Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a hormonal condition that affects women during the reproductive years. It results in the production of abnormally high levels of male (androgen) hormones such as testosterone and androstenedione. It can also cause the ovaries to develop numerous cysts (small sacs of fluid with immature eggs that cannot be released), instead of mature follicles (sacs of fluid with eggs that can be released). PCOS also results in lower-than-normal levels of follicle-stimulating hormone (FSH), which stimulates the production of follicles, and luteinizing hormone (LH), which triggers the ovary to release a mature egg. As the eggs do not mature in the cysts, it can be difficult to trigger ovulation (when your ovaries release eggs). This then causes low levels of oestrogen and progesterone, hormones that regulate the menstrual cycle. This can lead to irregular, prolonged, or missed menstrual periods, which can also affect your fertility. PCOS can also result in excess body and facial hair, metabolism, and weight problems, and acne. Additionally, PCOS can cause insulin resistance, which can lead to type 2 diabetes and obesity. It can also increase your risk of other medical problems, such as high cholesterol and high blood pressure, and psychological problems, such as depression.

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Get in touch to find out how we can help you. Contact us however you feel most comfortable, for example Whatsapp message us, or feel free to call us on +971 56 895 2347. You can also email or simply send us a query via our online form. Instagram message, Facebook chat… whatever works best for you!

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Polycystic means ‘many cysts’, however many individuals with PCOS do not have cysts. The condition can be presented differently in different individuals, for example, some people may have irregularities in their menstrual cycles whereas some may not. The same goes for other symptoms such as acne and weight gain. Symptoms of PCOS including the hormonal irregularities and infertility linked to it can be treated.

PCOS is the most common endocrine disorder among women between 15 and 45. It is also the most common cause when a woman is infertile due to lack of ovulation. It affects between 5-26% of women in this age group, depending on the definition and diagnosis. It is a very common cause of infertility and can be dated back to 1721. 

Symptoms

Signs and symptoms of PCOS typically develop after puberty during adolescence, however, they can develop later in life too. Symptoms vary between individuals, while some people experience several of them, some may only display a few. Most symptoms can be manifested as gynecologic, dermatologic, or metabolic. In many cases, PCOS goes undetected as you might not display prominent symptoms or just believe them to be a normal part of life. You may only discover that you have PCOS after struggling with weight gain or getting pregnant. The severity of the symptoms can be worsened by being overweight or obese. 

Common symptoms of PCOS include:

• Irregular, infrequent, prolonged, or missed periods 

• Heavy bleeding during periods 

• Pelvic pain

• Unwanted and excess hair growth typically on the face, chest, back, and stomach (hirsutism) 

• Hair loss or thinning hair on the head (typically male-pattern baldness)

• Oily skin and acne (on the face, chest, and upper back)

• Darkened skin patches on the neck, in the armpits, around the groin, and under the breasts (acanthosis nigricans)

• Excess skin (skin tags), especially on the neck or in the armpits

• Headaches and mood changes caused by hormone changes

• Infertility/difficulty getting pregnant 

• Sleep problems

• Weight gain, especially around the abdomen 

The most common symptom is irregular periods, followed by weight gain and excess hair growth. 70% of women with PCOS grow excess facial and body hair, and 50-80% struggle with weight problems including being overweight and obese. Acne, facial or body hair growth, and hair loss are common symptoms caused by excess testosterone which many people mistake as normal occurrences. 

Causes and Risk Factors

Although the exact cause of PCOS is unknown, there are factors that may play a role. These include:

Genes

Research has shown strong evidence that PCOS runs in families, thus it may be caused by certain genes. You are at a higher risk of having PCOS if your mother or sisters have it.

Insulin resistance and excess insulin

Insulin is the hormone that allows cells to use sugar from food for energy and so controls the sugar levels in your body. Up to 70% of women with PCOS have insulin resistance, causing the cells to be unable to use insulin properly. When this happens, the body demands more insulin so the pancreas produces more to compensate. This can create an excess of insulin that is not being used, which then triggers the ovaries to produce more male (androgen) hormones. Due to this, the ovaries have difficulty with ovulation and cannot release eggs, leading to infertility. Excess sugar in your bloodstream can cause diabetes and weight gain.

Inflammation

Women with PCOS often have increased levels of low-grade inflammation in their bodies. This inflammation stimulates polycystic ovaries to produce higher levels of androgens. This can lead to the symptoms of PCOS, such as irregular periods, infertility, hirsutism, acne, and more. Additionally, the inflammation can lead to blood-vessel- and heart-related problems, such as high blood pressure. 

Hyperandrogenism (excess androgens)

Excessively high levels of male hormones in women are what causes many symptoms of PCOS. Hyperandrogenism is a characteristic of PCOS that could be the cause of it. The androgens interfere with regular menstrual cycles and prevent ovaries from producing female reproductive hormones and releasing eggs. It is a key factor as genes, insulin resistance, and inflammation can all be linked to excess androgen production.

Obesity

While having PCOS can cause weight gain, being overweight or obese can also be a risk factor for PCOS. Obesity is another key factor as it has been found to contribute to insulin resistance and inflammation, which can then trigger hyperandrogenism. Obesity can also cause oestrogen levels to drop.

Complications and Comorbidities 

Women with PCOS are at risk for developing certain health problems. These additional complications include:

• Type 2 diabetes or pre-diabetes - PCOS can increase the risk of developing type 2 diabetes by fourfold, with more than half of women with PCOS developing diabetes by the age of 40.

• Gestational diabetes or pregnancy-induced high blood pressure - This can put you or the baby at risk during pregnancy, and can lead to type 2 diabetes later in life for both 

• Miscarriage or premature birth. Women with PCOS are twice as likely to deliver prematurely.

• Non-alcoholic steatohepatitis/fatty liver disease - Severe inflammation caused by fat accumulation in the liver, which is not caused by drinking alcohol.

• Sleep disturbances such as sleep apnea - This condition causes sleep interruptions due to repeated pauses in breathing through the night. This is 5-10 times more likely in obese women.

• Mental health conditions such as mood disorders and depression, anxiety, and eating disorders - This can be caused by hormonal changes or symptoms such as weight gain, hirsutism, acne, or hair loss. *link to pages on depression, anxiety, and eating disorders*

• Uterine bleeding and a higher risk of endometrial cancer - Due to a lack of ovulation the uterine lining can build up and not shed, which can increase your risk for endometrial cancer.

• Metabolic syndrome - This includes a cluster of conditions including high blood sugar, high blood pressure, high LDL (bad) cholesterols, and low HDL (good) cholesterol. These can increase your risk for cardiovascular disease, diabetes, and stroke. PCOS makes you twice as likely to develop metabolic syndrome.

• Infertility - When ovulation doesn’t happen and ovaries cannot release an egg to be fertilized you cannot get pregnant. PCOS is one of the leading causes of infertility and 70-80% of women with PCOS have fertility issues.

Prevalence

The global prevalence of PCOS is between 5% and 26% depending on the diagnostic method. It is the most common endocrine disorder among reproductive-aged women. Most women discover they have PCOS in their 20s or 30s due to fertility problems. You may develop PCOS at any age after puberty. Women of all races, ethnicities, and socioeconomic demographics are at risk of PCOS. Many women are unaware that they have PCOS, with one study finding that up to 70% of women with PCOS had not been diagnosed.

When to See a Doctor

You should see a doctor if you have irregular or missed periods, if you have been having trouble getting pregnant (for 12 or more months), unexplained weight problems, or experiencing signs of excess androgen such as hirsutism, hair loss/balding, or acne.

Diagnosis

There is no single test to definitively diagnose PCOS. Your doctor will start by asking about your medical history, menstruation cycle, and weight changes, as well as any other possible symptoms you are experiencing. The doctor may observe your skin to look for excess hair growth, acne, and discoloured skin patches. Your family’s medical history, especially if your mother or sister have experienced difficulty getting pregnant, will also be considered. You will then likely have a physical exam and blood tests to further assess whether you have PCOS. Early diagnosis and the right treatment can make it easier to manage symptoms and can reduce the risk of long-term complications such as type 2 diabetes and cardiovascular disease.

A diagnosis of PCOS requires the presence of two of the following three criteria: 

• Hyperandrogenism (excess androgen) - High levels of male hormones can be shown through physical symptoms such as acne, hirsutism, and male-pattern balding, or in blood tests.

• Ovulatory dysfunction (irregular menstrual cycle) - Infrequent, irregular, prolonged, or missed periods are a sign of this. Abnormally heavy periods can also be a sign. 

• Polycystic ovaries - Cysts in your ovaries can be shown in an ultrasound exam.

In younger girls who have just hit puberty, it is advised to wait two years after the first period and for all three criteria to be met for a diagnosis. 

As these findings may have causes besides PCOS, physical examinations are required before making a diagnosis. These tests include: 

• Pelvic exams - During a checkup with your gynaecologist they will visually and physically inspect your reproductive organs for anything unusual such as growths and lumps.

• Ultrasounds - This will produce an image of what your ovaries look like, and will show any cysts and any other problems in your uterus. Your ovaries may also be 1.5 to 3 times larger than normal if you have PCOS. It will also measure the thickness of your uterine lining, as it will be thicker if your periods are not occurring as they should. Using sound waves to create images, ultrasounds can show changes in the ovaries in 90% of women with PCOS. However, polycystic ovaries can also be found in 8-25% of women that don’t have PCOS and are a common side effect of levonorgestrel-releasing intrauterine devices (IUDs).

• Blood tests - Blood tests can analyze hormone levels. They can check if you have higher-than-normal levels of androgens such as testosterone and androstenedione, and lower-than-normal female hormones such as oestrogen, progesterone, FSH, and LH. They can also assess your levels of sex hormone-binding globulin (SHBG) which is a protein that carries the reproductive hormones around in your blood and can affect how much of them are available for your body to use. An anti-mullerian hormone blood test can also be done to check how your ovaries are working. Your doctor may also conduct additional blood tests to measure your glucose tolerance, insulin levels, cholesterol and triglyceride levels, and blood sugar levels.

If you are diagnosed with PCOS, you may need to get regular blood glucose tests to check for diabetes, lipid profiles for cholesterol and triglycerides levels to check for cardiovascular disease, and insulin tests to see how your body responds to insulin (if you are resistant) to prevent diabetes development. Your blood pressure and body mass index (BMI) should also be regularly measured. Additionally, you may need screening for sleep apnea, thyroid problems, tumours, and hyperplasia (organ-swelling due to too many cells). It can be helpful to also see a mental health professional for depression, anxiety, and eating disorders.

Treatment

As PCOS is a multifaceted syndrome that affects multiple parts of the body in various ways, the treatment must be individualized based on your specific symptoms and concerns. The treatment plan will be based on your goals such as treating infertility, regulating the menstrual cycle, treating metabolic complications, or controlling hyperandrogenic features such as acne and hirsutism. Treatment for PCOS can also help you manage symptoms and prevent long-term problems such as diabetes and heart disease. Your age, weight, lifestyle, desire for pregnancy, and symptom severity can all play a role in the type of treatment. You must discuss your particular problems and needs in detail with your doctor. The treatment can be a team approach involving your primary doctor and sub-specialists such as gynaecologists, dieticians, and psychiatrists. There are a variety of treatment types, all geared towards various problems. These include:

Lifestyle Changes

One of the best ways to manage PCOS and the severe symptoms linked to it is to eat well, exercise, and manage your weight. Many women with PCOS struggle with being overweight or obese which can cause several additional problems. Therefore, lifestyle change is a first-line treatment for overweight women with PCOS. Losing 5-10% of your body weight can ease symptoms, make your periods more regular, and help you control blood sugar, cholesterol, and insulin levels. Limiting carbohydrates, starchy and sugary foods can help you lower your blood glucose levels. This can ultimately prevent diabetes. Regular exercise can also help with psychological symptoms and improve hormonal acne. Additionally, losing weight can increase the effectiveness of medications, and can help with infertility. A healthy diet with exercise can help your body use insulin more efficiently and help you ovulate. The healthier lifestyle and related controlled hormonal and physical levels will also improve your odds of having a healthy and safe pregnancy.

Birth Control 

For women with PCOS who are not trying to get pregnant, birth control is the most common form of treatment. This can be in the form of pills, skin patches, vaginal rings, injections, or hormonal intrauterine devices (IUDs). These contraceptives elevate levels of oestrogen and progestin and reduce androgen levels, thus regulating your hormones and allowing for ovulation and regular menstruation cycles. Although they trigger ovulation, you should not take contraceptives when pregnant or trying to get pregnant as it may cause miscarriage or birth defects. Due to regular menstruation, the lining of your uterus will be restored to a normal thickness, reducing heavy periods and the chances of endometrial cancer. Oral contraceptives have been found to be more effective than other medications in lowering androgen levels and regulating menstruation. By enabling normal amounts of female hormones and reduced androgen levels, these contraceptives can also reduce acne and hirsutism. They are a first-line treatment for irregular periods and dermatologic symptoms such as acne and hirsutism.

Other Medications

There are a number of medications that can help to treat specific symptoms of PCOS. 

If you are trying to get pregnant, there are medications that can help with fertility. These work by triggering ovulation and allowing eggs to be released and fertilized normally. Some of these drugs may however increase the chances of multiple births (having twins or more). They may also cause the ovaries to hyper-stimulate and release too many hormones, resulting in bloating or pelvic pain. You can also get hormone injections such as gonadotropins which increase the production of the sex hormones FSH and LH allowing for eggs to be produced and released. 

Progestin therapy can be conducted, where you take progestin for 10-14 days every month, to regulate periods and shed the uterine lining to reduce chances of endometrial cancer. Although progestin is usually used in contraceptives, progestin therapy does not improve androgen levels or prevent pregnancy.

When a healthy diet or regular exercise is not working, medications can make it easier to lose weight and improve your health. Some drugs can stop your body from digesting some fat from food to improve cholesterol levels, while others can lower insulin levels to help with weight loss and prevent diabetes. Studies have found that taking diabetes medication while also making healthy lifestyle changes works more effectively in improving weight loss and lowering blood sugar than lifestyle changes alone. Certain diabetes medications have also been found to reduce androgen levels, lower insulin resistance, regulate ovulation, restore a normal menstrual cycle, and also slow hirsutism.

These are several medications, in oral and topical forms, that can be used to control and prevent unwanted hair growth. Chemical depilatory creams can break down the protein structure of hair so it falls out from the skin. Other medications can work by reducing androgen and slowing down hair growth. 

Certain medications can help control and reduce acne by regulating hormone levels and fighting acne-causing bacteria. Oral and topical medications can be used together for the best results.

Surgery 

When lifestyle changes and medications are unable to help, you may try surgeries.

If you are unable to lose weight and keep struggling with obesity, weight-loss surgeries can help. They will reduce your weight, which will then allow for your hormones and menstrual cycle to regulate. This will also decrease your chances of diabetes and cardiovascular disease. 

Surgeries to improve fertility include ovarian drilling, which uses a heated needle or a laser to make small holes in the ovaries to destroy the tissue that is producing excess androgens and so restores normal ovulation.

Other Procedures

In vitro fertilization (IVF) - When medications are not able to improve infertility problems or if you do not want to or cannot take medication, IVF is the best route to go. It is an effective method to get pregnant by fertilizing your egg with your partner's sperm in a lab and then placing the embryo back into your uterus. However, IVF can be expensive and challenging. You can get support from a therapist through this process. *Link to IVF page*

Laser therapy - Electrolysis or light-based lasers can get rid of unwanted hair on your face and body by destroying the individual roots of the hairs/hair follicles. Over time with a few sessions, your hair growth will slow down and will be finer. Laser’s can also help to fade acne scars and prevent them from becoming permanent. 

* Possibly add a PCOS quiz as such: https://www.endocrineweb.com/guides/pcos/do-have-pcos-pcos-symptoms-quiz *

FAQs

How do I know if I have PCOS?

Common symptoms of PCOS include:

• Irregular, infrequent, prolonged, or missed periods 

• Fertility problems

• Excess body or facial hair

• Acne

• Weight gain

• Thinning of hair on the scalp

• Dark skin patches

• Skin tags

What causes PCOS?

Genetics play a role in the development of PCOS as you are at a higher risk if your members of your family (such as your mom or sister) have PCOS. High levels of insulin due to insulin resistance and high levels of androgens (male hormones) are other risk factors that may cause PCOS. Inflammation can also cause polycystic ovaries and high androgen levels. Additionally, obesity is another key factor that may result in PCOS and also contributes to high insulin and androgen levels and inflammation. 

Can I get pregnant if I have PCOS?

Although PCOS can cause infertility due to a lack of ovulation, it is treatable. You can take medication to regulate hormones and promote ovulation. This will allow your ovaries to release eggs to be fertilized. IVF and ovarian drilling surgery are also options that can help you get pregnant. 

How can I prevent PCOS-related problems during pregnancy?

PCOS can cause difficulties and increase risks during pregnancy. Maintaining a healthy lifestyle and reaching a healthy weight before you get pregnant can reduce the risks. Reaching and maintaining a healthy blood sugar level is also important and can help. Additionally, taking folic acid can be useful.  

Does PCOS go away close to menopause?

While menstrual cycles become more regular as you get closer to menopause and fertility no longer becomes an issue, such symptoms do improve. However hormonal imbalances tend to stay the same even at older ages. PCOS-related health issues such as diabetes, cardiovascular disease, and stroke can become more likely and risky at older ages after menopause. 

How is PCOS diagnosed?

There is no single specific test to diagnose PCOS however there are a few tests you can take to determine whether you have it. Along with assessing your medical and family history physical examinations to check your BMI, the hair on your face/body, acne, and other symptoms of PCOS can be looked at. For a more definitive diagnosis, a doctor will conduct tests such as a pelvic exam to examine the reproductive system for any irregularities, an ultrasound to view if there are cysts in the ovaries, and blood tests to measure hormone levels as well as blood sugar and cholesterol levels. 

How can I manage my lifestyle to improve PCOS symptoms?

Lifestyle interventions are the first treatment type that doctors recommend for PCOS. Having a healthy diet and reducing carbohydrates, starch, and sugar in your diet can reduce your blood sugar levels and weight. A low glycemic index diet can be more useful than regular weight-loss diets. Being active also helps to reduce sugar levels and can prevent insulin resistance. Exercise can also help with psychological symptoms and symptoms such as acne and hirsutism. Studies have found that 30 minutes of moderate-intensity exercise at least three times a week can help women with PCOS reduce weight, improve insulin levels, cause ovulation, and improve other symptoms. Exercise and a healthy diet are most beneficial when combined. Maintaining a healthy weight is important as it can reduce insulin and androgen levels which can then restore ovulation and improve fertility. It can also lower your risk for diabetes and cardiovascular disease. Focusing on your mental health is also important for psychological symptoms and cosmetic treatments such as laser for hair removal and acne scars can increase self-esteem regarding your appearance.

What is the treatment for PCOS?

There is no ‘cure’ or single best treatment for PCOS. The type of treatment will depend on your symptoms and goals for what you want to achieve with the treatment. Lifestyle changes (healthy diet and regular exercise) can help improve weight problems which can, in turn, improve hormone levels and regulate your menstruation cycle allowing for ovulation. If you are not trying to get pregnant, contraceptives can regulate hormone levels and the menstrual cycle. They can also reduce acne and hirsutism. Other medications can be useful if you are trying to get pregnant, by regulating reproductive hormones and triggering ovulation. There are also medications for controlling insulin levels and cholesterol, preventing diabetes, reducing chances of endometrial cancer, and controlling hirsutism and acne.

Our mental health professionals are here to help you, whether you need to heal or want to thrive.

Get in touch to find out how we can help you. Contact us however you feel most comfortable, for example Whatsapp message us, or feel free to call us on +971 56 895 2347. You can also email or simply send us a query via our online form. Instagram message, Facebook chat… whatever works best for you!

Our goal is to make you comfortable.