What is PCOS?
Polycystic ovary syndrome, more commonly known as PCOS, is a hormonal condition that is increasingly finding mention in women health journals and lifestyle magazines. You must have already read statistics such as one-in-every-ten or nearly 11% have PCOS today. But what is this condition really?
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A more severe version of its cousin Polycystic Ovarian Disorder, PCOS is characterised by the presence of higher than usual levels of male hormones or androgens in the female body. As a result this, the patient may experience unnatural growths (cysts) on her ovary, the unchecked growth of hair, darkening of skin and difficulties getting pregnant.
If unchecked, PCOS can lead to weight gain and eventually contribute to long-term health problems like diabetes and heart disease.
In India, the prevalence of PCOS according to a 2019 report by the Indian Journal of Medical Research ranges from 3.7 to 22.5 percent depending on the population studied and the criteria used for diagnosis. The study also concluded that there was certainly a connection between lifestyle and the prevalence of the condition as the proportion of women diagnosed with PCOS was much higher in urban women than rural women. A similar study conducted in Mumbai, proved the same. However, a rider posed in a peer-review of the paper suggested the common counter that diagnosis may be higher in urban centres due to better medical facilities and more awareness among doctors.
Studies have further shown that PCOS affects most women in their childbearing years, and commonly shows up at the time of puberty; though cases in which they show up later in life (even post pregnancy) are not uncommon. Tragically, due to little awareness on the subject, and illiteracy among parents in developing nations, several young women (upto 70%) who have PCOS do not realise so until much later (commonly while dealing with infertility issues when they try to conceive).
A Brief History of PCOS
PCOS isn’t a new condition. Its symptoms were first described and documented by the Italian physician Antonio Vallisneri in 1721.
The first definitive study conducted on the condition was by American researchers Freiler Stein and Michael Leventhal nearly 85 years ago in a paper titled "Amenorrhea associated with polycystic ovaries”. Still considered an authority on research into the Polycystic Ovarian Syndrome, since Stein and Leventhal, there have been thousands of studies on PCOS. The 50 years between 1950 and 2000, according to a report by the American National Library of Medicine saw over 8,000 publications on the topic; whereas in just the first 15 years of the 21st century, over 20,000 publications were reported.
Causes of PCOS
Despite several rounds of research the causes of PCOS are yet unknown.
Since the symptoms of PCOS have been found to run in families, the symptom is understood to be caused, at least on some level, by the mutation of one or more genes. According to one research published by the US Department of Health and Human Services, PCOS occurs likely due to a combination of genetic and environmental factors that may affect the chemistry of the womb.
What we do know so far is that polycystic ovarian syndrome is broadly related to levels of androgens and insulin in the body.
- High levels of androgens. Called male hormones, androgens such as testosterone help regulate the function of many vital organs, including the reproductive tract, bone, kidneys, liver and muscle. They are also responsible for several changes that the female body may undergo at puberty, such as the growth of underarm hair. When these male hormones increase beyond normal levels they cause complications including extra hair growth, acne, and can prevent the ovaries from releasing an egg in the time of ovulation.
- High levels of insulin. Several women with PCOS have been diagnosed with insulin resistance, which is a condition where the body’s cells fail to respond normally to insulin causing complications such as Type-2 Diabetes. The hormone insulin controls how the food you eat is broken down into energy and utilised for the body’s daily activities. Women with PCOS who have insulin resistance are found to be commonly overweight, suffering from obesity, due to unhealthy eating habits and irregular physical activity.
Diagnosis of PCOS
In 1935, Stein and Leventhal described PCOS as a condition found in several women displaying the common symptoms of menstrual disturbances, hirsutism and enlarged ovaries with many small follicles. As time progressed newer technologies such as ultrasound imaging arrived and allowed for the easy detection of ovarian cysts. While this provided for a breakthrough moment in the diagnosis of PCOS it also had an unexpected fallback. Several women who had cysts caused due to other conditions were now diagnosed with PCOS, despite not having any other symptoms (such as high levels of androgens or elevated growth of body hair). In many country, especially Asian and African ones, this trend still persists.
Eventually, in 2003, in a convention held in Rotterdam, Netherlands, a set criteria defined as the Rotterdam criteria was formulated which continues to be followed around the world, till date. According to this Rotterdam Criteria, to be diagnosed with polycystic Ovarian Syndrome, a patient must display at least three of the following criteria.
- Irregular or absent ovulation,
- elevated levels of androgenic hormones,
- enlarged ovaries containing at least 12 follicles each.
However, there is no single test to diagnose PCOS. Thus, to rule out other conditions and conclusively arrive at a diagnosis of PCOS, your doctor may conduct various physical examinations and medical tests. These would likely include:
- A physical exam where the doctor checks your BMI, blood pressure, waist size and looks for excess hair on your face, chest, back, and other body parts. This exam will also check for acne, skin discolouration and certain other internal signs such as enlarged thyroid glands.
- A pelvic exam, where the doctor may look for signs of male hormones as proved by the presence of physical symptoms such as an enlarged clittoris or enlarged ovaries, as seen on an ultrasound.
- A pelvic ultrasound or sonogram, where the doctor and lab technician use sound waves to examine your ovaries for cysts and check the uterine lining (endometrium) for unnatural growths or ruptures. This is usually always done to confirm for PCOS.
- Blood tests which could be used to check levels of male hormones in your body to make sure everything is within range. Blood tests also provide information about thyroid disease, cholesterol, and insulin, a hormone whose production and effectiveness is often interrupted due to PCOS.
Common Symptoms of PCOS
PCOS affects the functioning of the woman’s ovaries that in preparation for fertilisation of an egg every month prepare both male and female hormones. The female hormones, estrogen and progesterone regulate the menstrual cycle while the male hormone, testosterone, as mentioned earlier, regulate other body functions.
Every month, in a process called ovulation, the ovaries release eggs to be fertilised by a sperm in the uterus. In case the fertilisation doesn’t happen, the uterine lining (endometrium) tears, resulting in a period.
PCOS affects this process in the following ways:
- Sac-like cysts are formed in the ovaries which result in the production of higher levels of male hormones and interruptions in the cycles of ovulation. These sacs are effectively fluid-filled follicles each continuing an immature egg that will never mature enough to trigger ovulation. The word ‘polycystic’ derives itself from this feature, i.e. the presence of many cysts in the ovaries.
- Due to the lack of ovulation, the levels of hormones such as estrogen, progesterone, Luteinizing Hormone and Follicle Stimulating Hormone are altered while androgen levels are higher than usual. As a result of these hormonal changes, women with PCOS experience disrupted or prolonged ovulation. Some women may get fewer than eight periods a year. As the uterine lining builds up for a longer period of time, the periods you get can be heavier than usual.
The most common PCOS symptoms are as follows:
- Irregular periods due to interruptions in the process of ovulation.
- Heavy bleeding due to the building up of the uterine lining.
- Elevated hair growth, a phenomenon called hirsutism, due to which women experience the growth of hair on their back, belly, chest and face.
- Male hormones cause the eruption of acne, oily skin and breakouts of pimples on the face, chest and upper back.
- Darkening of the skin and dark patches on the neck, groin area and under the breasts.
- Weight gain due to changes in insulin levels in the body
- Male pattern baldness.
- Headaches and, in some cases, even migraines.
Complications caused by PCOS
PCOS and the elevated male hormones in the body that collect as a result of it can lead to various complications. A few of these are:
- Infertility: PCOS, as mentioned earlier, affects ovulation, or the release of eggs by the ovary. Since the release of eggs is interrupted, fertilisation and therefore conception can be a challenge.
- Sleep apnea: PCOS can lead to hot flashes and difficulty breathing at night leading to interrupted sleep. This is especially common in women suffering from obesity.
- Metabolic issues: Close to 70% women with PCOS are overweight or veer towards obesity. This alongside an elevated risk of high blood sugar, high blood pressure, low HDL cholesterol, and high LDL (“bad”) cholesterol can cause hindrances to the wellbeing of the body. All of these conditions together, if unchecked, can result in a risk of diabetes, heart disease and stroke.
- Endometrial cancer: Protracted ovulation can lead to the thickening of the uterine lining or the endometrium. A thickened endometrium can increase your risk of cancer.
- Mental illness: Unwanted hair growth, irregular hormones, inability to sleep and weight gain can propel the development of depression and anxiety. Many women who have PCOS fail to understand that they are not at fault, and are not to blame for symptoms such as weight gain. It is extremely important that women suffering from PCOS have adequate mental support either from understanding friends and family or mental health professionals.
Other complications include: potential miscarriages, severe liver inflammations and abnormal uterine bleeding.
PCOS Diet and Treatment
Unfortunately, despite active research, no comprehensive treatment to cure PCOS has been found yet. Your doctor would normally recommend lifestyle changes such as weight loss through exercise and changes in diet. According to some studies, using just 5% of your body weight can help regulate your menstrual cycle, improve cholesterol levels and reduce risks of diabetes and heart disease.
Various studies recommend low-carb diets as effective means to lower insulin levels and trigger weight loss, especially when the latter seems sluggish. Diets that are low in glycemic acid and high in iron have been found to work better than commercial weight-loss diets. Meanwhile, even 30-min of moderate intensity exercise can help regulate ovulation and push sluggish fat from problem areas.