What is PCOS?
Polycystic ovarian syndrome is the leading cause of female infertility and if untreated can lead to diabetes and heart disease
By Melanie Phipps-Morgan, MSN
When CNN Headline News health anchor Kat Carney was 21, her doctor discovered a small ovarian cyst during a routine exam. Carney’s doctor didn’t seem too concerned, so Carney wasn’t either. Looking back, the reporter realizes she was already beginning to exhibit other classic symptoms of polycystic ovarian syndrome (PCOS), including hirsutism (excess facial or body hair), loss of hair on her head, long and irregular periods, and obesity. “It wasn’t like my hair was coming out by the handful, but there was always a whole bunch of it on the bathroom floor,” says Carney. “And I was plucking a few hairs from my chin. I also always had a problem keeping my weight down. If I had mentioned these other symptoms, doctors probably would have been able to put it together.”
An aching back in her mid-20s, perhaps due to her weight gain, eventually propelled Carney to seek more medical attention. “I made an appointment with another doctor and got on the scale to be weighed, and it said 240 pounds. I told the nurse the scale was wrong—that’s how much in denial I was.” Carney’s weight gain, as well as her hair loss and spotting between periods, led her doctor to suspect PCOS. An ultrasound showed Carney’s ovaries were also filled with cysts, another frequent symptom of PCOS.
Carney’s doctor told her she needed to be treated for PCOS, gave her two prescriptions, explained she’d be on them until she was ready to have children, and sent her on her way. However, after suffering side effects from the medications, Carney decided to do some online research on PCOS. “I located a medication that I thought would be better for me, consulted with several doctors, and then worked with a new doctor to find a course of treatment that I could tolerate,” she says. Carney also decided not to depend solely on medication and worked to change her lifestyle habits through improved nutrition and exercise. Her revised plan worked—she shed 90 pounds and is now completely off her PCOS medications.
Diagnosing the condition
The prevalence of PCOS includes approximately 5 percent of all women of reproductive age—making it one of the most common reproductive disorders, according to the American College of Obstetrics and Gynecology. And yet most, like Carney, don’t even know they have it. Among women with ovulatory dysfunction, about 70 percent have PCOS (ACOG Practice Bulletin, 2002, vol. 99, no. 2). And that’s bad news, considering PCOS is one of the leading causes of infertility in women. In addition, women with PCOS are often at increased risk for diabetes and heart disease and, possibly, endometrial cancer, if left untreated. Although the syndrome has been described in medical literature for more than 60 years, its exact causes are unknown. An inability to respond properly to insulin is believed to be the root of the problem.
Polycystic refers to the appearance of the ovary and comes from the Greek poly, meaning many, and kystis, meaning pouch. A polycystic ovary usually looks smooth and pearly white with prominent surface vessels, in contrast to the normal ovary’s pale-yellowish, wrinkled appearance. The covering of a polycystic ovary is usually thick and fibrous, with superficial follicle cysts often shining through. These follicles are what, under normal circumstances, produce eggs. Polycystic ovaries may be enlarged and occasionally are detected by an abdominal ultrasound. However, the fact that not all women who have PCOS have ovarian cysts makes diagnosis a challenge.
“The reason PCOS is difficult to diagnose is because it’s a syndrome and not a disease,” explains Mark Perloe, MD, medical director at Georgia Reproductive Specialists Center in Atlanta, where he sees numerous PCOS patients. “The diagnosis is generally based on what the patient complains of and not specific tests. There is no one specific PCOS test. So the testing [we do] is mainly to make sure there’s not another condition that’s causing these symptoms or to determine whether one treatment might be more effective.”
Adding to the difficult diagnosis is the fact that polycystic ovaries can also occur in women who ovulate, such as Carney, or who have no history of infertility. Because the ovaries may not appear unusual (leading some experts to call for a renaming of the syndrome), the presence of PCOS is based primarily on two other factors: irregular menstruation and hyperandrogenism (high levels of the male or androgen hormones in the blood). The weight gain Carney experienced is also a common symptom, as is facial hair, male-pattern hair loss, acne, and skin discoloration.
Understanding the biology
The organs most specifically involved in the regulation of the menstrual cycle are the hypothalamus and pituitary (both located in the brain), the ovaries, and the uterus. The release of an egg is a reminder of the intricate balance and interplay of our hormones, the serums that our cells produce to communicate with other cells at a distance. In fact, many hormones “talk” to each other to properly produce an egg every month. Sometimes, though, the system becomes unbalanced, causing irregular periods.
In women with regular periods, the hypothalamus releases a pulse of the gonadotropic-releasing hormone approximately every 60 to 90 minutes. In women with PCOS, these pulses are thought to increase, which in turn stimulates the pituitary gland to increase the secretion of luteinizing hormone (LH) and decrease the secretion of follicle-stimulating hormone (FSH). Because of the low FSH levels, ovulation does not occur.
The increased secretion of LH causes the ovaries to enlarge and thicken and stimulates them to produce an excess of the androgen hormones, testosterone and androstenedione. Because the pituitary is making low amounts of FSH, the ovarian follicles are unable to break down the circulating testosterone. An enzyme in the body’s fat converts some of these androgens to estrogen, so women with PCOS are not estrogen-deficient. In fact, they often have excessive amounts of estrogen from a high level of body fat. However, because of the high levels of circulating androgens, it is common for some women with PCOS to have facial hair and acne.
Why women get PCOS
There seems to be a genetic component to the development of PCOS, though one’s genes are not a conclusive or an adequate explanation for its occurrence. Instead, studies indicate that a combination of genetic and lifestyle or environmental factors is probably responsible for the development of the syndrome.
Studies indicate a strong correlation between PCOS and insulin resistance. Current studies also indicate a strong correlation between PCOS and insulin resistance, the precursor to diabetes (British Journal of Obstetrics and Gynaecology, 2000, vol. 107, no. 11). Studies indicate that up to 40 percent of women with PCOS have either impaired glucose tolerance or type 2 diabetes by age 40.
“When the body takes in calories, it has a choice of either burning them for energy or turning them into fat and storing them,” explains Perloe. “In about two-thirds of women with PCOS, the body takes this energy and stores it as fat. It appears that the way one stores fat is related to the types of food one eats, and their sensitivity to insulin. So in other words, in some people, insulin levels are high and they’re going to store their calories. Some people say, ‘Well, just diet and lose weight.’ But we find that a combination of diet, exercise, and medication works best. [PCOS patients] need to eat low glycemic-index carbs and eat foods that are less likely to increase blood sugar insulin.” For example, potatoes, breads, and cereals tend to have high glycemic indexes and should therefore be consumed in moderation.
Treatment that works
If you’re being treated for PCOS, your health provider should first address the most pressing symptom, whether it is infertility, facial hair, irregular periods, obesity, or something else. However, the long-term implications of PCOS, including diabetes and possible cardiovascular risk, cannot be ignored. Because of the potential to develop diabetes, women with PCOS should be tested for high blood sugar with a fasting glucose test. Cardiovascular risk factors, such as high blood pressure and high cholesterol, should also be assessed.
Many take an alternative or holistic approach to treating PCOS. From an herbalist’s perspective, for example, some polycystic ovarian syndrome symptoms are often thought to result from the body’s inability to effectively metabolize sugars. In addition, ovarian cyst formation suggests fluid sluggishness or lack of energy. When working with PCOS clients, Ithaca, New York–based herbalist Emma Whiteoak Lee first addresses the basics: sleep, diet, exercise, and identifying sources of stress. Her goal is to help PCOS clients get to a state in which the healing process can begin. This rebalancing usually lasts two weeks to one month. In a dietary assessment, she looks at a woman’s intake of protein, whole grains, and good-quality fats. High insulin levels in the bloodstream can respond well to improvements in eating habits. (See “Herbs for Treating PCOS” for herbal recommendations.)
Polycystic Ovarian Syndrome
Association; www.pcosupport.org; 877.775.PCOS
Androgen Disorders in Women
by Theresa Cheung and James W. Douglas (Hunter House, 1999)
Balancing Hormones Naturally
by Kate Neil and Patrick Holford (Judy Piatkus Publishers, 1998)
PCOS: The Hidden Epidemic
by Samuel S. Thatcher, MD, PhD (Perspectives Press, 2000) Lifestyle changes can also help to resolve many PCOS symptoms. In obese women, as little as 7 percent weight loss has been shown to restore fertility and lead to a reduction in insulin and androgen levels (Clinical Endocrinology, 1992, vol. 36, no. 1). And Carney is proof of that. After her lifestyle modification, the reporter lost 90 pounds in 14 months and got off the medication.
Whatever method you choose to treat PCOS, Carney recommends that you do your research. “There are still so many doctors out there who don’t really have a good grasp on what the disorder is and others who know what it is but aren’t aware of all the different treatment options,” says Carney. She also offers advice for those who are newly diagnosed: “First, take a deep breath, because this is livable. Everything feels bad when you have it, and it has such a scary name—I wish they’d name it something else. Also, consider treating it holistically. We can’t go fill up on junk and expect to be well. On my way home from the doctor the day I was diagnosed I thought, ‘I’m putting premium gasoline in my car, but I don’t even treat my body that well.’ And that just can’t be.”
Melanie Phipps-Morgan was recently a research nurse at the College of Physicians and Surgeons at Columbia University in New York City.