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What is PCOS?
Polycystic Ovarian Syndrome (PCOS) is a hormonal condition believed to affect up to 1 in 5 women. The ‘polycystic’ refers to the appearance of certain ovary types as seen on internal ultrasound scans of the pelvis (trans-vaginal ultrasound). They are slightly larger than normal ovaries and have twice the number of follicles (small cysts). The ‘syndrome’ aspect refers to the hormonal symptoms experienced by a woman with PCOS.
Although relatively common, it can affect different women in different ways and to varying extents. It is common for some women to be totally unaware that they are affected or experience only very minor symptoms. It is important to note that PCOS is not to be confused with PCO (Polycystic Ovaries), which affects up to 1 in 3 women, and is when a woman has polycystic ovaries but does not experience symptoms related to the syndrome such as irregular or missing periods, impacted ovulation and/or other hormonal symptoms.
Normally, a woman’s ovaries prepare several follicles which will grow to become ready for ovulation but just one will mature enough to release its egg (the dominant). However, in the ovaries of a woman with PCOS, many more follicles (12+) are present and no single follicle matures its egg enough to become dominant, which can impact ovulation .
For most women, a proper diagnosis and treatment plan is the first step to regaining control of the syndrome.
Causes of PCOS
At the moment, there is no known cause of PCOS. There is no single gene abnormality present in women with the condition but research suggests it could be the result of several different gene combinations. This type of genetic circumstance is described as a ‘poly-genetic’ condition, meaning multiple genes contribute to a possible inherited condition.
Symptoms of PCOS
Women with PCOS may experience any number of the following symptoms:
Irregular or missing periods
Most women with this condition do not have regular cycles or bleeds. A woman suffering from PCOS may experience irregular periods outside of the normal menstrual cycle (more or less often than once every 23-35 days), or may experience no periods at all which is a condition called amenorrhea. In some cases, women may experience extremely heavy bleeds or unpredictable intermittent bleeding.
When an egg is not released, it interrupts the normal progression of hormones needed for successful continued ovulation. Normally, a burst of the hormone progesterone is released immediately after ovulation but if ovulation does not occur (anovulation), the ovaries continue to produce only two of the three necessary hormones – oestrogen and testosterone. This interrupted cycle is why a woman with PCOS may have no period at all or experience infrequent bleeds.
Growth of excessive facial or body hair
Due to an increase in male type hormones (androgens), a woman suffering from PCOS may experience an increase in facial or body hair. This kind of symptom is called hirsutism, and may continue to occur until androgen levels are lowered. Areas of hair growth differ and may include a darkening and/or thickening of facial hair, hair on the arms, legs, abdomen, back, chest and an increase in pubic hair.
Scalp hair loss
Similarly to hirsutism (excessive body hair), high testosterone levels can lead to male pattern balding which will continue to be an issue until testosterone levels are lowered.
Acne and/or oily skin
A common first symptom is acne or oily skin which can be surprising for women well out of puberty. It is most likely to flare in ‘hormone sensitive’ areas such as the cheeks, jawline and neck. The acne might range from small bumps under the skin to larger, painful lumps that take a long time to clear.
Sudden or unexplained continuous weight gain
PCOS makes it difficult for the body to appropriately use the hormone insulin, which normally helps to convert sugars and starches from our food into energy the body can use. In a woman with PCOS, the body becomes resistant to insulin and instead it builds up in the bloodstream, leading to an increase of sugar and starch in the body and resulting in weight gain. In turn, high insulin levels can trigger the release of more male type hormones which can lead to weight gain in areas such as the abdomen rather than an overall increase in body fat.
PCOS and hormones
Insulin is a hormone that controls the release of energy from the food we eat. Produced by the pancreas, insulin has the important job of releasing or storing the right amount of energy from food so that our blood sugar remains at a normal level. If you have more sugar in your body than needed, insulin helps store it until a later time when you can use the energy effectively, such as during physical activity or when your blood sugar level lowers in between meals.
Many women with PCOS have what is called insulin resistance, meaning the cells in the body reject the normal level of insulin. If this occurs, the body starts to produce an increased amount of insulin to keep up with the body’s blood sugar level, which in turn makes the body produce an overload of testosterone.
Androgens are often called “male hormones” or “male type hormones”, but don’t let that fool you – all men and women produce androgens, just in different amounts. The two principle androgens are testosterone and androstenedione, which play a role in important male traits and the reproductive system. In women, the main purpose of androgens is to be converted into female hormones called oestrogens.
In women with PCOS, the body produces more androgens than needed in a female body which can prevent the ovaries from successfully releasing an egg during the menstrual cycle and lead to symptoms such as increased body/facial hair and acne.
Unfortunately there is no cure for PCOS, but with the right treatment, symptoms can be managed very well.
A healthy lifestyle is most important and will help reduce any further health risks as a result of the condition. Maintaining a healthy weight and increasing your daily exercise are two important steps to start with.
Around 75% of women with PCOS are overweight, with 50% of those women being obese. Overweight women suffering from symptoms of PCOS may find effects are lessened by losing just 5-10% of their body weight . Studies show that this small amount of weight loss can combat symptoms by reducing insulin resistance by up to 50%, restoring ovulation, improving fertility and increasing overall emotional health. Weight management is an important aspect of fertility for any woman, but particularly for women experiencing the symptoms of PCOS.
Metformin is a medication commonly prescribed to treat Type-2 Diabetes and helps the body’s response to insulin. It may be prescribed for women with PCOS who have problems with an over-production of insulin and testosterone. Metformin works by increasing the body’s sensitivity to insulin, helping the body to accept the normal amount produced. Metformin can only be prescribed by your medical practitioner.
Hormonal birth control
Taking some form of hormonal birth control may improve your chances of maintaining (or regaining) a regular period. The oral contraceptive pill works using two synthetic hormones – progestin and oestrogen – to lower and regulate hormone levels. Also lowering androgen (“male hormone”) levels, the oral contraceptive pill can help combat symptoms such as increased body hair and acne.
Anti-androgen medications are less commonly prescribed than medications such as Metformin, but work to block the effect of androgens and aim to reduce symptoms such as acne, increased body/facial hair and scalp hair loss. It is important to have a good conversation with your doctor concerning any new medication and ask them to explain in depth what the medication is doing and any side effects, as they are contra-indicated if you are trying to fall pregnant.
Dealing with symptoms of PCOS can be difficult for a lot of women and research shows that levels of anxiety and depression are higher in women with the condition compared to the general population. If you’re a woman suffering from PCOS and feeling like you might be presenting symptoms of anxiety and/or depression, rest assured you’re not alone.
Some women react to the diagnosis of PCOS with a form of grief and may experience emotions such as shock, anxiousness, numbness, disbelief, anger and frustration – all contributing to a reduction in overall emotional health. Furthermore, some symptoms commonly presented in sufferers of PCOS such as weight gain and an increase in body/facial hair can cause a poor self-image and low self-esteem.
Poor mental health can make it difficult for you to follow a healthy lifestyle, but doing so will improve your ability to get on top of PCOS symptoms. If you are seeking fertility help from Monash IVF, utilising available counselling services is an important way of maintaining good mental health, reducing stress and understanding your own journey to pregnancy – everyone is different.
PCOS, fertility and conception
PCOS is a leading cause of female infertility. Because of the increase in androgens (male type hormones), a woman with the condition may experience an irregular menstrual cycle which prevents ovulation. In turn, this means natural conception can be difficult. Women who are overweight or obese with PCOS have the most difficulty conceiving, whether naturally or with fertility help. With the right treatment, 60% of women with PCOS can conceive naturally and without any fertility clinic intervention.
Monitoring your ovulation can be a useful way of managing your fertility and understanding more about your own unique cycle. The usual method of counting days between bleeds may prove inconsistent for women with PCOS, so the most effective way to monitor your ovulation may be by checking your cervical mucus. Just before ovulation, your cervical mucus – the small amount of pale-coloured discharge released from your vagina – will resemble egg-whites and be slippery and clear. This is your body’s way of telling you that you are about to ovulate, as the sperm can be passed easily through the mucus at this time. You can also buy ovulation predictor kits from your pharmacy, which usually measure your cycle through your urine or saliva.
Ovulation induction and timing to achieve pregnancy
However, if lifestyle, weight loss and ovulation tracking have not improved fertility, ovulation induction (OI) may be an option. OI is a treatment designed to stimulate the ovaries to increase egg production by using tablets or injections over a sustained period of time.
Oral medications prescribed by health practitioners are used to increase hormone production from the pituitary gland, causing development of healthy egg follicles. While a woman with PCOS is taking oral medications, follicle growth is monitored via ultrasound. Once the follicles have grown to the right size, spontaneous ovulation can occur or an injection to cause ovulation is administered.
With ovulation timing monitored, a woman with PCOS can be advised of the best time to have sexual intercourse to achieve pregnancy, drastically increasing the chances of pregnancy over ‘blind’ intercourse.
Assisted reproductive technology
If you are concerned about your fertility and experience the symptoms associated with PCOS, consulting a fertility specialist may help put your mind at ease or answer any questions you might have. As well as introducing simple management options such as ovulation induction, a fertility specialist can help you on the right path to pregnancy.
IVF may be recommended by a fertility specialist if a strategy such as timed intercourse has failed to achieve pregnancy or if you are dealing with other complications such as blocked fallopian tubes. Looking at getting some fertility help doesn’t need to be difficult or daunting – you can chat to a fertility nurse who can help recommend a fertility specialist with expertise in PCOS.