Many of the symptoms of PCOS are due to increased production of ovarian testosterone and chronically elevated levels of insulin (hyperinsulinemia). In polycystic ovarian syndrome patients, the body’s cells do not respond normally to a “given amount” of glucose and they “over produce” insulin to compensate.
This excess insulin drives the ovaries to increase androgen (testosterone) production and decrease serum sex hormone-binding globulin. The elevated testosterone impedes the growth of ovarian follicles and leads to lack of ovulation. Lack of ovulation will cause amenorrhea and increases the risk of endometrial hyperplasia. Metformin has been shown effective in lowering insulin levels in women with PCOS.
Women with PCOS exhibit enlarged ovaries with numerous cystic follicles. Many of the cysts that occur in a polycystic ovary are follicles that matured to produce an egg, but due to abnormal hormone levels, were never released into the tube (ovulation) to be fertilized (pregnancy) or disposed of during the menstrual period. In a normal ovary, a single egg develops and is released each month.
Many studies suggest that the polycystic appearance is due to increased production of androgens (male hormones) which lead to lack of ovulation resulting in the follicle atresia (arrest of development).
PCOS produces many symptoms affecting different body systems that include:
- Amenorrhea (no menstrual cycles), Oligomenorrhea (irregular menstrual cycles)
- Hirsutism and/or acne is seen in up to 70%of cases
- Hyperandrogenism- elevated androgens (male hormones)
- Infertility seen in 55-75%
- Polycystic ovaries -enlarged ovaries with multiple small follicles
- Chronic pelvic pain
- Obesity or weight gain. 70% of PCOS patients are obese and 30% are thin
- Insulin resistance is estimated to be present in 80% of patients and obesity increases the incidence of insulin resistance.
- Dyslipidemia, which includes elevation of cholesterol/triglycerides seen in 70% of women
- Acanthosis nigricans
Women with PCOS usually present with enlarged ovaries with numerous enlarged peripheral cystic follicles and increased central stroma (the middle section of the ovary which produces androgens). Many studies suggest that the polycystic appearance is due to increased production of androgens, which leads to lack of ovulation resulting in the follicle atresia (arrest of development).
One of the most common symptoms of polycystic ovarian syndrome is infrequent or absent menses. Some women have oligomenorrhea, which is defined as less than 8 menses in one year. Other women may go for months without ovulating and require the use of medication to induce their menses. Long-standing absence of menses may increase the risk of cancer of the lining of the uterus by three fold.
Women who do not ovulate regularly have a hormonal imbalance between estrogen and progesterone which leads to irregular heavy bleeding or no bleeding at all. It is important to note that having menses every month does not necessarily mean that ovulation is occurring regularly.
Heavy bleeding can also be associated with a variety of gynecological changes such as ovarian cysts, uterine polyps, and uterine fibroids. Typically, a pelvic ultrasound and or a hysteroscopy (placing a telescope like probe in the uterus) can rule out most conditions.
There is sufficient research linking PCOS and insulin resistance. This is further verified by the resumption of ovulation that occurs when insulin-sensitizing fertility drugs like metformin are administered. In women with PCOS, the body’s cells do not respond properly to a given amount of insulin so the body compensates by increasing insulin production. Insulin resistance is diagnosed if the glucose to insulin ratio is greater than 4.5, if the 2 hour glucose tolerance test is greater than 140, or if fasting insulin is greater than 10. We also check the two hour insulin levels and if the insulin levels increase at the two hour level, it is indicative of insulin resistance. Insulin resistance eventually can lead to diabetes mellitus when pancreatic insulin secretion cannot keep up with the glucose consumed by the diet.
Hair loss around the scalp is called androgenic alopecia and is due to an increase in androgens causing hair “thinning
Acne can occur at any age and it is often due to excess androgens. Oral contraceptives in combination with antibiotics can be effective. Accutane has been used with varying degrees of success.
Thickening and dark areas around the neck, groin , underarms and skin folds. This is due to excess insulin and may be a sign of underlying insulin abnormality. Reducing the levels of insulin may lighten the patches and Retin-A may also be effective in reducing the skin color and thickness.
Excess Body Hair (Hirsuitism)
Elevated testosterone, a male hormone, causes thinning of the scalp hair while increasing facial hair (hirsutism) in women. * It can also cause PCOS symptoms including lowering of the voice, classic” pear shaped” body appearance, irregular (or no) ovulation, and other symptoms. Normalization of testosterone levels can often be achieved by using a combination of oral contraceptives and Aldactone. Aldactone is a diuretic and it also decreases androgen production.
All patients with hirsutism undergo a physical and laboratory examination, which includes menstrual history, evaluation of progression of hair growth, review of current medications, etc. The laboratory evaluation should include thyroid hormones, prolactin levels, fasting insulin, glucose levels, free testosterone, DHEAS and 17-hydroxprogesterone. These laboratory fertility tests are typically performed in the morning before day eight (8) of the menstrual cycle.
Hirsutism is present in approximately 25% of women and in a higher percentage of those who areinfertile. Hirsuitism may signal underlying endocrine, or metabolic, abnormalities such as androgen excess and PCOS. Other signs of elevated androgens include hair loss, irregular menses, acne, Acanthosis Nigerians infection, and others. Approximately 5-15 % of women with hirsutism have no identifiable underlying cause.
This condition is seen in up to 40% of patients who have insulin resistance and in 85% of patients with type II diabetes. The syndrome by definition will include 3 or more of the following:
- Hypertension - 130/85 mm Hg or higher
- Triglyceride levels - 150 mg/dl or higher
- HDL-cholesterol levels - less than 50 mg/dl
- Abdominal obesity - greater than 35 inches waist circumference
- Fasting glucose - 110 mg/dl or higher
High Blood Pressure
Women with PCOS often suffer from high blood pressure, elevated levels of “bad cholesterol”, and hypertension which are serious risk factors in developing coronary heart disease which, in turn, can lead to heart attack or stroke.
Depression, anxiety and mood swings
It’s unclear whether depression and/or anxiety are due to the hormonal imbalances seen in PCOS or a natural response to the weight gain, excessive hair growth, acne, and infertility that come with the condition. It’s vital to a normal healthy life to manage your PCOS symptoms, so you can manage your moods.
There is substantial evidence that the increased lipids and insulin resistance associated with PCOS can result in an increase in cardiovascular disease. The following are found to be increased in patients with PCOS.
- Increased CRP (C reactive protein is a marker of inflammation and correlates with the risk of cardiovascular disease
- There is an increase in the measured coronary artery (vessels feeding the heart) calcium which can increase the risk of heart disease
- There is an increase in the carotid intima- media thickness (vessels which supply the brain) which can increase the risk of strokes
Fatigue or Sleep Apnea
Sleep Apnea may be caused by insulin resistance in the system or an increased body mass index (BMI) which makes sleep uncomfortable. Fatigue is just as common and may be related to insulin resistance or low thyroid function (hypothyroidism) either of which can cause reduced energy levels.
Studies show a link between PCOS and an under-active thyroid, a condition known as hypothyroidism, Hashimoto’s Disease or chronic lymphocytic thyroiditis. For this reason, women who’ve been diagnosed with PCOS should undergo routine thyroid function testing.
Learn more about PCOS treatment options at the Advanced Fertility Center of Texas or to schedule an appointment at any of our locations, please call (713) 467.4488.