying to get pregnant)

– Ovulation induction (for women who are actively wanting to get pregnant)

– Maintaining a healthy weight

To these ends, management may include:

Management of ‘hyperandrogenic’ symptoms

There are several approaches to managing the symptoms of excess male hormones (eg. ‘excess’ hair, acne, frontal baldness). The combined oral contraceptive pill (COCP) is considered the best first-line approach for these symptoms.

If six months on the COCP has not a sufficient improvement in these symptoms, an anti-androgen medicine (such as the tablet ‘spironolactone’) can be considered. Of note, if it’s not safe for you to take the COCP (for whatever reason), spironolactone can be started by itself. It’s important to rule out pregnancy before starting to take spironolactone, and to use a form of reliable contraception (eg. the Mirena intra-uterine device) while on spironolactone.

With regards to preventing the regrowth of unwanted hair: there aren’t any quick fixes. Unwanted hair is best removed by using mechanical methods, such as: shaving, waxing, depilatory creams, electrolysis, or laser.

Contraception

Some combined oral contraceptive pills (COCPs) are thought to be better than others, for helping women with PCOS who don’t want to conceive.

As noted in our previous blog posts, there are many different COCPs on the market. With regards to PCOS, we generally recommend a Pill that contains the progesterone hormone norethisterone, desorgestrel, cyproterone or drosperinone. The table below provides some guidance as to which Pills available in Australia contain one of these progesterone ingredients:

In terms of contraception for women with PCOS, alternatives to the COCP include:

– Mirena progesterone-containing intra-uterine device.

– Taking the progesterone-only contraceptive pill (POP)

Preventing overgrowth of the uterine lining

Stimulating the uterine lining to shed regularly is thought to reduce the likelihood of the uterine lining overgrowing, thereby decreasing the risk of uterine cancer.

There are various different ways that overgrowth of the uterine lining can be disencouraged, including:

– Taking the COCP, which stimulates a ‘period’ every month

– Taking progesterone tablets (‘medroxyprogesterone acetate’, or MPA) in the second half of your menstrual cycle (eg. if the first day of your period is ‘day one’, taking daily progesterone from days 15 – 25 inclusive). Like the COCP, this prompts the uterine lining to shed every month, which reduces the risk of pre-cancerous overgrowth. Ceasing the progesterone tablet on day 26 would then prompt your uterine lining to shed, causing a period.

– Having a Mirena (progesterone-containing) intrauterine device inserted, which keeps the lining of the uterus thin

– Taking the POP, which keeps the uterine lining quite thin

Unless there is a good reason not to take the COCP, it is considered first-line therapy for women with PCOS, in terms of both regulating the timing of your period, plus also preventing overgrowth of the uterine lining.

Second-line management to prompt regular periods is a tablet called ‘metformin’, which restores regular periods in approximately 40% of women with PCOS.

Conception

As noted above, having irregular periods (eg. only every three months) means that you have fewer days per year when you are fertile, and able to conceive naturally. There are several management options for this ‘oligomenorrhoea’, which include:

– Achieving and maintaining a healthy weight. If you are over a healthy weight, losing as little as 5% of your bodyweight can help to regulate your menstrual cycle, and improve your ability to conceive naturally

– Ovulation induction, which is the technical name for the process of bringing on more regular ovulation. This can be done using several different medicines, such as ‘clomiphene’ or ‘letrozole’. If you’d like to talk about this in more detail, please consider making an appointment with Maven Centre’s Dr Melissa Cameron.

Second-line approaches to stimulating ovulation include laparoscopic surgery to perform ‘ovarian drilling’. If the above methods aren’t successful, IVF may be needed.

Many, if not most, women with PCOS who are wanting to conceive eventually need to see a fertility specialist to undergo ovulation induction.

Maintaining a healthy weight

There are no easy answers when trying to maintain a healthy weight: for many women with PCOS, their hormones are working against them, and it’s an uphill battle to maintain a healthy weight. Regular aerobic exercise and maintaining a healthy balanced diet are vital: for more information on dietary management of PCOS, please see this blog, or make an appointment with Maven Centre’s dietician, Dr Steph Pirotta, who has a PhD in the dietary management of PCOS.

In addition to diet and exercise, approaches to maintain a healthy weight include medicines (such as ‘ozempic’) and bariatric surgery.

There are many potential benefits to achieving a healthy weight if you have PCOS, including a likely improvement in your ovulation and fertility, after losing ‘only’ 5% of your bodyweight.

Possible complications of PCOS

Unfortunately PCOS has several possible health implications, as outlined below.

Cardiovascular complications

Women with PCOS are more likely to run into problems with: diabetes, cholesterol, and / coronary heart disease (blockages of the blood vessels which supply oxygen to the heart itself. If you are diagnosed with PCOS, your GP should consider:

– Measuring your blood pressure, body mass index and waist circumference

– Testing your blood for cholesterol, using a ‘fasting lipids’ blood test

– Checking whether or not you already having diabetes, using a ‘glucose tolerance test’. This test should be done at least every two years thereafter.

Pregnancy complications

Once you conceive, your PCOS unfortunately places you at higher risk of several pregnancy complications, such as:

– Miscarriage

– Diabetes of pregnancy (‘gestational diabetes’)

– High blood pressure (‘gestational hypertension’)

– Pre-eclampsia

– Premature birth

– Caesarean section

If you are known to have PCOS, and do conceive, it’s important that your GP refers you to the antenatal clinic of your local hospital early, so that measures can be put in place to manage the above potential issues.

Increased risk of uterine cancer

The hormonal changes that often occur in PCOS can lead to long-term over-stimulation of the uterine lining, and an increased risk of both pre-cancerous changes (‘endometrial hyperplasia’) and endometrial cancer.

This risk can be reduced by using any of the approaches outlined above, including: the COCP; progesterone tablets; or the Mirena IUD.

Metabolic conditions

Through no fault of their own, women with PCOS are at higher risk of metabolic conditions such as: diabetes, high cholesterol, and cardiovascular disease (such as coronary heart disease). Your women’s health GP or endocrinologist should be able to talk you through the management options for diabetes and cardiovascular disease related to PCOS, which may include:

– Achieving and maintaining a healthy bodyweight

– Metformin medication

– A class of medicines called ‘thiazolindinediones’ (which include rosiglitazone)

Frequently asked questions (FAQs)

Can PCOS be diagnosed in teenagers?

Many ‘normal’ teenagers have polycystic ovaries, which can persist for several years after their periods start to occur. It is considered best practice not to diagnose PCOS in women who have started to have periods within the last 8 years.

My ultrasound shows polycystic ovaries. Does this mean that I have PCOS?

As noted above, to be diagnosed with PCOS, you have to have at least two of the following:

– Polycystic ovaries

– Irregular or absent periods

– Symptoms or blood tests suggestive of excess male hormone levels

Hence, if polycystic ovaries are seen on ultrasound, but you don’t have either of the other two ‘Rotterdam diagnostic criteria’, you do not have PCOS.

Can PCOS be reversed?

Achieving and maintaining a healthy bodyweight (which is easier said than done!) can help to reverse most (if not all) of the symptoms and signs of PCOS.

How can I manage my excess hair?

As noted above, there are several ways that unwanted hair can be managed. These include:

– A COCP that contains norethisterone, cyproterone or drosperinone as its progesterone hormone ingredient

– An anti-androgen medication such as ‘spironolactone’

– Any number of mechanical approaches, such as: waxing, shaving, depilatory creams, laser and / or electrolysis

While many women with PCOS find unwanted hair the most distressing symptom, unfortunately there aren’t any quick permanent fixes to ease that distress.

Conclusion

While PCOS is thought to affect up to 10% of women of reproductive age, unfortunately it remains pretty poorly understood. As a result, there are often long delays in both diagnosis and treatment: over half of women with PCOS see at least three health professionals before the diagnosis is made. For a third of patients, it takes over two years for their diagnosis of PCOS to be made.

Hence, there is a lot of improvement to be had, amongst us clinicians! Having a good understanding of PCOS, and seeking out care from learned and sympathetic clinicians, can go a long way towards easing the symptoms and signs of PCOS, and helping to manage its potential complications.