UNDERSTANDING PCOS
Understanding Poly cystic ovarian syndrome (pCOS): possible causes, treatment options and why getting a proper assessment is key
You’ve maybe heard the term “PCOS” - but what is it and how do we diagnose?
Polycystic Ovarian Syndrome (PCOS) is a relatively common endocrine (hormonal) condition that can impact upwards of 10% of people assigned female at birth. PCOS is a complex condition that can present with different symptoms for different people. Although the name suggests that cysts on the ovaries are the primary issue, a diagnosis of PCOS can be made without the presence any cysts!
The diagnostic criteria have evolved over the years, and we are getting a lot better at identifying cases that might have otherwise been missed. The most common way to diagnose is based on the “Rotterdam Criteria” which require two out of the following three symptoms to make the diagnoses:
clinical (symptoms) and/or laboratory (blood work) findings of elevated testosterone.
ovulatory dysfunction (long intervals between periods or absent period)
multiple “cysts” on the ovaries (found with an ultrasound)
Depending on how you are diagnosed, and what symptoms you present with, your concerns and goals for treatment might be a bit different. PCOS impacts a range of body systems including our reproductive, metabolic and psychological health.
Common symptoms include:
Menstrual cycles longer than 35 days (counted from the start of your period, until the next first day of your period)
Acne (especially acne that has been resistant to treatments or came back after Accutane)
Hair growth on the face and body that doesn’t seem consistent with other people in your family/culture.
Hair loss on the scalp
Darkening in patches of your skin – especially around areas where the skin folds.
Weight gain
Low mood
Challenges getting or staying pregnant
Many of these symptoms overlap or are present in other conditions. For instance, hypothyroidism can also lead to longer cycles or lack of period, hairloss, weight gain and low mood. It’s important to investigate appropriately with the right practitioner to ensure we are treating the correct diagnosis. Some conditions also present together, which can complicate things. While hypothyroidism can have a similar symptom picture as PCOS, it also occurs commonly in patients who have been diagnosed with PCOS! When considering fertility, patients with PCOS, and hypothyroidism should be evaluated for both conditions as it can impact our ability to conceive, meaning we may need to treat both to improve our odds of successful and healthy pregnancy.
What is the cause of PCOS?
Although we don’t have a full understanding of why some people develop PCOS, it’s likely that there is a strong genetic component. This means you may be at higher risk for PCOS if you have relatives who also have PCOS.
Theories are still evolving in the research around other causes. One of the main issues with understanding the cause of PCOS is due to the complex symptom picture, and various different hormones involved, which can impact each other.
What Hormones are involved?
Elevated androgens (testosterone, DHEA-S), ovulation dysfunction, changes in hormones released from the brain (specifically Luteinizing Hormone - LH), and insulin resistance have all been implicated in how PCOS develops – and, as mentioned above, each of these exacerbates the others.
How does Insulin play a role?
Insulin resistance plays a role in up to 80% of cases of PCOS and can play a role no matter your body size. Insulin resistance is typically the cause of the symptoms of weight gain. However, lean folks with PCOS can still have some degree of insulin resistance – especially at the level of the ovary. When insulin is in excess. it can plays a role in stimulating more testosterone production. This impacts not only symptoms of hair growth and acne, but also menstrual cycle changes.
Testosterone
With increased testosterone production, the follicles in the ovary don’t develop appropriately and we end up with lots of smaller developing follicles accumulating. These follicles produce more anti-Müllerian hormone (AMH). AMH is a blood marker used to estimate a person’s ovarian reserve (how many eggs you have left) and is often used in the fertility space. In PCOS, this number is elevated due to the immature follicles (“cysts”) and makes it impossible to use this value to draw any real conclusions about future fertility potential.
When hormone production is impacted, feedback signals are sent to the brain which further alter our hormonal events in our normal menstrual cycle. This results in an elevated Luteinizing hormone (LH) relative to Follicle Stimulating Hormone (FSH). As these two hormones are involved in orchestrating the act of ovulation (with a specifically timed surge in LH to trigger the release of the egg), these changes in PCOS often result in cycles in which we don’t ovulate (what we call anovulatory cycles). This can lead to long cycles (over 35 days), fertility struggles (you can’t get pregnant without ovulation!) and sometimes, heavy bleeding when your period does come (however we don’t expect pain).
It's important to remember that you didn’t cause your PCOS
In discussing the causes of PCOS it is important to remember that despite the role insulin, genetics and our other hormones play - this is not due to your lifestyle or anything you did wrong. Some theories of PCOS think that elements of PCOS may develop in vitro, while our mothers are pregnant, speaking to the genetic predisposition. We have no research that says PCOS is caused by lifestyle factors - just that we can use them to improve our PCOS symptoms!
What we see in the clinic
Awareness around PCOS is growing rapidly – especially with the help of social media. This is a great thing in many ways, as more and more of you are in touch with your menstrual cycle and understanding what’s normal. It is also great for patients advocating for themselves within the healthcare system.
In other ways, it also breeds stress around a diagnosis (that hasn’t been confirmed or investigated) and self-treatment. Treatment for PCOS in the social media space often involves restrictive (and not backed by evidence) dietary and lifestyle changes. A diagnosis of PCOS also requires some investigation because we want to make sure there’s not something else causing your missing period, hair growth, fatigue, weight gain – you name it! Sometimes we have patients come see us who are convinced they have PCOS… but it turns out their missing period was actually due to their undereating and overexercising (which they thought was helping their PCOS!).
How can we treat PCOS?
The first step is getting assessed. A practitioner will ask you about your health history, family history, how your symptoms started, and likely run blood work or send you for imaging.
From there, treatment is partially dependent on your symptoms and goals. Conventionally, treatment often involves oral contraceptives (to induce a normal period), and/or medication that impacts insulin sensitivity or androgens (or both!). If your goals don’t involve fertility in the near future, the pill might be an option for you if you are also looking for contraception. The pill decreases androgens and tends to help with symptoms, but those symptoms do tend to return when you stop taking it.
From a naturopathic perspective, whether you choose conventional treatment or not, there’s a lot we can do to support you.
Nutritional and lifestyle recommendations are always part of the plan and then we often include targeted supplements to manage symptoms alongside your goals. We also have the time to discuss any of your questions and concerns around your PCOS diagnosis.