Understanding PCOS: How it shows up in your life

If you are struggling with PCOS, you are all too familiar with the frustration of irregular periods, embarrassment of unwanted facial hair and acne, stress of infertility, and the concern of preventing or managing diabetes. Some of my patients are relieved by a PCOS diagnosis because they get an explanation for their confusing constellation of symptoms. Have you faced the fear and uncertainty of such a complex diagnosis? Luckily, there are many treatments that can help manage PCOS from pharmaceuticals, to herbs, to lifestyle changes. As naturopathic philosophy teaches, I always prefer to treat the cause of a condition and not just symptoms, so let’s spend some time understanding PCOS.

What is PCOS?

According to the US Department of Health, approximately 1 in 10 premenopausal women (women of child-bearing age) in the United States have PCOS –  polycystic ovarian syndrome. PCOS is considered a syndrome – a condition characterized by a group of signs and symptoms.  The symptoms of PCOS cover both hormone-related and metabolic signs and symptoms:

• Dark hair growth
• Acne
• Male-patterned hair thinning
• Infrequent or no periods (in a premenopausal woman)
• Polycystic ovaries (seen on ultrasound imaging), obesity, and insulin resistance.

Irregular periods and insulin resistance? What a difficult combo!  My patients often feel overwhelmed by PCOS, especially since our female cycles/hormones and metabolic health are each difficult to manage on their own. Women don’t need all of these signs or symptoms to have PCOS, and PCOS can be diagnosed by doctors clinically (meaning based upon the office visit without the need for tests).

With a syndrome made up of several symptoms like PCOS, doctors will gather together and make a list of criteria that have to be met in order for someone to be diagnosed with that syndrome. For PCOS, this is called the Rotterdam criteria (1).  A woman has to fulfill 2 of these 3 criteria in order to be diagnosed with PCOS:

1. Oligomenorrhea (fancy term for infrequent periods, or going longer than 35 days between periods) or amenorrhea (which means absence of a period, or skipping at least three periods in a row)
2. Clinical and/or biochemical signs of hyperandrogenism.  Typical clinical signs include acne, hirsutism (or unwanted male-patterned hair growth-think face, neck, chest, and/or back hair).  Biochemical signs means elevated free testosterone, total testosterone, or DHEAS in bloodwork.
3. Polycycstic ovaries or enlarged ovaries seen on ultrasound.

What causes PCOS?

The exact causes of developing PCOS are currently unknown, but there are several factors that increase the likelihood of developing PCOS. PCOS is considered a complex condition, meaning it is influenced by both genetics and our environment.

Genetics

PCOS seems to cluster in families; if a woman is diagnosed with PCOS, there is a 20-40% chance that she will have a first degree relative (parent, sibling, or child) who also has PCOS (2).  We’ve also learned that the severity of PCOS differs with ethnicity – South Asian women tend to be at higher risk.

Environment

Exposure to male hormones, like testosterone, while very young can predispose one to PCOS.  Researchers are realizing that environmental toxins, like plastics, mimic male hormones in our bodies (3). Our bodies may see these environmental compounds and respond like they were seeing male hormones.

Obesity

While obesity does not directly cause PCOS, it may exacerbate PCOS in a woman who is already more likely to develop it (either due to her genetics or environmental factors). Fat cells contribute to metabolic problems like glucose intolerance and high levels of insulin, which may worsen sex hormone alterations.

What is actually happening with my hormones?

We’ve discussed what PCOS looks like and some of the factors that contribute to PCOS, but what is actually going on with hormones and insulin levels?  This is more complicated, but let’s see if we can boil it down some:

Increased pulses of GnRH from the brain

Women who develop PCOS tend to release a hormone called GnRH at slightly faster pulses from their brains than other women (4). GnRH is the hormone that signals our pituitary gland to release both FSH and LH (which are both important hormones that regulate ovarian and testes function). If GnRH gets pulsed faster than normal, it causes our pituitary glands to release more LH and less FSH than normal. The higher levels of LH go to the ovaries via the blood, and cause a certain type of ovarian cell to make more androgens including testosterone.

• We aren’t sure why, but the brain releases a hormone differently in women with PCOS
• This causes the ovaries to make more testosterone

Higher levels of androgens like testosterone

So now there is higher than normal testosterone being released by the ovary. This testosterone is the main contributor to symptoms of PCOS like excess body hair, acne, and male-pattern balding.  The excess androgens in the ovary also cause it to stop developing eggs like normal, and the ovary pauses in activity, which creates the cysts of PCOS. When the ovaries pause and stop ovulating, this causes a decrease in progesterone levels.  To further complicate the whole picture, when progesterone levels fall, the brain will increase the pulsing of GnRH, which brings us all the way back to the top of the cycle.

• Higher testosterone causes many symptoms of PCOS, including excess hair and acne
• It also causes the ovaries to stop functioning normally and make cysts

High insulin levels

Not everyone with PCOS struggles with changes in insulin levels, but about 50-70% of people do experience some sort of metabolic changes (5). High levels of insulin, or hyperinsulinemia, can be caused by the same factors we’ve already discussed: genes, obesity, and environment. Hyperinsulinemia can further worsen someone’s excess androgen state and worsen their PCOS symptoms.  This is because hyperinsulinemia can increase enzymes in the ovary that make androgens like testosterone. It can also decrease levels of a protein called sex hormone-binding globulin, or SHBG. SHBG’s job is to hold onto hormones like testosterone and make them less active in our bodies.  If SHBG levels decrease, there is less SHBG to hold onto testosterone, and testosterone will be more active in the body. The other problem with hyperinsulinemia is that it leads to insulin resistance and eventually diabetes.

What’s Next?

Hopefully this article helped you better understand PCOS, which is such a complex condition! Treatment of PCOS is often a multi-step process for most people. Goals for treatment include normalizing hormone levels, restarting or normalizing ovulation, decreasing unwanted symptoms like thick hair and acne, and preventing or improving metabolic conditions like insulin resistance and diabetes.  We often see PCOS patients frequently when we first begin our work together since there is a lot we need to address, and often patients can achieve a happy, healthy life with very well-managed symptoms. Visit Heart Spring Health in Portland, Oregon to see a PCOS-focused provider today!

References

1. T. Williams et al.: Diagnosis and Treatment of Polycystic Ovary Syndrome. AFP 94, 106 (2016)
2. C. C. Dennett et al.: The Role of Polycystic Ovary Syndrome in Reproductive and Metabolic Health: Overview and Approaches for Treatment. Diabetes Spectr. 28, 116 (2015)
3. E. Palioura et al.: Polycystic ovary syndrome (PCOS) and endocrine disrupting chemicals (EDCs). Rev. Endocr. Metab. Disord. 16, 365 (2015)
4. M. O. Goodarzi et al.: Polycystic ovary syndrome: etiology, pathogenesis and diagnosis. Nat. Rev. Endocrinol. 7, 219 (2011)
5. G Garrutiet al.: Adiposetissue,metabolicsyndromeandPCOS:a review. Vol 19. No 4. 2009 552–563 Reproductive BioMedicine Online

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