As a medical student, one of the conditions that was hardest for me to get my head around was PCOS (polycystic ovarian syndrome). It took me several years of advanced training to understand the ins and outs of the syndrome.
PCOS is a complex hormonal condition that involves multiple organs systems. It’s is a clinical diagnosis, meaning that doctors diagnosis patients with PCOS based on symptoms – not on a specific lab test that is “positive of negative” for the condition. PCOS is diagnosed if a woman has two or more of the following symptoms:
Signs of too much male hormone (excess dark hair growth on chin, cystic acne or elevated testosterone on blood tests)
Menstrual cycles > 35 days apart
Enlarged ovaries on ultrasound
As hard as it was to grasp in med school, and as challenging as it is to explain it to my patients in a 10-minute office visit, it’s not surprising that there are a lot of misunderstandings about PCOS floating around.
Myth #1 “PCOS is caused by your ovaries”
PCOS is caused by a full body hormonal miscommunication – the actual polycystic ovaries are merely a symptom. There are many different metabolic issues going on that contribute to PCOS. The brain sends the ovary mixed signals causing it to secrete excess male hormones, which affects the delicate fluctuations of female hormone that trigger ovulation. At the same time, fat cells contribute to the problem by resisting insulin, triggering the body to make excess insulin when carbs are eaten. This insulin increase not only prompts the ovary to produce too much male hormone, but also causes weight gain. The ovaries can’t manage to ovulate because the hormones are all wrong.
Myth #2 “Women with PCOS are infertile”
Women with PCOS can have difficulty getting pregnant, but the infertility associated with PCOS is often easy to treat. Women who have PCOS and are overweight can often begin to ovulate regularly with very modest weight loss of even 10% of their body weight. Medication can also help; 50% of women with PCOS will conceive with clomiphene treatment (an inexpensive ovulation-inducing pill). Of women who conceive on clomiphene, the majority conceive within 4 months, so it should not be taken for an extended amount of time.
Myth #3″PCOS causes pain”
During a normal menstrual cycle, the chosen egg of the month begins to grow within a small follicle cyst on the ovary. When ovulation occurs, the egg escapes the cyst and makes a run for the fallopian tube, and its former cyst usually dissolves over time. In PCOS the ovaries are trying to ovulate but because of the body’s confused hormones, the ovulation cyst gets stuck and is unable to fully develop to the point it can spit out the egg, hence the ovary becomes swollen with underdeveloped cysts. These cysts cause the ovaries to become enlarged, but the cysts do not usually rupture or cause pain.
Myth #4 “Women with PCOS are overweight”
PCOS is often associated with obesity, but not always. At one time, PCOS was defined as having all three symptoms plus obesity, but we now recognize that there are different “types” of PCOS. You only need two of the three symptoms of PCOS to have the condition. The treatment of PCOS is based on the sub-type and your goal (for example, birth control pills do an excellent job of controlling the irregular cycles and treating the abnormal male hormone of PCOS, but would not be the best option for someone try to conceive). For overweight PCOS patients, a low carb diet with regular exercise is recommended. (My personal recommendation is the nutrition plan in The Obesity Code by Dr. Jason Fung)
Myth # 5 “PCOS patients have very high risk pregnancies”
I often have patients worry that since PCOS makes it challenging to get pregnant, it will also put them at super high risk during pregnancy. Once pregnant, PCOS patients are at an increased risk of gestational diabetes and high blood pressure, but most go on to have normal pregnancies. They do not have an increased risk of miscarriage as previously thought.
Around 10% of women meet the criteria for PCOS worldwide and our understanding of the condition and treatments has evolved over the last 20 years. If you have symptoms of PCOS, don’t get discouraged by the myths. Instead, talk to doctor about customized treatment of your condition.
Diagnosis of polycystic ovary syndrome (PCOS) is challenging, and there should be no rush to label an adolescent as having the condition before a thorough evaluation of symptoms, according to a leading endocrinologist who was speaking at the RCOG World Congress 2018 in Singapore.
“Common features of PCOS such as hirsutism, acne, and obesity are often present in otherwise ‘normal’ adolescents,” said Dr Veronique Celine Viardot-Foucault from the KK Women’s and Children’s Hospital, Singapore, adding that these features may not necessarily be indicative of PCOS.
Appropriate diagnosis of PCOS in adolescents should involve careful evaluation of symptoms such as menstrual irregularities, hyperandrogenism, and polycystic ovarian morphology, she said. Menstrual irregularities—including secondary amenorrhoea and oligomenorrhoea in girls beyond 2 years after menarche, or primary amenorrhoea in those who have completed puberty—may be indicative of androgen excess. [Horm Res Paediatr 2017;88:371-395]
As symptom such as acne is common in adolescence and usually transient, it may not be indicative of hyperandrogenism, said Viardot-Foucault. Also, isolated cases of acne and/or alopecia should not be considered as diagnostic criteria for PCOS in adolescence, but moderate or severe inflammatory acne that is unresponsive to topical therapy may require investigation of androgen excess. [Horm Res Paediatr 2017;88:371-395]
Another feature commonly seen with PCOS is hirsutism, which can be evaluated using the modified Ferriman–Gallwey (FG) scoring system. “However, the FG scoring system is not applicable to younger, perimenarchal patients [younger than 15 years old],” she advised, pointing out that biochemical evidence of hyperandrogenism is preferred in this group.
As there is no clear cut-off of testosterone levels for adolescents, biochemical hyperandrogenism should be defined based on the methodology used, informed Viardot-Foucault. “Ideally, to establish the existence of androgen excess, assaying for free testosterone levels is the gold standard as it is more sensitive than measuring the total testosterone levels,” she said. “But a downside of this is that it requires equilibrium dialysis techniques which are costly and not widely available.”
However, most commercial laboratories use direct analogue radio-immunoassay, which is notoriously inaccurate for measuring free testosterone, cautioned Viardot-Foucault. “If uncertain regarding the quality of the free testosterone assay, it is preferable to rely on calculated free testosterone, which has a good concordance and correlation with free testosterone levels measured by equilibrium dialysis methods,” she suggested. [J Clin Endocrinol Metab 1999;84:3666-3672]
Also, the value of measuring other androgens besides free testosterone in patients with PCOS is relatively low, although increased levels of dehydroepiandrosterone sulphate (DHEAS) have been observed in 30–35 percent of PCOS patients. [Ann N Y Acad Sci 2006;1092:130-137]
“Transabdominal pelvic ultrasound has a lower diagnostic accuracy,” said Viardot-Foucault. “The presence of polycystic ovarian morphology [on ultrasound] in an adolescent who does not have hyperandrogenism or oligo-anovulation does not indicate a diagnosis of PCOS.”
When menstrual irregularities are concerned, the first-line treatment should be cyclical progestogens when contraception is not required and there are no signs of hyperandrogenism, according to Viardot-Foucault. If there is clinical hyperandrogenism or a need for contraception in those sexually active, third-generation oral contraceptives such as ethinyl estradiol 30 µg can be considered.
“There is room for local treatment of hirsutism such as laser [hair removal, but only for patients beyond] 16 years old and [who are] at least 2 years post-menarche,” she said. “If there are metabolic complications, [patients should be referred] to the endocrinologist.”
There are some period problems that are unfortunately par for the course, like cramps, irritability, and bleeding more than you would like to be bleeding from your vagina.
But there are also some period problems that you should bring up to your doctor—just in case—because they’re a bit outside of what’s normally expected during menstruation. Here are some things to keep an eye out for.
1. You soak through a pad or tampon in an hour or less, your period lasts longer than seven days, or both.
The clinical term for an exceedingly heavy or long period is menorrhagia. These are basically horror movie-style periods, but some people don’t even realize this kind of bleeding is abnormal. “One of the biggest problems is someone being so used to heavy bleeding that she underplays the amount,” Lauren Streicher, M.D., an associate professor of clinical obstetrics and gynecology at Northwestern University Feinberg School of Medicine, tells SELF. “She’ll come in and say her periods aren’t too bad, then say she has to change her tampon every hour.” Passing clots larger than a quarter is also a sign your bleeding is too heavy, according to the Centers for Disease Control and Prevention (CDC).
It’s not just that bleeding way too much or for too long is messy and inconvenient. Losing more than the typical two to three tablespoons of blood during your period or bleeding for longer than seven days can lead to anemia, the CDC says. If you have anemia, you lack enough healthy red blood cells to get oxygen to all your tissues, so you may feel tired and weak, according to the Mayo Clinic.
Bleeding too much can also be a sign of various health issues, like uterine fibroids, which are benign growths in and on the uterus that can sometimes come along with problems like pelvic pain and frequent urination. Uterine polyps, which are growths on the inner lining of the uterus, can also cause heavy bleeding, as can cervical polyps, which are lumps that emerge from the cervix. Both types of polyps are typically non-cancerous but, in rare cases, may contain cancer cells.
The hormonal issue polycystic ovary syndrome (PCOS) can also cause heavy bleeding. Worse, this bleeding can strike after months of an MIA period. This gives your uterine lining a chance to build up over time, leading to an abnormally heavy period when it finally comes, Mary Jane Minkin, M.D., a clinical professor of obstetrics, gynecology, and reproductive sciences at Yale Medical School, tells SELF. PCOS can also cause symptoms like excess face and body hair or severe acne, thanks to high levels of male hormones.
Heavy menstrual bleeding could even be a sign of a disorder that causes you to lose too much blood, like idiopathic thrombocytopenic purpura (ITP). ITP usually comes along with other symptoms like easy and excessive bruising or a rash of reddish-purple dots on a person’s lower legs.
Clearly, figuring out what’s causing your heavy bleeding won’t be easy on your own, so you should see your doctor. They’ll typically ask about your other symptoms and perform exams to determine what exactly is going on, and treatment will depend on what you’re dealing with.
2. Your period brings days of pain that make it practically impossible to leave your bed.
Dr. Streicher’s rule is essentially that if you’re experiencing even an iota of period pain beyond what you’re fine with, it’s too much. The first step is typically to take nonsteroidal anti-inflammatory drugs, since they block hormone-like chemicals known as prostaglandins that cause uterine cramping. If that knocks out your cramps, you’re good to go. If you’re still curled up in the fetal position after a few hours, that’s a sign that you need evaluation, Dr. Streicher says. You’re dealing with dysmenorrhea (severe menstrual cramps), and doctors can help.
There are many different causes of overboard menstrual cramps. Fibroids are a common culprit. So is endometriosis, a condition many experts think happens when tissue lining the uterus travels outside of it and begins growing on other organs. (Other experts believe that tissue is actually different in that it can make its own estrogen, which can create painful inflammation in people with endometriosis.) In addition to causing extremely painful periods, endometriosis can lead to painful intercourse, occasional heavy periods, and infertility, according to the Mayo Clinic.
Adenomyosis, which happens when the endometrial tissue lining the uterus grows into the muscular walls of the organ, can also cause terrible menstrual pain, along with expelling big clots during your period and pain during intercourse.
3. You never know when your period is going to show up.
Pour one out for all the times you thought you’d have a period-free vacation, only for it to show up right as you hit the beach. Fun! Irregular periods could be due to a number of different things that are (at least somewhat) in your control, like stress and travel, Dr. Streicher says. But they can also happen because of various health conditions.
Take thyroid issues, for instance. Hypothyroidism, which is when your thyroid gland in your neck doesn’t produce enough hormones, can lead to an irregular period, according to the Mayo Clinic. It can also cause myriad other symptoms, like heavier than usual periods, fatigue, constipation, dry skin, weight gain, impaired memory, and more. Treatment typically involves taking medication that mimics the thyroid hormone.
On the flip side, hyperthyroidism, which is when your thyroid gland is overactive, can cause light or infrequent menstruation, along with issues like sudden weight loss, rapid heart rate, increased appetite, and more frequent bowel movements, according to the Mayo Clinic.
Irregular periods are also a sign of premature ovarian failure, which is when a person younger than 40 starts losing their normal ovarian function, according to the Mayo Clinic. It can also cause menopausal symptoms like hot flashes, night sweats, vaginal dryness, and difficulty conceiving. Doctors can offer estrogen therapy to relieve symptoms like hot flashes (typically in conjunction with progesterone to avoid the precancerous cells that may take hold if you take estrogen alone). They can also counsel you about the possibility of in vitro fertilization if you’d like to physically conceive and carry children in the future.
PCOS and uterine polyps be behind irregular bleeding, too.
4. Your period decides not to show up for a while.
While it’s true that you can sometimes randomly miss a period for reasons like stress, you shouldn’t just ignore a long-term missing period. Suddenly being period-free may feel blissful, but you’ll want to make sure there’s not a health issue going on, like PCOS, an eating disorder or excessive exercise affecting your menstruation…or, yes, pregnancy.
“If you’re menstruating normally then suddenly go months without a period, that’s not something to ignore,” Dr. Streicher says. If your period vanishes for three months or longer (this is known as amenorrhea), see your doctor for evaluation.
It’s worth noting that the use of some hormonal birth control methods—especially the hormonal IUD—can make your period basically disappear. Still, check with your doctor, just in case, when this happens.
5. You’re dealing with a lot of unexpected spotting between periods.
It could be something that’s ultimately pretty harmless, like a benign uterine or cervical polyp that’s causing bleeding between periods. But spotting is also a hallmark of pelvic inflammatory disease (PID), which is the result of sexually transmitted bacteria from infections like chlamydia and gonorrhea spreading to reproductive organs like your uterus, fallopian tubes, and ovaries. In addition, pelvic inflammatory disease can cause issues like fever, strange vaginal discharge that smells bad, and burning when you pee.
If you have PID, your doctor will first address the STI in question with antibiotics, says the CDC, then treat your partner for an STI if necessary. Pelvic inflammatory disease is a leading cause of chronic pelvic pain and infertility in women, so if you suspect you have it, treatment is of the essence.
More rarely, spotting in between periods can be a sign of cervical cancer, according to the Mayo Clinic. Cervical cancer can come along with watery, bloody discharge that might have a bad odor and pelvic pain, including during intercourse. Even though this likely isn’t your issue, you’ll want to get checked out, just in case. Treatment for cervical cancer may involve a hysterectomy, radiation, or chemotherapy.
6. You experience debilitating mood issues before your period.
When your estrogen and progesterone drop before your period, you may experience the typical mood swings that mark premenstrual syndrome (PMS). (Bear in mind that this may not be as drastic if you’re on hormonal birth control, which stabilizes your hormones throughout your cycle.)
But if you deal with severe mood swings, irritability, anger, a lack of enjoyment in things you usually enjoy, and other symptoms that affect your life, you may have premenstrual dysphoric disorder (PMDD). PMDD happens when you experience these symptoms in the week before your period, then they start getting better in the first few days of bleeding, and disappear in the weeks after your period. It’s listed in the DSM-5, the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, for good reason: This psychological issue can completely turn your life upside down.
“If you suspect you have PMDD, the one thing I would encourage is keeping a daily record of the severity of your symptoms,” Dr. Minkin says. If these symptoms only rear their head the week before your period, PMDD might be your issue. If you realize you’re constantly dealing with them and your period just makes them worse, it might be premenstrual exacerbation, which is another way of saying you have a mental illness like depression that gets worse during your period.
Either way, a doctor can help. If you have PMDD, your doctor may have you take antidepressants in the timeframe when you usually experience symptoms, then stop once your period starts, Dr. Minkin says. (If you have premenstrual exacerbation, they may recommend staying on the antidepressants through the month and potentially upping your dosage in the week before your period.)
Or your doctor may suggest you go on birth control using a synthetic version of progesterone called drospirenone, Dr. Minin says, like Yaz and Beyaz. These are FDA-approved to treat PMDD. Though experts aren’t sure why they can be so successful in this arena, it may be because drospirenone reduces a person’s response to hormonal fluctuations. It’s also a diuretic, meaning it can flush out liquids that could otherwise cause fluid retention and contribute to annoying issues like bloating.
7. You have excruciating migraines before or during your period.
If migraines had any home training, they’d at least leave you alone when you’re about to get your period. Unfortunately, period migraines are indeed a thing.
It’s not that menstruation will just randomly cause migraines in unsuspecting people who have never had one, but women with a history of migraines may experience them before or during their periods, according to the Mayo Clinic, which adds that this may be due to estrogen fluctuations. “They tend to get the headache right as they go into their periods, and it seems to get better after they have had their menses for a day or two,” Dr. Minkin says.
If you’re dealing with this, your typical migraine medication may work for you. As you probably know if you’ve grappled with migraines, the treatment options are legion. They include pain-relieving medications to relieve symptoms ASAP and preventive drugs to ward off migraines altogether, according to the Mayo Clinic. In the former camp, you have choices like anti-nausea meds and triptans, which constrict swollen blood vessels and block pain pathways in the brain. In the latter, you’ve got meds like tricylic antidepressants, which affect brain chemicals like serotonin that may be implicated in migraines.
No matter what your period problem may be, you don’t have to suffer in silence.
You have no reason to feel embarrassed about your period—or the myriad problems that can come with it. After all, celebrities are out here talking about menstruation! Some pad commercials even—gasp—use red “blood,” these days! What a time to be alive.
If you’re having period problems, see your doctor for help. If they aren’t committed to relieving your symptoms, that’s a sign you should try to find a more sympathetic medical professional who can help you find the best treatment.
Read this before feeling weird about your nipples.
If you’ve ever noticed a rogue nipple hair, it probably prompted an array of emotions including confusion (um, hi, what are you doing here?) and annoyance (what does one even do about unwanted nipple hair?). But, in most cases, having hair around your nipples is actually perfectly ordinary. Think of it this way: You have hair all over you body, so your breasts shouldn’t be any exception.
Pretty much everyone has some level of hair on their breasts.
What people typically call “nipple hair” usually isn’t on the actual nipple at all. Instead, this hair often pops up on the areolae, aka the pigmented circles surrounding your nipples, and other non-nipple breast skin. “It is extremely common for women to have hair around the nipples,” Joshua Zeichner, M.D., a New York City-based board-certified dermatologist and director of cosmetic and clinical research in dermatology at Mount Sinai Medical Center, tells SELF.
The exact percentage of how many women have breast hair isn’t known, since this isn’t something that has been studied at large or that women usually report to their doctors. Still, women’s health expert Jennifer Wider, M.D., agrees, telling SELF that breast hair is “very common.”
But…why does it exist? Biologically speaking, humans likely developed body hair for many reasons, some of which scientists haven’t yet fully pinpointed. Hair around your nipples may be a holdover from when body hair was an important part of regulating your temperature, Dr. Zeichner says. Since things like air conditioning, heaters, and fuzzy sweaters can do that now, the hair around your nipples doesn’t seem to serve any present-day purpose. Consider it boob decoration.
There are a few factors that can determine how much (or how little) hair you have on your boobs.
Like any other kind of body hair, breast hair can vary in amount, thickness, and color from person to person. Similarly to your pubic hair, it can also look different from the hair on the rest of your body, Dr. Zeichner says.
You may notice more hair growing around your nipples if your hormones are fluctuating more than usual, like during pregnancy, Sherry A. Ross, M.D., a women’s health expert and author of She-ology: The Definitive Guide to Women’s Intimate Health. Period., tells SELF. The pregnancy-induced surge of estrogen can prolong your hair’s growth phase, so just like the hair on your head can seem especially long and lush when you’re expecting, so can the hair on your breasts, Dr. Wider explains. It’s all normal.
If you notice that you’re producing a lot more hair here than you used to, it could be a sign of a condition like polycystic ovary syndrome (PCOS), which can cause excessive hair growth on your face and body. This type of hair growth is known as hirsutism and can happen because of elevated male hormones, like testosterone, which are a common characteristic of PCOS, Dr. Ross says.
Keep in mind that having hair around your nipples without any other symptoms isn’t a sign of PCOS, Dr. Wider says. But if you’re noticing a lot more than usual and you’re also getting hair on your face, coupled with symptoms like bad acneand irregular periods, it’s worth flagging for your doctor. They can evaluate you and, if necessary, recommend treatment like birth control or other medications to prevent excessive hair growth.
Bottom line: Hair surrounding your nipples is usually just a part of having breasts.
There’s no reason to feel weird about it, or like your breasts need to be as smooth and hairless as a baby dolphin. But if you really can’t stand having breast hair, you can pluck it just like you would pluck your eyebrows (and it might hurt, just like it can with your eyebrows). The skin around your nipples is delicate and can be easily irritated, Dr. Zeichner says, so razors and wax are dicier options than simply tweezing.
If you have more hair around your nipples than you care to pluck, a dermatologist can talk to you about electrolysis (a procedure that involves inserting a tiny needle into the hair follicle and sending in an electric current to destroy the root) or laser hair removal, Dr. Zeichner says. (Just keep in mind that laser hair removal runs the risk of creating skin discoloration or other side effects, so you want to make sure you see someone who knows what they’re doing.)
Again, having hair around your nipples is super normal and not something you need to stress about or consider removing if it’s not bothering you. But, if it does bother you or it seems like a sign something’s up with your health, talk to your doctor to discuss ways you can nip any bothersome breast hair in the bud.
Experts believe that more than half of women with polycystic ovary syndrome don’t even realize they have it.
If you’ve skipped a period or two (and know you’re not pregnant) and have been breaking out like you’re a teenager again, it’s easy to chalk it all up to stress. But something more serious may be going on, such as polycystic ovary syndrome (PCOS), a stealth health issue caused by a hormonal imbalance and marked by a series of small cysts on the ovaries.
Five to 10 percent of women of childbearing age are affected by the condition, but less than half of women are diagnosed, according to the PCOS Foundation. That means millions of women have PCOS and don’t even know it. To shed some light on this silent disease, here are the most common not-so-obvious signs of the hormonal disorder. If you’re experiencing any of these symptoms, bring them up with your gynecologist or general practitioner and get them evaluated.
1. Your cycle is all over the place.
Unpredictable menstrual cycles or skipping several periods are one of the hallmarks of PCOS. “Our menstrual cycle is like a vital sign,” says Maryam Siddiqui, MD, assistant professor of obstetrics-gynecology at the University of Chicago Medicine. “It tells us if our metabolism is in a good state; if you’re too thin, overweight, or stressed, that can throw your cycles off. Having irregular periods or more likely, skipping multiple periods could be a sign of a hormonal imbalance like PCOS.” Menstrual irregularities like these should raise a red flag and warrant a doctor’s attention.
2. You’re growing hair in unexpected places.
With PCOS, the ovaries produce excessive amounts of a type of hormones called androgens, which stimulate hair growth. We’re not talking about the hairs on your head. “You’ll get hair growth in funny places—around the nipples, on your chest, the inside of your thighs, and your belly,” says Siddiqui. “Places were women don’t typically have a lot of hair growth.”
Those same high levels of androgens also trigger acne. The hormones boost sebum production, and the combo of excess oil and old skin tissue plugs pores. To add insult to injury, bacteria that flourish on sebum increase, triggering inflammation.
4. There’s a dark “ring” around your neck.
You might blame it on a cheap necklace leaving a ring of residue on your skin at first, but PCOS can cause a stubborn darkening of the skin around the back of your neck. “It’s a velvety, dark discoloration that doesn’t wash off,” explains Siddiqui. The pigmentation and skin texture changes can also appear under your arms and around the vulva.
5. Your belly is getting bigger and you don’t know why.
Unexplained, persistent weight gain, particularly around the abdomen, is a sign of the hormonal disorder. Although it’s not fully understood why weight gain is a symptom, insulin resistance appears to play a role. “With PCOS, you can have trouble metabolizing blood sugar, known as insulin resistance,” explains Siddiqui. “When you have insulin resistance, your pancreas has to work really hard and make a lot of insulin just to lower your blood sugar. That is linked to weight gain and central obesity.” (Women with PCOS are at higher risk for developing diabetes.)
6. Those annoying skin tags keep popping up.
Although it’s not fully understood why, those flesh-colored nubs of excess skin tend to crop up around the neck area and under the arms of women with PCOS, according to the U.S. Department of Health and Human Services. It’s worth noting, though, that skin tags, which are benign and can be triggered by friction, are also common in people who don’t have PCOS, so don’t automatically freak out if you have them.
7. You’re having trouble getting pregnant.
The hormonal imbalance interferes with the body’s ability to ovulate normally, which is essential for pregnancy to occur. So it’s no surprise that PCOS is one of the most common causes of infertility. In fact, it’s responsible for 70 percent of infertility problems in women who have trouble ovulating, according to the PCOS Foundation.
A new study has found evidence that the common and debilitating reproductive condition, polycystic ovary syndrome, could start in the brain, not the ovaries, as researchers have long assumed.
If verified, the research could change the way we think about the painful and severely misunderstood condition, which affects at least one in 10 women worldwide.
Anyone who has polycystic ovary syndrome (PCOS) – or knows someone with the condition – will be aware of how incredibly frustrating it can be.
Thanks to the variety of symptoms it can cause – from weight gain, large ovarian cysts, difficulty ovulating, acne, facial hair, depression, and agonising and heavy periods – it can take women years to get diagnosed.
Even then, there’s very little in the way of treatment options. Most women are simply told to go on the pill or take other hormonal medications to manage their individual symptoms, but not the underlying cause.
In the long-term, PCOS can lead to metabolic disorders, such as type 2 diabetes, cardiovascular disease, and hormonal dysfunction, including infertility. In fact, PCOS is the cause of more than 75 percent of anovulatory infertility, which is infertility caused by a woman not ovulating.
And yet, despite the severity of the condition, researchers still don’t understand how PCOS arises and how we can treat it.
Now, researchers led by the University of New South Wales in Australia have shown that mice without receptors for androgens – a group of steroid hormones commonly associated with males, such as testosterone – in their brains can’t develop PCOS. But if the androgen receptors in the ovaries are removed, the condition can still arise
Seeing as mouse and human reproductive systems share many similarities, it’s compelling early evidence that doctors and scientists might have been focussing on the wrong piece of the puzzle all along.
“For the first time we have a new direction of where we should be looking to try and develop treatments that will treat the cause of PCOS, the androgen excess in the ovary but also in the brain,” said lead researcher Kirsty Walters in an emailed press release.
Before this, researchers knew that an increase in androgens, known as hyperandrogenism, was linked to the onset of PCOS. But exactly how and where these androgens act in the body was poorly understood.
“Hyperandrogenism is the most consistent PCOS characteristic; however, it is unclear whether androgen excess, which is treatable, is a cause or a consequence of PCOS,” the researchers write in their paper.
To get a better idea, the researchers took four groups of mice:
a control group of normal mice
a group of mice genetically engineered to have no androgen receptors (ARs) anywhere in their bodies
a group that had been engineered to have no ARs in just their brains
a final group that only had ARs missing from their ovaries.
The team then used a high dose of androgen to attempt to trigger PCOS in all four groups of mice.
While the control group developed PCOS as they expected, the mice missing ARs entirely, or just missing them from their brains, didn’t get the condition.
Interestingly, the mice that were only missing ARs from their ovaries still went on to develop PCOS, although at a lower rate than the control group. That means androgens acting on the ovaries can’t be the sole cause of PCOS.
The result suggests two important things: researchers were right about an excess of androgens triggering the condition; and the action of androgens on the brain is important to the development of PCOS.
That means if we can find a way to stop those excess androgens in the brain, it could signal a new way to treat PCOS.
“These data highlight the previously overlooked importance of extraovarian [outside the ovary] neuroendocrine androgen action in the origins of PCOS,” the researchers explain.
To be clear, this study has only looked at mice so far, and the results need to be replicated in humans before we can get an idea of whether the same thing is happening in our own reproductive systems.
But this is a big deal because, until now, the focus when looking for effective treatments and preventions has been on the ovaries – and we haven’t had much luck.
The new study, though it’s still early days, gives researchers a new target to look into, and it could hopefully lead to new, more effective treatments for people with the condition.
To Deborah E. Savage, a trip to the doctor was frequently an exercise in humiliation.
For more than 15 years, Savage’s doctors doled out the same advice: You need to stop gaining weight. When Savage replied that she had tried watching her diet and exercising, only to pack on more pounds, it was clear they simply didn’t believe her. Her family was equally skeptical.
“I would eat like my sister, and I would gain weight but she wouldn’t,” recalled Savage, a civil engineer who lives in Montgomery County and turns 31 next month.
Savage’s inexorable weight gain, which began in middle school and resulted in obesity, was not her only problem: For years, she also struggled with eruptions of painful acne and facial hair. “These things made me feel ugly,” she said.
For years, Debbie Savage kept gaining weight. She was plagued by horrific acne and apathetic doctors.
Last year, after Savage had trouble getting pregnant, an inability she suspected was linked to her irregular periods, she consulted a new obstetrician/gynecologist. The doctor suggested that Savage’s constellation of problems might have a single cause. But it took a second OB/GYN to conduct the proper tests, which led to a definitive diagnosis of a common — and consequential — disorder.
“It’s frustrating to me that so many doctors” didn’t think of this, she said. “If I’d known, I would have made changes years ago.”
From the time she was 12, Savage recalled, her inability to lose weight became one of the defining elements of her life. And because she is short — 5-foot-3 — extra pounds were particularly noticeable. Her family’s comparisons with her older, thinner sister rankled.
At her mother’s suggestion, Savage joined a gym, but that didn’t help her lose more than a few pounds.
Savage said she was too intimidated to ask her doctors why her weight didn’t budge much, even when she faithfully followed a diet and worked out.
Nor did she mention the other problems that plagued her. “The facial hair thing was embarrassing, so I didn’t want to talk about it,” she recalled. “Same with the acne. I felt so sensitive about it.”
Savage wasn’t sure what to make of her irregular menstrual periods, but doctors did not seem concerned. At times she went three months without a period; at other times they lasted for two weeks. She managed to lose a little weight in college, but her acne and other problems persisted.
In her early 20s, Savage said, her gynecologist chided her about how heavy she was; every year, she seemed to gain 10 pounds. “I explained that I had tried diet and exercise, but he said I was not trying hard enough,” Savage recalled.
To regulate her menstrual cycle and tame her acne, the doctor prescribed oral contraceptives, which helped clear her skin and made her periods somewhat less irregular.
When she got married in 2010, Savage and her husband joined a popular weight-loss program to see whether they could motivate each other.
Savage said she lost only about eight pounds after several months, while her husband, who followed the same diet, had no trouble shedding much more weight.
“It was very frustrating,” she recalled. “I was serious about following the rules, but it didn’t pay off. I kind of gave up.”
By early 2015, she was desperate. She had stopped taking the pill nearly a year earlier, in hopes of getting pregnant; without it, her acne had roared back and her facial-hair problem had worsened. Savage was at her heaviest weight — about 240 pounds — and her family doctor warned that her cholesterol, at 210 mg/dL, was too high.
In March, sheswitched gynecologists. Her new doctor zeroed in on her irregular periods and her weight and asked Savage whether she had heard of a metabolic disorder called polycystic ovarian (or ovary) syndrome.
Polycystic ovarian (or ovary) syndrome is a condition that affects up to five million American women, but it often goes undiagnosed. Here are the basics. (Gillian Brockell/The Washington Post)
Savage replied that a friend in college had been diagnosed with PCOS. She was surprised when the doctor responded that she suspected Savage might have it, too.
An explanation at last
PCOS is a common hormonal imbalance that often begins in puberty and affects as many as 10 percent of women. Its cause is unknown, but heredity appears to play a role: Women whose mothers or sisters have the disorder are at higher risk. Many women with PCOS have enlarged ovaries containing fluid-filled cysts that produce excess androgens — male sex hormones, which interfere with ovulation. Other signs of PCOS include irregular, absent or prolonged periods, acne and excess facial and body hair, a condition known ashirsutism.
Because it also disrupts the regulation of insulin, many women with PCOS are overweight or obese. The disorder, which can be controlled but not cured, also increases the risk of Type 2 diabetes, high blood pressure and heart attack.
The gynecologist told Savage that she also suffered from PCOS. When Savage asked whether it was possible to test for the disorder, she said that the gynecologist told her, erroneously, that there were no tests. The best way to treat the problem was to lose weight, the doctor advised. And, the gynecologist added, she held weight-loss seminars in her office and urged Savage to sign up.
Savage declined. Two weeks later, she consulted a third OB/GYN, Neil Horlick, who practices in Montgomery and Frederick counties.
Horlick, after taking her history and performing an exam, said he suspected she had PCOS. When Savage told him she had been told there was no test for it, he assured her that testing was available and that he would order it.
Because abnormalities of the thyroid or adrenal glands can cause similar symptoms, those must be ruled out first. PCOS is essentially a diagnosis of exclusion, made on the basis of blood tests, a patient’s symptoms and an ultrasound of the ovaries.
“We generally look for two out of three criteria for PCOS,” Horlick said. These include a history of irregular or absent periods, elevated levels of male hormones, particularly testosterone, and the presence of ovarian cysts. In Savage’s case, an ultrasound showed no cysts, but she did have an elevated testosterone level.
Horlick said he was surprised that Savage’s condition went undiagnosed for so long. “PCOS is always on our radar” when a patient with irregular periods complains of weight gain and hirsutism, Horlick said.
He told Savage that her best chance of getting pregnant involved losing weight. Horlick prescribed metformin, a diabetes drug that can promote weight loss. Metformin is commonly given to PCOS patients and may help promote ovulation as well.
Savage decided to take a new approach to food. She began following a paleo diet, which emphasizes meat, vegetables, nuts and fruit, and drastically reduces the intake of carbohydrates, sugar and processed foods.
The first month, she said, she was elated to discover that she had lost 15 pounds; between April and September, she shed 50 pounds and her cholesterol dropped 20 points. Her acne also improved, her level of testosterone dropped, and her menstrual cycle became more regular.
Savage said she asked relatives whether anyone else had been diagnosed with PCOS. “My parents had never heard of it,” she said.
In October 2015, she and her husband were elated to learn that she was pregnant with identical twin boys. Savage spent six weeks hospitalized at Maryland’s Shady Grove Medical Center under close observation, because her twins have a rare condition in which they share a single amniotic sac and placenta, a condition unrelated to PCOS. The babies were born April 22.
Savage said she hopes that her experience will spare other women from “struggling for years the way I did.”
“This isn’t a bizarre disorder,” she said. “It shouldn’t take [this many] doctors to find out, when I have a textbook case.”
Measures of reproductive success in women with polycystic ovary syndrome after ovulation induction may be independently predicted by serum 25-hydroxyvitamin D levels, according to study data.
“Our current study reaffirms a relevance of adequate 25-(OH)D for procreative success in women with PCOS undergoing [ovulation induction],” the researchers wrote. “Beyond reaffirming a consistency in directionality of the previously observed associations, we have additionally noted that this association becomes apparent at serum 25-(OH)D levels that are well beyond the threshold of 30 ng/mL that is currently deemed as a target ‘normal’ level.”
Lubna Pal, MBBS, FRCOG, FACOG, associate chair of education in the department of gynecology and reproductive sciences at Yale School of Medicine, and colleagues evaluated data from the Pregnancy in Polycystic Ovary Syndrome (PPOS I) randomized controlled trial on 540 women (mean age, 28 years) with PCOS to determine whether any links exist between vitamin D status and ovulation induction outcomes.
Primary outcome was live birth, and secondary outcomes included ovulation and pregnancy loss after ovulation induction. Vitamin D status was defined as sufficient ( 30 ng/mL), inadequate (20-29.9 ng/mL), deficient (< 20 ng/mL) or severely deficient (< 10 ng/mL).
During the 6-month trial duration, 74% of participants had evidence of ovulation. Compared with participants with 25-(OH)D levels of at least 20 ng/mL, those with 25-(OH)D deficiency were less likely to achieve ovulation (P = .006).
Live birth rate was nearly 19% overall. Compared with participants who did not deliver a live birth, serum 25-(OH)D was higher in those who did (P= .046). The likelihood of live birth was increased by 2% with each 1 ng/mL increase in 25-(OH)D (OR = 1.02; 95% CI, 1-1.04). Participants who were vitamin D sufficient had a 26% live birth rate, whereas the likelihood of live birth decreased in participants with vitamin D insufficiency (OR = 0.74; 95% CI, 0.57-0.96), vitamin D deficiency (OR = 0.61; 95% CI, 0.35-1.08) and vitamin D severe deficiency (OR = 0.48; 95% CI, 0.19-1.23).
Participants with vitamin D levels greater than 45 ng/mL had a fourfold increased likelihood of live birth (OR = 4.5; 95% CI, 1.27-15.72), whereas there was a 44% reduction in likelihood of live birth among participants with 25-(OH)D levels less than 30 ng/mL (OR = 0.58; 95% CI, 0.35-0.92). There were progressive improvements in the odds for live birth at 25-(OH)D thresholds of at least 38 ng/mL (OR = 1.42; 95% CI, 1.08-1.8) and at least 40 ng/mL (OR = 1.51; 95% CI, 1.05-2.17).
Twenty-nine percent of positive pregnancy tests were followed by pregnancy loss, and there was an 82% reduced likelihood of pregnancy loss with serum 25-(OH)D levels of at least 38 ng/mL compared with lower levels (OR = 0.18; 95% CI, 0.02-0.9).
“Our data suggest that for infertile women with PCOS, [vitamin D] status, as reflected by serum levels of 25-(OH)D, is relevant for procreative success,” the researchers wrote. “We hypothesize that decline in circulating 25-(OH)D below the [lower reproductive threshold] may be contributory to ovulatory dysfunction, whereas at levels at and above an [upper reproductive threshold], achieved through supplementation, may result in improved endometrial receptivity, as has been previously suggested, thus yielding improved treatment [live birth] rates and reduce risk of [pregnancy loss] in women with PCOS, a population that is already an enhanced risk for pregnancy wastage.” – by Amber Cox
Bariatric surgery can improve cardiometabolic health in women with polycystic ovary syndrome and obesity, according to findings of a retrospective cohort study presented here.
McAntoAntony, MBBS, a second-year resident at Medstar Washington Hospital Center in Washington, D.C., and colleagues evaluated data from Medstar facilities on 19 women with PCOS (mean age, 18.4 years; 53% black; 41% white; 6% Asian) who had undergone a bariatric surgical procedure. The most common procedure was gastric sleeve, followed by lap band with fewer Roux-en-Y gastric bypass, according to Antony. Researchers compared BMI, blood pressure, HbA1c, and triglyceride and HDL levels before and at least 6 months after surgery (mean time between surgery and follow-up, 7.9 months).
Compared with presurgical values, postsurgical reductions were observed in body weight (mean, 271 kg vs. 205.4 kg; P < .0001), BMI (mean, 45.9 kg/m2 vs. 35 kg/m2; P < .0001), systolic BP (mean, 133.4 mm Hg vs. 119.5 mm Hg; P = .0002), diastolic BP (mean, 81.9 mm Hg vs. 73.1 mm Hg; P= .007), triglycerides (mean, 143.2 mg/dL vs. 111.5 mg/dL; P = .04) and HbA1c (mean 6.6% vs. 5.8%; P = .03); mean HDL level increased (44.8 mg/dL vs. 52.5 mg/dL; P = 0.04). Before surgery, participants had a mean 2.7 components of metabolic syndrome on average, which decreased to 1.9 after their procedure (P < .01). Forty-seven percent of participants had at least three of the five components of metabolic syndrome, meeting criteria for the condition, before surgery. Following surgery, prevalence dropped to 21%.
“Bariatric surgery is definitely an option in the obese woman with PCOS to reduce her risk of developing cardiovascular disease in the future,” Antony told Endocrine Today. “ – by Jill Rollet
Among women with polycystic ovary syndrome, those aged 30 years or older are potentially at higher risk for developing early atherosclerosis, based on elevated lipid levels, lipid ratios and hypertension rates, compared with younger women with or without polycystic ovary syndrome, according to research in the International Journal of Endocrinology.
Subclinical cardiovascular disease was more prevalent in women aged at least 30 years with PCOS regardless of BMI, according to researchers.
“If we consider that women with PCOS are exposed to risk factors for CVD early in life, the diagnosis of subclinical atherosclerosis in this population would be of importance,” the researchers wrote.
Djuro Macut, MD, of the University of Belgrade, Serbia, and colleagues compared data from 100 women with PCOS (26.32 ± 5.26 years; BMI, 24.98 ± 6.38 kg/m²) with 50 healthy women (27.96 ± 5.6 years; BMI, 24.66 ± 6.74 kg/m²). Baseline blood samples collected after 12 hours of fasting during the follicular phase of the menstrual cycle, or randomly in the case of amenorrhea, were analyzed for levels of total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, apolipoprotein A, ApoB, glucose, insulin, total testosterone, sex hormone-binding globulin, androstenedione and dehydroepiandrosterone sulfate.
Patients aged at least 30 years with PCOS (n = 24) had higher BMI (P < .001) waist-to-hip ratio (P = .008), systolic blood pressure (P < .001), diastolic BP (P < .001), all lipids and their ratios, and ApoB (P = .014) than younger women with PCOS (n = 76), according to researchers. After adjustment for BMI, significant differences remained for systolic BP (P = .003), diastolic BP (P = .003), triglycerides (P = .05), insulin (P = .028) and free androgen index (P = .043).
In the older subgroups, women with PCOS had a significantly higher prevalence of hypertension than women without PCOS (n = 18; 61% vs. 17%, P = .003).
“A more proper assessment of the clinical phenotypes and use of specific metabolic indicators could be a valuable tool for the evaluation of [CV] potential and outcomes in future randomized studies on women with PCOS,” the researchers wrote. – by Regina Schaffer