What is PCOS?

Written By Temika Smith

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders in women, affecting approximately 1 in 10 females of reproductive age. My awesome student Temika Smith has pulled together an incredibly comprehensive resource containing heaps of current info about PCOS and how to help manage the condition and its symptoms.

PCOS is a hormonal disorder that can cause a range of problems including:

  • period problems (more or less frequent)

  • subfertility (reduced ability to conceive) or infertility (inability to conceive)

  • feelings of depression and anxiety

  • acne

  • excessive hair growth (hirsutism)

  • weight gain

  • darkening of the skin

In addition, it can increase your risk of Type-II Diabetes, cardiovascular complications, and endometrial cancer.

PCOS is commonly diagnosed through at least two of the following criteria:

  • elevated levels of androgens (hormones like testosterone that are naturally produced in women) as shown by a blood test OR the physical presentations of acne, or hirsutism, or menstrual abnormality, and

  • the presence of multiple cysts on the ovaries (detected by ultrasound)

  • irregular periods or no periods

What causes PCOS?

To understand what happens in PCOS, let’s take a refresher in what a normal menstrual cycle looks like.

There are four phases to a woman’s menstrual cycle: menstrual, follicular, ovulation, and luteal. Beginning with menstrual phase, we see the shedding of the endometrium (lining of the uterus) through the vagina (this is menstruation, or what most women call their period). The follicular phase starts on the first day of menstruation when your hypothalamus (the hormone “boss” in your brain) tells your pituitary gland (the “secretary”) to release follicle stimulating hormone (FSH). This hormone, like the name suggests, stimulates your ovaries to produce between five and twenty follicles which form like beads on the surface of your ovaries. Each follicle contains an immature egg. While a number of follicles develop, usually only one will become dominant, and capable of reaching maturity, while the others stop growing and disintegrate.

The developing follicle triggers an increase in oestrogen (another hormone). As the ‘boss’ of hormone delivery, the hypothalamus notices these rising levels and releases gonadotrophin-releasing hormone (GnRH) which prompts the pituitary gland to increase levels of luteinising hormone (LH) and FSH.

The ovulation phase is reached when the increased LH level triggers the release of the mature egg from the follicle and sends it on its way into the fallopian tube, toward the uterus. Meanwhile the luteal phase begins. The follicle (now missing the mature egg) left on the surface of the ovary transforms into a corpus luteum which releases a hormone called progesterone, and small amounts of oestrogen. Together, these hormones work to help thicken the lining of the uterus in preparation for the implantation of a fertilised egg. If the egg is fertilised, these hormones are released to maintain the lining. If no egg is fertilised, the uterine lining withers and dies, progesterone levels drop, and the lining of the uterus sheds, triggering the commencement of a new menstrual cycle.

What happens in a PCOS cycle?

In women with PCOS, an abnormal number of follicles accumulate on the ovaries because elevated androgen levels prevent the eggs from maturing enough to trigger ovulation. These unreleased, immature eggs become ‘cysts’ that prevent the conversion of testosterone (an androgen) to estradiol, a form of estrogen. As a result, the balance of normal hormones (estrogen to progesterone, LH and FSH) is impacted and we begin to see the expression of PCOS symptoms.

Doctors still don’t know exactly what causes PCOS but there are multiple theories suggesting that genetics, hormones, and lifestyle factors all play a role in the development of PCOS.

Genetics: PCOS tends to run in families and women with PCOS are 50% more likely to have a mother, aunt, or sister with the condition. Type II diabetes may also be common in families with PCOS.

Inflammation: inflammation occurs when your immune system reacts to foreign substances to protect your body from harm. Unfortunately, sometimes your body may inappropriately react to your own cells and tissues. Both chronic stress and being overweight can contribute to inflammation. Changes in lifestyle factors like diet, sleep, and other stress reducing activities could help to reduce inflammation and PCOS symptoms.

Insulin Resistance: Insulin resistance is where the cells in your body are not responsive to the level of insulin being produced so the pancreas produces more and more. Insulin resistance may be caused by lifestyle factors like diet, physical inactivity, and by being overweight. It can also be caused by genetic factors and can occur in women of all weight ranges.

It is important to know that through regular activity and healthy eating, you may be able to manage or reduce your insulin resistance and improve the symptoms of PCOS.

Androgens: Androgens are normally produced by the ovaries and adrenal glands but may be increased in women with PCOS, contributing to symptoms like acne, hirsutism, and irregular periods. These androgen levels may be increased due to higher levels of LH or insulin which may be elevated due to genetics or lifestyle (science isn’t yet conclusive!).

Elevated levels of insulin form a cyclical relationship with androgen levels, whereby insulin increases the production of testosterone, in turn promoting insulin resistance.

The fact there are different causes of PCOS (e.g., insulin resistance, androgens, genetics, inflammation etc.) may suggest different phenotypes (forms) of PCOS experienced by women.

Different forms of PCOS

There is no one distinct form of PCOS. The condition varies tremendously in terms of its presentation and the underlying causes. Indeed, researchers have struggled to reach a consensus regarding the PCOS forms, because the underlying causes vary. Some research suggests that there are two main forms:

1) those with polycystic ovaries and subfertility and

2) those with metabolic risk due to insulin resistance,

But some research suggests that there is a 3rd, less common lean form of PCOS characterised by low body fat and elevated androgens.

This concept of a “lean PCOS” might make sense to those women who don’t “fit” the characteristics of the prevalent form of PCOS (commonly a body type which is overweight with insulin-resistance and hyperandrogenism; 61 to 76% of Australian and US women with PCOS are in the obese weight range). Unlike the more common form of PCOS, those women with the lean form are less likely to be diabetic, have insulin resistance or metabolic abnormalities, be anovulatory (i.e., they probably do still have a period), and have less visceral fat. Current research (based on the Rotterdam diagnosis criteria) suggests these four different phenotypes:

Insulin resistance is more likely to be present (and severe) in women with phenotypes A and B. Extensive evidence suggests that hyper insulinemia (high insulin resistance) directly effects fertility in PCOS. For women with PCOS and these phenotypes, it is important to be mindful of prediabetes, diabetes, and metabolic syndrome. Weight loss is recommended for women with these phenotypes to reduce the chance of developing these conditions, in addition to careful management of diet and lifestyle. Medications such as metformin (which helps the way the body processes insulin) are also used often.

Phenotypes C & D (the lean forms) are not exempt from insulin resistance or the risk of developing metabolic syndromes such as Type II diabetes. While the risk of developing these conditions is lower for Phenotypes C&D, than the more common PCOS forms, the risk is still greater than in women without PCOS. Hormonal birth control (e.g., the pill) is a frequently recommended way to reduce the symptoms of PCOS. Other management strategies include careful diet, exercise, and stress management. You can find some anecdotal use of the strategies for lean PCOS here.

PCOS and Ethnicity

It is important to know that the presentation of PCOS varies cross culturally and so you may struggle to get diagnosed simply because you present differently. For example, women from the Pacific Islands are less likely to have acne and hirsutism than European women. It may be important for you to keep these differences in mind when you talk to your health professionals about treating and managing your PCOS symptoms. For example, someone from Eastern Asian heritage may be more concerned about central fat (around the stomach)  and the implications for their future health compared to someone of Hispanic heritage who may be more concerned about their BMI.

*The following link includes a BMI calculator

* Metabolic syndrome is a collection of conditions including insulin resistance, high blood pressure, obesity, high blood triglycerides, Type II diabetes (T2D), stroke, and heart disease.

*Groups at risk for metabolic syndrome and T2D may manifest PCOS at younger age

PCOS: Fertility and Pregnancy

It is important to keep in mind that women with PCOS generally have the same number of children (with or without assistance) as women without PCOS. About 70-80% of women with PCOS have fertility problems where it may take longer to conceive or require medical assistance to fall pregnant. PCOS disrupts a normal menstrual cycle making it difficult to fall pregnant, particularly when you don’t ovulate. However, this does not mean that you are infertile! Interestingly, despite experiencing severe symptoms due to the hormone imbalances associated with polycystic ovaries, some younger women may have the imbalance correct itself as they age, and their follicle number drops. This may result in them having more eggs in their thirties and a better chance at conception. Of course, this is unlikely the case for everyone, and you may need to be assisted in your pregnancy using treatments that improve your ovulation. Treatments may include IVF, insulin sensitisers such as Metformin that reduce the impact of insulin resistance, and ovulation inducing drugs such as Clomiphene. It is recommended that you consider planning a family early to reduce the added risk of age-related fertility factors that begin around the age of 35. Losing weight and reducing blood sugar levels can also help your chances of having a healthy pregnancy.

Once pregnant, women with PCOS do have a higher risk of pregnancy complications including miscarriage, preeclampsia, and gestational diabetes. Daughters of women with PCOS also have a 50% chance of also having PCOS. Sometimes the hormonal fluctuations after pregnancy and breastfeeding may alter your PCOS symptoms, however these symptoms still need to be managed. Give yourself some time to settle into your new normal.

PCOS and Mental Health

PCOS not only affects us physically, but also emotionally and mentally. Coping with symptoms like hirsutism, acne, weight changes and fertility problems can affect several mental health issues including anxiety, depression, body dissatisfaction, eating disorders, diminished sexual satisfaction, and lowered health-related quality of life.

Depression: Women with PCOS are more likely to experience depressive symptoms, but we don’t really understand which specific features of PCOS might cause depression. Contrary to expectations, higher androgen levels, hirsutism, and infertility have not been found to account for depression. Obesity, which affects two thirds of women with PCOS, is not necessarily the culprit, as some studies have found that obesity was related to greater depression scores, but others have indicated that it is unrelated to depression.

Anxiety: The connection between anxiety and PCOS symptoms seems to be similar to the connection to depression symptoms, but some research also suggests that anxiety may be rooted in insulin resistance.

Some researchers suggest that anxiety and stress may actually contribute to the development of PCOS, as stress activates the hypothalamic-pituitary adrenal axis (HPA) which produces adrenal hormones. Healthy women produce 25% of their testosterone from adrenal androgens and  women with PCOS have a stronger HPA response, suggesting that they may be producing more testosterone as a result. Women with the lean form of PCOS may be more prone to disturbances in the HPA and it has been suggested that this might relate to the development of the condition.

Body Dissatisfaction and Eating Disorders: Appearance related symptoms like hirsutism, acne and weight can be (understandably) particularly upsetting to women with PCOS as they may see themselves as unfeminine or unattractive. Even women with PCOS who are of normal weight tend to view themselves more negatively than women without PCOS. Body dissatisfaction may be playing a role in triggering depression and anxiety and can interfere with our willingness to socialise with others. Interestingly, those who are dissatisfied with the way they look are likely to also feel less fit and healthy, and not just unhappy with their outward appearance.

Quality of Life: PCOS is related to a reduced quality of life due to sexual dissatisfaction, depression, anxiety, bodily pain, life dissatisfaction, infertility, weight difficulties, menstrual irregularity, and poorer interpersonal functioning. Women with PCOS are often more stressed and worried about their future health than women without PCOS.

The journey to a diagnosis of PCOS and then its management is long and frustrating. There is help available to you to improve your emotional health. If you are worried about any of the mental health issues discussed earlier (or simply your mental health in general), it is important that you talk to your health professional.

If you are worried about your immediate mental health, please seek help!

Mental Health Links:      Beyond Blue ½ Headspace ½ Lifeline ½ SANE Australia

PCOS Management

Keep in mind that PCOS is a condition that is manageable with the right treatments. As PCOS has many symptoms, a variety of treatments my be required to manage the condition. A team of health professionals can help. They might include:

  • general practitioner/doctor (primary care co-ordinator)

  • dietitian – supports a healthy dietary intake

  • exercise physiologist – supports an active lifestyle

  • counsellor and/or psychologist – provides psychological support

  • gynaecologist – provides specialist care for reproductive health

  • endocrinologist – provides specialist care for hormonal conditions

  • fertility specialist – provides specialist care to assist in becoming pregnant

  • dermatologist – provides specialist skin care (for acne or excess hair growth)

  • nurse practitioner – provides educational support

The table below illustrates a number of treatments that may help improve symptoms. For more detailed information about how these treatments help reduce the symptoms, please visit the attached links.

Temika Smith
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