PCOS, THEN (1935) AND NOW (2022)
INTRODUCTION—WHAT IS PCOS?
Depending on the criteria used for diagnosis, up to 10% of women will experience a condition called polycystic ovarian syndrome (PCOS). It is a multi-problem dysfunction within the endocrine system (glands that secrete hormones). This syndrome gets its name from the multiple ovarian cysts that are often seen on ultrasound.
PCOS is unfair to women: there is nothing they do to get it; there isn’t anything they should have done, either, to prevent it. Besides the physical miseries it produces, the final insult is that it causes infertility, a condition that—according to many women—prevents one of their most important experiences in life, pregnancy.
WHAT CAUSES PCOS?
It’s crude to say, “it just happens to some women,” but because PCOS probably has a genetic cause (at least in part), the statement applies. Another villain is insulin resistance, a condition in which your tissues aren’t as sensitive to the function of insulin as they should be, so your body is forced to make more to compensate. This leads to the development of type 2 diabetes. Obesity is also associated with—if not a contributing cause of—PCOS. And all of these things probably conspire together.
We’ve come a long way in both understanding and treating PCOS in the last 87 years. The condition used to be called Stein-Levinthal syndrome after being described by Drs. Stein and Levinthal in 1935.
At the time, it was felt that the entire menstrual cycle, which depends on ovulation as a necessary part of its function, got bogged down biochemically, causing the many problems seen with polycystic ovaries (cysts from many egg follicles failing to ovulate), hirsutism (male-like hairiness and hair-thinning), and oligo-/amenorrhea (rare/no periods, respectively).
With all due respect to Stein and Levinthal, they weren’t exactly right. And based on the “thick and tough capsule” explanation, women were subjected to surgeries in which little holes were drilled into the ovaries, or a wedge of tissue was removed to make it easier for eggs to ovulate. While it was claimed that this often worked, it involved surgical procedures.
Today, the stalled menstrual cycle is restarted by giving clomiphene, an oral drug that stimulates ovulation (over and beyond whatever biochemical barriers are there). For women who don’t desire pregnancy for the time being, suppressing the biochemical processes of PCOS with birth control pills can temporize it until pregnancy is desired.
WHAT REALLY CAUSES PCOS?
While taking pills may seem like easy treatment, they only treat the result of having PCOS, not its cause. PCOS is a genetic disorder that coexists and interacts with certain specific endocrine processes in the body. The actual definition has been modified since the original descriptions by Stein and Levinthal. Currently, here are the essential criteria:
- ovulatory dysfunction (with menstrual abnormalities) for 1-2 years, and
- evidence of androgen excess (hyperandrogenism), such as hirsutism (hairiness) and/or elevated testosterone seen in blood tests.
Besides hyperandrogenism (male-like hair and/or acne) and menstrual cycle dysfunction, unfortunately, other systems are affected in this syndrome:
- Insulin resistance, which leads to elevated blood sugars and type 2 diabetes
- Excess luteinizing hormone (LH)-an ovulation hormone that is overproduced when ovulation doesn’t occur- which probably contributes to the production of many cysts (egg follicles) in the ovaries, i.e., “polycystic ovaries”
SIGNS AND SYMPTOMS OF PCOS
In medical jargon, signs are things that can be seen or measured, and symptoms are effects noticed by the patient. As expected, common signs and symptoms of PCOS include
- Irregular menstrual periods (thus, the absence of rhythmic ovulation)
- Infertility (an effect of unreliable ovulation)
- Insulin resistance, or type 2 diabetes
- Obesity and overweight (in 33-88% of women with PCOS) associated with insulin resistance
- Acanthosis nigricans—a dermatologic condition that results from the metabolic changes related to diabetes, obesity, and testosterone in which patches of skin in characteristic parts of the body (neck, armpit, groin) become thick, velvety, and dark
- Multiple over-sized egg follicles in the ovaries, which occur when ovulation does not take place
- Insulin resistance and metabolic syndrome (that stems from the cells’ inability to accept glucose from the blood, causing whole-body effects, i.e., obesity, cholesterol problems, and high blood sugar levels)
and signs and symptoms of androgen excess (hyperandrogenism), such as
- Hirsutism—excess hair growth, especially in a male pattern on the abdomen, chin, and upper thighs, or hair thinning
- Oily skin
The absence of these characteristics rules out PCOS.
HOW IS PCOS DIAGNOSED?
Menstrual cycles that don’t repeat regularly and signs of male-like hair patterns, acne, and other characteristic signs and symptoms raise the clinician’s suspicion for PCOS. Irregular menstrual periods are documented from a patient’s medical history, and hyperandrogenism can be determined with blood tests for total and free testosterone and by noting acne and hirsutism on a physical exam. Another sign of PCOS is the finding of multiple ovarian cysts on an ultrasound study.
Adolescents often have irregular periods, which can make the diagnosis difficult, delaying it. Such a delay can progress into missed opportunities for treatment, leading a young girl into metabolic, cosmetic, and even psychological complications that are otherwise preventable. Delays can also lead to misdiagnoses that result in unnecessary surgery that can risk her fertility in the future.
HOW IS PCOS TREATED?
This is an interesting topic. The plan for treatment varies based on whether a woman wants to get pregnant or would rather avoid pregnancy. Fortunately, either way, the treatment for PCOS also addresses its associated problems, such as the acne, excess hair, and irregular or absent periods.
FOR A WOMAN WANTING PREGNANCY
Without regular periods, there can be no regular ovulation. This is because these depend on each other in the cycle that repeats itself monthly. Thus, ovulation is stimulated with medications. As mentioned above, the drug clomiphene (Clomid) is used. It binds to estrogen receptors in the brain, jumpstarting the cycle. Other drugs are available for use if clomiphene fails, but it is usually the one tried first. Its drawback is that it may overshoot and make the follicles grow from regular cysts into really big cysts. This can be painful and may even make surgery necessary.
Once ovulation is successfully reestablished, the ovary makes progesterone (which is normally done in the second half of the cycle). This will continue until the natural hormonal support of the pregnancy kicks in, in a couple of months.
FOR A WOMAN DECLINING OR WANTING TO DELAY PREGNANCY
Oral contraceptives (birth control pills) basically mask the PCOS disturbance by “hijacking” or taking over the menstrual cycle. The signs and symptoms of PCOS can fade away. Taking them also allows a woman time to address the problems associated with PCOS, such as obesity. Women who manage this way “grow out” of PCOS by the time they attempt menstrual cycles, without oral contraceptives.
BEYOND FERTILITY, WHAT ARE PCOS’ OTHER HEALTH ISSUES?
- Obesity and diet,
- The potential for hyperglycemia, and
- The psychological fallout from infertility or
- The cosmetic effects of acne and hirsutism
For woman with PCOS, who want to conceive, there is a hierarchy of concerns. Treating her infertility becomes the priority. Depression may not be far behind.
Whether PCOS is caused by or causes insulin resistance and obesity isn’t important. What’s important is the insulin resistance, which is the beginning of the journey toward real diabetes and—then—real problems. Thus, treating insulin resistance early as if it were diabetes is the best way to avert the other health issues. As such, lifestyle changes are important, including exercise and diet.
Where diet is concerned, there is no magic involved. Information about how to maintain a healthy diet is easy to find, including calorie restriction with an emphasis on low glycemic index foods. Also, the diet can be fine-tuned further by supplementing with omega-3s, eliminating saturated fats, and considering alpha-linoleic acid supplementation. Also, a healthy A1C will support weight loss because this test measures a type of hemoglobin that reflects long-term blood glucose levels, giving you more information to act on than just a “spot-check” fasting blood sugar at one point in time.
PCOS presents a number of conditions associated with ovulation failure—obesity, increased androgens, irregular periods, and insulin resistance. Treating the absence of ovulation by either stimulating or suppressing it tends to address all aspects of PCOS. This is important to improve a woman’s quality of life, reestablish the possibility of pregnancy, along with lowering the risk of related health concerns.