Polycystic Ovary Syndrome (PCOS)

Introduction

Polycystic Ovary Syndrome (PCOS) is a common hormonal condition affecting how a woman’s ovaries work. It is estimated to affect roughly 1 in 10 women in the UK, though many remains undiagnosed.

It is a long-term (chronic) condition characterized by a triad of features: irregular periods, excess androgen (male hormones), and enlarged ovaries containing fluid-filled sacs (follicles). While it cannot be “cured” in the traditional sense, its symptoms can be effectively managed with the right medical and lifestyle interventions.

Symptoms

Symptoms usually become apparent during the late teens or early twenties. They can vary significantly between individuals.

• Common Symptoms:
  • Irregular periods or no periods at all (amenorrhea).
  • Difficulty getting pregnant (due to irregular ovulation).
  • Excessive hair growth (hirsutism) usually on the face, chest, or back.
  • Weight gain or difficulty losing weight.
  • Thinning hair or hair loss from the head (alopecia).
  • Oily skin or persistent adult acne.
• Severe Symptoms:
  • Heavy, painful periods when they do occur.
  • Significant pelvic pain.
  • Severe mood swings or depression.
• Red-Flag Symptoms:
  • Sudden, sharp pelvic pain (potential ovarian cyst rupture).
  • Extremely heavy bleeding (soaking through pads every hour).

Causes and Risk Factors

The exact cause of PCOS is unknown, but it is closely linked to abnormal hormone levels.

• Insulin Resistance: The body’s tissues become resistant to the effects of insulin, causing the body to produce more. High levels of insulin cause the ovaries to produce too much testosterone.
• Hormonal Imbalance: Imbalances in luteinising hormone (LH) or low levels of sex hormone-binding globulin (SHBG).
• Genetics: PCOS often runs in families.
• Inflammation: Low-grade inflammation is often seen in women with PCOS, which stimulates polycystic ovaries to produce androgens.

Types or Classification

While not always formally sub-typed, PCOS is often viewed through “Phenotypes”:

• Insulin-Resistant PCOS: The most common type, driven by high insulin levels.
• Post-Pill PCOS: Occurs after stopping oral contraceptives (often temporary).
• Adrenal PCOS: Driven by a massive stress response rather than insulin.
• Inflammatory PCOS: Driven by chronic inflammation and gut health issues.

Diagnosis

A diagnosis is typically made if at least two of the following “Rotterdam Criteria” are met:

• History: Evaluation of irregular or infrequent periods.
• Examination: Checking for physical signs like hirsutism or acne.
• Blood Tests: To measure hormone levels (Testosterone, LH, FSH) and check for diabetes/cholesterol.
• Ultrasound Scan: An ultrasound (often transvaginal) to look for “polycystic” ovaries (many small follicles).

Treatment

Medications

• Combined Oral Contraceptive Pill: Used to regularise periods and treat acne/excess hair.
• Metformin: Traditionally for Type 2 Diabetes, it is used “off-label” in PCOS to improve insulin sensitivity and support ovulation.
• Spironolactone: An anti-androgen used to reduce excessive hair growth and acne.
• Clomifene or Letrozole: Medications used to encourage ovulation for those trying to conceive.
• Progestogen Tablets: To induce a period if they are very infrequent, protecting the womb lining.

Non-Medication Treatment

• Weight Management: Losing even 5% of body weight can significantly improve PCOS symptoms.
• Low GI Diet: Eating foods that cause a slow rise in blood sugar helps manage insulin levels.
• Regular Exercise: Strength training and cardio improve insulin sensitivity.
• Hair Removal: Electrolysis, laser hair removal, or creams (Eflornithine) for hirsutism.

Advanced or Hospital Treatment

• Laparoscopic Ovarian Drilling (LOD): A surgical procedure using heat or a laser to destroy the tissue in the ovaries that is producing androgens.
• IVF: If medications do not help with fertility, assisted reproduction may be necessary.

Complications

If left unmanaged, PCOS can lead to:

• Type 2 Diabetes: Due to chronic insulin resistance.
• Endometrial Cancer: If periods are infrequent (fewer than 4 a year), the womb lining can thicken, increasing cancer risk.
• High Cholesterol and Heart Disease.
• Sleep Apnoea.
• Depression and Anxiety.

When to See a Doctor

• If you have irregular periods or your periods have stopped.
• If you are struggling to get pregnant after 12 months of trying.
• If you develop excessive facial hair growth or severe acne.

Emergency Signs

Seek urgent medical help if you experience:

• Sudden, severe pelvic pain.
• Heavy vaginal bleeding causing dizziness or fainting.

Prevention

While you cannot prevent the genetic predisposition to PCOS, you can prevent its complications through:

• Weight Maintenance: Keeps insulin levels stable.
• Regular Screening: Regular checks for blood pressure and glucose.
• Smoking Cessation: Smoking increases androgen levels and cardiovascular risk.

Prognosis and Recovery

PCOS is a lifelong condition, but it is highly controllable. Symptoms often change over time—acne may improve with age while the risk of metabolic issues (like diabetes) may increase. With proper management, most women with PCOS can lead healthy lives and have successful pregnancies.

Quick Patient Advice

• Do: Eat a balanced, low-sugar diet and stay active.
• Do: Keep a diary of your menstrual cycle to show your GP.
• Avoid: “Crash dieting,” which can disrupt hormones further.
• Seek Help: If you feel your mood is consistently low; PCOS is linked strongly to mental health.

FAQ

1. Can I get pregnant with PCOS? Yes, many women with PCOS conceive naturally; others may need medication to help them ovulate.
2. Does PCOS mean I have cysts on my ovaries? Not exactly. They are underdeveloped egg follicles, not large “cysts” that require removal.
3. Is PCOS the same as Endometriosis? No, PCOS is a hormonal/metabolic condition; Endometriosis involves tissue growing outside the womb.
4. Can Metformin help me lose weight with PCOS? It can help manage insulin, which may make weight loss easier alongside diet and exercise.
5. Why am I losing hair on my head but gaining it on my face? This is due to high levels of androgens (male hormones) affecting different hair follicles.
6. Do I have to take the pill if I have PCOS? No, but it is one of the most effective ways to regularise periods and protect the womb.
7. Is PCOS linked to the thyroid? They are separate, but many women with PCOS also have an underactive thyroid.
8. Can I have PCOS if my periods are regular? Yes, you can still have PCOS if you have other symptoms like high androgens or polycystic ovaries on a scan.
9. Does PCOS go away after menopause? The hormonal imbalances remain, and the risk of diabetes/heart disease continues, though periods stop.
10. What is the best exercise for PCOS? A mix of resistance (weight) training and moderate cardio is best for insulin sensitivity.