Polycystic Ovarian Syndrome (PCOS): All Too Often Misunderstood & Mistreated
If you have weight loss resistance, menstrual irregularities, excessive unwanted hair growth, loss of hair on head, and/or acne…keep reading…there is a good possibility you have PCOS.
Polycystic Ovarian Syndrome (PCOS) is a common endocrine (hormonal) disorder resulting in multiple medical problems and serious health risks. It affects millions of woman, many without their knowledge. It is estimated that between 5-10% of women have PCOS and that 70% of these women are undiagnosed. In fact, PCOS is the most common endocrine disorder in premenopausal women. And for postmenopausal women, menopause neither cures nor eliminates PCOS. In fact, PCOS usually worsens at menopause due to weight gain and loss of hormones.
PCOS seems to have a strong genetic component, so if a woman in your family has menstrual irregularities, diabetes, or a diagnosis of PCOS, there is a chance you may have it. It can be passed down from either your mother’s or father’s side of the family.
Unfortunately, one of the biggest problems with PCOS is that most physicians either miss the diagnosis altogether, mistreat it, or only partially treat it.
Why is PCOS So Confusing to So Many Physicians?
Because of its name, Polycystic Ovarian Syndrome, most physicians think PCOS is a gynecological disorder. Not true. Yes, it usually has gynecological effects, but it’s primarily a metabolic disorder, not a gynecological disorder. And again, because of its name, many doctors think that women with PCOS all have cysts on their ovaries. Also not true. So when many physicians suspect a woman has PCOS, they refer them to a gynecologist, who will typically just place the woman on birth control pills. Another error – and an incomplete treatment at best.
PCOS is a syndrome of insulin resistance, resulting in increased androgen (male sex hormone) sensitivity due to decreased production by the liver of a protein called sex hormone binding globulin (SHBG) and increased gonadotropin secretion (hormones that stimulate the gonads). The underlying defect remains unknown. But the decreased production of SHBG results in an increased sensitivity to testosterone because SHBG binds testosterone. So women with PCOS usually have normal levels of total testosterone but increased free testosterone levels, because so little of their testosterone is bound by SHBG.
And not all women have all of the symptoms of PCOS all of the time, making diagnosis even more difficult.
What Are the Main Symptoms of PCOS?
The most common symptoms include:
- menstrual irregularities (pain, missed or lack of periods, irregular bleeding)
- infertility or difficulty getting pregnant
- hirsutism (abnormal, excessive hair growth on the face and body)
- loss of hair on head
- weight gain/weight loss resistance (although 50% of women with PCOS are not overweight
- miscarriage (women with PCOS are affected with a 1st trimester miscarriage rate between 30-50%)
Why is PCOS So Problematic?
Treated incorrectly or impartially, PCOS can have serious, life-threatening consequences for a woman. That’s why it is imperative that any women who suspects she may have PCOS see a physician who will treat it as the metabolic disorder it is.
The most serious complications of PCOS:
- 30-50% 1st trimester miscarriage rate
- Increased incidence of Coronary Artery Disease
- Increased incidence of Stroke
- Increased incidence of Type 2 Diabetes
- Increased incidence of Metabolic Syndrome (a disorder of energy utilization and storage)
- Increased incidence of Breast Cancer
- Increased incidence of Endometrial (Uterine) Cancer
- Increased incidence of Depression
- Increased incidence of Obesity
- Increased incidence of Non-alcoholic Fatty Liver Disease
The risk of endometrial cancer and breast cancer is increased six-fold as a result of anovulation due to the loss of progesterone production. Anovulation exposes the uterus to unopposed estrogen, increasing a woman’s risk of endometrial cancer.
Also, over 50% of lean women with PCOS will have non-alcoholic fatty liver disease due to various degrees of the syndrome.
So How is PCOS Diagnosed?
The diagnosis of PCOS is mainly a clinical one. This means it is usually diagnosed by patient history, symptoms, and physical examination. Again, meaning your choice of physician is so important.
Normally, a woman has a higher level of Follicle Stimulating Hormone (FSH) than Lutenizing Hormone (LH). PCOS can often be confirmed by this ratio being reversed: Meaning in PCOS the LH:FSH ratio can be 3:1 (note: testing should be avoided mid-cycle because there is often less of a reversed ratio at that time). And if a woman is on birth control pills, she needs to stop them for at least one month before testing the LH:FSH ratio.
If you have weight loss resistance, menstrual irregularities, excessive unwanted hair growth, loss of hair on head, and/or acne, there is a good possibility you have PCOS.
So How is PCOS Properly Treated?
- Diet and Exercise: If a woman has PCOS and is overweight, the mainstay of treatment is weight loss. So diet and exercise are extremely important components of any treatment plan. The effectiveness of PCOS treatment is increased with a well-balanced low-carbohydrate diet and a personally tailored exercise program.
- Metformin: Since much of the problem with weight gain is insulin resistance, it should also be treated with a medication called metformin. Metformin is a medication used to treat insulin resistance. Metformin increases insulin sensitivity and therefore assists weight loss. Not all women with PCOS are insulin-resistant but may still respond to metformin and other medications in treatment.
- Spironolactone: The androgen sensitivity (causing excessive hair growth and acne) is treated with metformin and another medication called spironolactone. Spironolactone blocks the androgen receptor and decreases androgen synthesis by decreasing lutenizing hormone. Spironolactone should be used in any woman greater than 40 years old regardless if she has acne or hirsutism because it will block due aldosterone (which causes tissue inflammation leading to coronary artery disease and other vascular problems).
- Birth control pills: These can also be an alternative for certain women. Birth control pills suppress Luteinizing Hormone (LH) and therefore lower androgen production and increase SHBG, lowering free testosterone levels. In fact, anything that increases SHBG will decrease a woman’s androgen sensitivity. But remember, this will not address the underlying metabolic defect and will only partially treat PCOS.
- Thyroid hormone: Treatment with thyroid hormone, specifically T3, will also increase SHBG and decrease androgen sensitivity. It can also assist with weight loss and maintenance of a healthy body weight.
- Bio-identical Oral Progesterone: Lack of ovulation can also be treated with bio-identical oral progesterone. Avoid synthetic progestins such as Provera, which increases breast cancer risk, or progesterone creams (which do not achieve adequate blood or tissue levels to be effective). The chronic loss of progesterone in a woman with PCOS puts her at a much higher risk than the general population for both endometrial (uterine) and breast cancers. Bio-identical progesterone will lower the risk of both of these often deadly diseases. Bio-identical progesterone has also proven to be effective for inducing fertility when there are problems with ovulation. Research indicates that bio-identical progesterone therapy poses no risk, and is likely to benefit women who want to become pregnant. It also helps maintain pregnancy through the early months.
It is also important to note that removing the ovaries does not help PCOS, since ovarian removal or suppression does not cure the insulin resistance or associated problems due to the disordered metabolism of PCOS. However, it has been found that treating the insulin-resistance results in a reduction of symptoms and stimulates ovulation. We treat lack of ovulation in PCOS firstly with metformin. But If anovulation persists despite adequate treatment with metformin, the treatment of choice is bioidentical progesterone since chronic progesterone loss puts a woman at risk for breast and uterine cancer. Continuing metformin after conception is important because it lowers a woman’s miscarriage rate to less than 10%. Metformin also markedly reduces the high incidence of gestational diabetes in women with PCOS.
Goals of Treatment for Women With PCOS
- Reduce insulin resistance
- Correct menstrual irregularities and/or lack of ovulation
- Prevent endometrial (uterine) and breast hyperplasia and cancer
- Attain and maintain a healthy weight
- Decrease risk of Type 2 Diabetes
- Decrease risk of Coronary Artery Disease and Stroke
- Block the effects of androgens on the skin (acne, unwanted hair growth)
- Stop loss of hair on head
- Treat depression if present
We still have so much more to learn about PCOS, what causes it, and how to treat it to best take care of women who suffer from it. Many women avoid seeking help because they think their symptoms are unrelated or not connected to an underlying disorder. As more women become aware of PCOS and its symptoms, and bring those concerns to their doctors, the medical profession’s understanding of PCOS and how to treat your health short-term and long-term will improve.
If you suspect you have PCOS, or think someone you know may have it, it’s imperative to be evaluated and treated properly. The sooner the better. Please make an appointment with a physician who thoroughly understands the disease and will offer adequate treatment which addresses underlying defects and risks and not just symptoms. It can dramatically improve the quality of your life and save you from a lifetime or health challenges.
To schedule an evaluation with Dr. Mike Carragher, call 1-323-874-9355.