Ovary-acting hormones, unpredictable periods and excessive hair growth – peak into the world of PCOS!

I call the next patient in.

Miss S is 22 years old, has brown hair, a contagious smile and has the most vibrantly colourful handbag that I make note to ask her about at the end of the appointment.

I was parallel consulting at the time which meant I conducted the interview and examined the patient, then I would call in the GP and handover / discuss my suggested diagnosis and management plan.

She tells me that she has had issues with her weight for as long as she can remember, her periods are extremely irregular and she has had to shave her facial hair for the past 3 years.

We chat for a bit, I examine her, and, almost more importantly, I find out where she bought her glorious handbag from, and I then call the doctor in.

She reveals to her GP that she has resorted to ‘Dr Google’ and questions if she may have Polycystic Ovarian Syndrome (otherwise known as ‘PCOS’) – I promptly nodded in agreeance to her suggestion – not because I was the smartest first year medical student alive …. but because I hadn’t the faintest clue what was going on and was keen for the doctor to explain what the cause for this strange cluster of symptoms could be! 

Fortunately, since then I have explored what PCOS actually is, how it presents, what its complications are and how it can be managed – annnddddd as September is PCOS awareness month I thought I would go ahead and share what I have learnt!

Let’s break it down –
Polycystic – just literally means ‘many cysts’.
Ovarian – is in the name because of its association with ovarian pathology.
Syndrome – is just a term that describes the combination of signs or symptoms that characterise a particular condition.

So, PCOS is a common and complex metabolic/endocrine condition that results in particular manifestations that often includes many cysts on the ovaries.

How common is it? 
PCOS affects approximately 1 in every 10 women of child bearing age – however, a large portion of women with PCOS remain undiagnosed.

How is PCOS diagnosed?
As there is a wide range of signs and symptoms that PCOS can present with, no two women with the diagnosis are the same!

And – my lecturer would be extremely proud to hear me say this haha – if you truly understand the pathophysiology (the functional changes) of a disease, then it is easier to understand the ‘why’ and ‘how’ the manifestations of a disease occur!

So, the main pathophysiological features of PCOS are hyperandrogenism and insulin resistance –

Hyperandrogenism;
o   Women with PCOS have abnormalities in the production and metabolism of androgens (sex hormones) which ultimately leads to hyperandrogenism (high levels of sex hormones)
o   Androgens are classically thought to be ‘male hormones’ – however, all women actually have these hormones too! – but with PCOS, there is an imbalance, with women often having significantly elevated androgens such as testosterone.

Insulin resistance;
o   Insulin is a hormone that is secreted by the pancreas which enables cells to take in glucose (energy) for its day-to-day functioning.
o   Insulin resistance means those cells fail to adequately respond to the circulating insulin.
o   Then, because the insulin isn’t working as well as it should, the body responds by producing mooooore insulin so that it can try and keep the blood glucose levels within the normal range.
o   And on top of that, the elevation in insulin levels can in turn increase the production of even more androgens in the ovaries as well as increasing the risk of diabetes! 

So with that in mind, a diagnosis of PCOS is made when 2 out of the following 3 criteria are met;

1 – Hyperandrogenism 

• High levels of a group of hormones that can either have clinical or biochemical manifestations 
• Clinical = hirsutism (abnormal male pattern facial or body hair growth on a woman – upper lip, chin, back etc) or less commonly male pattern alopecia (hair loss) 
• Biochemical = elevated testosterone levels in the blood 

2 – Polycystic ovaries

• Multiple fluid filled cysts (seen via ultrasound)
• To explain why this happens we have to go back to year 12 PE a little bit –
  • Normally, during a menstrual cycle multiple follicles develop within an ovary
  • One decides to become Queen B and dominates – this follicle will grow the biggest and will mature, become an egg and get released – if this egg is fertilised hellooooooo baby! but if it isn’t fertilised, cue the chocolate, ice cream and rom-com sesh because you my girl will have a period in precisely 14 days’ time!
  • The other follicles just tend to tap out and die off – bye, Felicia!
  • Buuttttt in PCOS, you often don’t get one brave follicle deciding to take charge and become the dominant one, therefore there is no mature egg that can be released – so this leaves behind multiple little follicles that eventually form multiple little cysts

3 – Oligo-ovulation and/or anovulation

• Oligo-ovulation = infrequent menstrual periods
• Anovulation = the absence of ovulation i.e where the ovaries don’t pop out a mature egg during a menstrual cycle

So now you understand that part you’ll be able to put together why the presentation of PCOS commonly includes;

• Menstrual irregularity
  • Because of the high levels of androgens and insulin preventing ovulation
• Infertility
  • Because a mature egg isn’t always popping out to be able to be fertilised
• Abnormal hair growth
  • Because of the increased levels of testosterone stimulating the hair follicles
• Acne
  • Because androgens increase the size of the oil production glands in the skin
• Obesity
  • This actually is a complicated chicken/egg debate – being obese is a risk factor for developing PCOS….BUUT PCOS is associated with too much insulin, or insulin that doesn’t work properly, which can lead to weight gain or trouble losing weight!
• Acanthosis nigricans
  • Pronounced ‘ak-an-thoe-sis nie-grih-kans’ – sounds like a Harry Potter spell right?! haha
  • These are dark, velvety, thick skin patches usually seen in skin folds
  • It is related to insulin resistance and commonly seen in people with diabetes (even those who don’t have PCOS)
• Sleep apnoea
  • Which is abnormal pauses in breathing while asleep
• Mood changes
  • Such as depression and anxiety

Are there any complications of PCOS?
Aside from potential fertility issues, those with PCOS are at a greater risk of developing cardiovascular disease (heart attack and stroke), type 2 diabetes, endometrial hyperplasia (abnormally thick lining of the uterus due to chronic anovulation) and potentially endometrial cancer.

Ok that doesn’t sound the best then – how can we manage it? 
Have no fear my fellow uterus housing humans – you have options! 

First things first – as we have now established, obesity is related to PCOS very intimately – so, aiming to have a healthy and active lifestyle is paramount and achieving a normal body weight and waist circumference is one of the first steps.

Weight loss for obese patients helps to restore ovulatory cycles (improving fertility), reduces the cardiovascular and diabetic risk and aids in preventing the lining of the womb from excessively thickening (decreasing the risk of cancer) while also commonly improving mood (win win really!)

To address the irregular periods AND the excessive body hair AND the acne, regulating a woman’s hormones is key – and guess what, going on hormonal contraceptives (‘the pill’) is an effective and simple way to do this – plus it will provide contraception if you don’t currently want any babies (it is the actual bom dot com right?!)

To further tackle the anovulatory infertility, there is a medication called Clomiphene Citrate (‘Clomid’).
It works by blocking particular estrogen receptors, disrupting a feedback loop, causing an increase in particular hormones (gonadotropins, follicle-stimulating hormone, and luteinizing hormone), which ultimately go on to stimulate ovulation – voila!!

Furthermore, some women use an additional medication called Metformin.
It works in approximately 30-50% of women by reducing androgen levels which helps to regulate menstrual periods and ovulation as well as reducing insulin resistance (woo-hoo!)

Aside from taking medication, or the temporary measure of shaving or waxing, excessive hair growth can also be managed really well by laser hair removal.

And, as to be expected with any chronic condition, there is a significant proportion of women who experience emotional and mental distress due to PCOS.
Whether it is due to worrying about the condition itself, the increased risks they may have, the potential for a bit more of a journey to becoming a parent, or their appearance – it is well known that many women unfortunately suffer in silence so I feel the need to push here that there is definitely a significant role for psychological counselling (big hugs also go a long way!)

So ladies, this is where I highly suggest booking in with your lovely GP if you are concerned you may be ticking a few of these boxes and need to have a chat about what might be going on!

Ok – so back to Miss S.
She left our consultation with a form for a blood test and an ultrasound, an appointment with a dietician and, for the first time in a long time, some optimism for her future.

I am a strong believer that life experiences shape who we are – but, shared experiences are even more powerful!

Your life, your story, your unique familiarity with a disease when shared becomes an invaluable and influential tool.

Your words can not only break down feelings of isolation, but can contribute to building supportive communities, spreading knowledge and information and can help in dissolving the stigma associated with medical conditions. 

You all know a fair bit about me by now – so, what about you? What have you experienced that has changed your perspective or given you insight that others could benefit from hearing about? What have you learnt by living your life a little closer to the medical field while being the one under the hospital sheets?

Tenae,
XXX

“It is your reaction to adversity, not the adversity itself that determines how your life’s story will develop.”

Dieter F. Uchtdorf