Commonly known as PCOS or PCOD, it is one of the most commonly encountered endocrinological problems in women of fertile age groups i.e. between the ages of 18 to 44 years.
As the title suggests, there are two separate conditions – one is simply polycystic ovaries which means that the woman has simply been found to have multiple small ‘cysts’ seen during an investigative method called ultrasound. She doesn’t have any associated symptoms of the syndrome as discussed in detail in the following part of the article. The incidence of such women is about 25%. These women can have polycystic ovaries (or PCO) on scan but they are completely well with it and don’t have PCOS. These women don’t have the associated symptoms, seen in about 20-25% of women, which lead to development of the syndrome.
So to clarify the prevalence a little bit more:
If I randomly pick up 5 females in fertile age groups from my readers, then:
1 will have polycystic ovaries but not the syndrome
1 or 2 will have PCOS with symptoms
1 will have PCOS without any symptoms
1 or 2 will have nothing wrong
So, I think you’ll agree that it is a pretty common condition but surprisingly it’s no where near as well recognised or understood as some of other well documented and talked about endocrinological problems, such as diabetes or hypothyroidism.
The symptoms associated with polycystic ovaries in women with PCOS (although – just to confuse matters even more – some women can have polycystic ovarian syndrome without having polycystic ovaries at all!!) :
1. Menstrual disturbances : late periods (more than 35 days cycles) or missed periods
2. High levels of male sex hormones, called testosterone – It’s normal for our ovaries to release 3 types of hormones – ‘female hormones’ – estrogen, progesterone and ‘male hormone’ – testosterone. In women with PCOS, the amount of testosterone is much higher than usual. This causes masculinisation symptoms such as male pattern hair growth – coarse hair on chin or chest; male pattern hair loss. The other common manifestation is acne.
3. Infertility – as I am about to explain in the following text, these women do not have normal ovulation and their ovaries do not release egg – either not at all or not in any rhythmic fashion, making it very difficult for these women to track their ovulation and consequently causes fertility issues. It’s not to say that these women can’t fall pregnant but as they don’t have an egg in each cycle, their chances get much less.
4. Insulin resistance – Women with PCOS have fourfold to sevenfold chances of developing diabetes due to the increased incidence of insulin resistance seen in these women. PCOS is not a disease of only obese women as about 10-15% of slim women with PCOS can have insulin resistance but the rate of insulin resistance is more than double, at about 20-40% for obese women, so clearly weight plays a role. Weight and insulin resistance is bit of a chicken and egg situation. Whilst obesity doesn’t cause PCOS as such but weight gain is an important contributing factor to developing PCOS – in some women an increase in weight unmasks an underlying predisposition to developing this condition. So it seems that if you gain weight then you have higher chances of developing PCOS and if you have PCOS then you have higher chances of developing insulin resistance which can cause further weight gain! So the underlying message seems to be that of not gaining weight as far as PCOS is concerned. In fact, in women with established PCOS and significant menstrual problems with absence of periods for months at end, a weight loss of just about 5-10% of total body weight has been shown to lead to restoration of normal menstrual cycle.
In the second paragraph I’ve highlighted the term ‘cysts’. This is because these are not really cysts (= fluid filled sacs) but are follicles.
To explain the term follicle bit more in detail we will have to look a bit deeper into our physiology. and get to grips with some basics:
Every woman is born with her quota of eggs in her ovaries which are called oocytes. There are about 1 million of these at the time of the birth but only about 500 get used in our lifetime during ovulation and the rest are wasted! Women that have to go through the process of IVF will pay somewhere around 2-4K AUD for undergoing the scientific process of acquiring one of these guys and making it do the job it was naturally meant to do!
These egg cells are contained in structures called follicles, which we are talking about today. As she enters the age of menstruating, each month, around the time when the woman is somewhere in the middle of her menstrual cycle, one of these egg cells will start maturing and increasing in size. To give you an idea in simpler terms, you can imagine having a plate full of peas (= these are the egg cells) and one of them will start looking like a grape ( = distinctly bigger and clearer to see: these are the structures that the sonographers see when they do an ultrasound and comment on a ‘maturing follicle’ or a functional cyst) . Eventually this maturing follicle (grape in the plate of peas) will rupture, leading to the release of the egg (=ovulation). This egg will either get fertilised,leading to a pregnancy, or the associated hormonal changes will bring about menstruation, in about a fortnight after the release of the egg.
In polycystic ovaries this fundamental natural clockwork routine is broken and many follicles try to mature at the same time. So our plate that was full of peas and was meant to have one large grape will now have about ten-twenty, or sometimes even more, blueberries! So these blueberries are representatives of the same follicles (peas in our analogy) that are part of our natural anatomy but just started misbehaving by not letting one of them to take the lead and be the boss for that month (so no grape). So in the end no one wins and there is no release of the egg. Too many blueberries but no grape –> no egg –> no menses. So that’s why these women typically tend to have periods that are generally quite late and they can sometimes even miss periods for months.
I hope that the talk about peas, grapes and blueberries hasn’t confused you even further but I find it quite a useful way to explain to patients when they are having difficulty understanding the concept of multiple ‘cysts’ and their immediate first reaction is to look at ways of getting rid of these cysts as they believe that the cysts are the problem and they often feel that if they can get rid of them then their periods will get back to normal. As you can see, it’s not the case. The cysts are not the cause but are just a manifestation of the syndrome. If you get rid of some of the blueberries from the plate then the rest of the peas will simply make more blueberries and this cycle goes on in PCOS.
It’s cause can be genetic or environmental in nature. About 35% of mothers and 40% of sisters of PCOS patients are affected as well. This clearly shows that it can run in families. An important environmental contribution is weight excess or obesity and lack of enough physical activity. So one of the most important management options for PCOS is weight control which will be the topic of our next conversation.