Medically reviewed by Dr. Stacy Hengisman MD and Felice Ramallo MSRD.
PCOS is a reproductive health condition that refers to a set of physical, psychological, and emotional symptoms that - taken together - indicate a hormonal imbalance in the body. PCOS can be difficult to diagnose, since there isn’t one single test that definitively decides whether an individual has PCOS; instead, a diagnosis is often made based on several factors, including medical history, physical symptoms, blood tests, and a discussion with the patient in which a doctor may ask questions, like when symptoms first arose and aggravating factors. Interestingly, PCOS is relatively common, thought to affect approximately 1 in 10 women of reproductive age in the US, according to the CDC.
Because of PCOS’ short term health implications (symptoms can range from mild to extremely disruptive and upsetting) and long term implications (raising one’s risk of developing type 2 diabetes, for instance), more research and capital should doubtless be invested into understanding the root causes of PCOS - since this is not well understood enough yet - as well as expanding treatment options further. For the purposes of this article, though, we’ll go over what PCOS encompasses, give a high-level overview of symptoms and treatment options, and then touch on the latest studies within the last 5 years on this topic and their key takeaways. Let’s dive in!
Understanding PCOS at a glance
In a nutshell, PCOS is a complex condition characterized by an imbalance of hormones in the body. Specifically, women with PCOS have higher-than-normal amounts of male hormones (known as androgens), which trigger symptoms like missed periods, acne, excess hair growth, weight gain, and other issues. Less well known is that women with PCOS often also test for high estrogen levels, which could be to blame for heavy periods (when they arrive, since PCOS is associated with irregular ovulation) and painful cramps. Beyond these immediate effects, PCOS is also associated with long-term health implications like type 2 diabetes, inflammation, uterine cancers, and heart disease.
Because of PCOS’ impact on a woman’s ability to ovulate, PCOS is associated with trouble getting pregnant as well. In fact, PCOS is understood to be the leading cause of infertility (as well as the most common endocrine disorder) among reproductive-age women. And this condition may be more common than you might think: like we mentioned earlier, the CDC estimates PCOS affects between 6% and 12% of US women who are of reproductive age, while one study found that 70% of women with the condition didn’t even know they had it. Although, with proper treatment, most people with the condition are able to become pregnant.
Symptoms and treatment of PCOS
It’s important to briefly touch on symptoms of PCOS, since much research takes the “clinical presentations” of PCOS and tries to understand what internal processes are causing these outward symptoms that impact patients' lives.
According to a 2013 study, the 3 most common factors of PCOS are:
- Cystic ovaries
- Increased androgen levels
- Ovarian irregularities
These factors in turn are thought to be responsible for the following symptoms:
- Weight gain and insulin resistance
- This is a common finding thanks to the insulin insensitivity that accompanies the majority of women PCOS.
- Women with PCOS seem to have reduced insulin sensitivity, by an average of 35-40%, compared to women without PCOS, according to one study. This means for women with PCOS that insulin levels need to increasingly rise in order to get sugar into their muscle cells, but as the body becomes more and more desensitized to insulin, the body needs to create more of it to get cells to open. This eventually leads to a build up of sugar (otherwise known as glucose) in the blood, which in turn can make it harder to lose weight and put women with PCOS at increased risk of type 2 diabetes. Check out our article on everything you need to know about sugar and PCOS for more information on this topic.
- Thought to be triggered by excess levels of androgens such as testosterone, acne is a common side effect with physical and emotional implications, as many women report feeling distress, shame, and even depression as a result of stubborn acne.
- Excess hair growth
- Also known as “hirsutism,” this symptom is again thought to be the culprit of too-high androgen levels. This excess hair growth is often found on the face, chest, and back, and is a common manifestation of PCOS.
- If this hair growth does bother you, there are medications which may help. Also electrolysis and laser treatment are accessible solutions which can be permanent (or at least long-lasting).
- Irregular or no period
- The menstrual cycle begins from the first day of your period to the first day of your next period, with the average menstrual cycle hovering around the 28 day mark. Menstrual flow occurring every 21 to every 40 days is considered normal, with a flow that lasts two to seven days. For the first few years after menstruation, longer cycles are common (as is irregularity), but tend to shorten and become more regular as one ages.
- If you get your period more often than every 21 days, or you go longer than 40 days between periods, then that is considered irregular.
- Pelvic pain
- Androgenic alopecia
- This presents as hair loss on the head, particularly around the hairline and center of the crown.
- Skin tags and darkened skin patches (acanthosis nigricans)
- Though innocuous, these can be indicative of PCOS
Treatment of PCOS will depend on your symptoms, but typically includes a combination of medications, lifestyle changes, and dietary changes. Your doctor will work with you to see whether metformin or birth control may be helpful in managing undesirable symptoms, while they also may test you for vitamin and mineral deficiencies to get a more holistic idea of what your body needs, and what prescriptions will be most helpful in addressing symptoms.
Latest PCOS Studies (And What They Tell Us)
Before we dive into the studies themselves, we need to explain what the Rotterdam criteria is, since many of these studies include this term for describing women with a positive PCOS diagnosis. The Rotterdam criteria simply refers to 3 boxes, 2 of which need to be ‘ticked’ to be diagnosed with PCOS (if a doctor subscribes to this methodology, that is). Here are the three criterion:
- Irregular periods (also called oligomenorrea) or no periods (amenorrhea)
- If you go frequently 35 days or more between periods, this could be a sign you have PCOS. Additionally, if you have ‘slightly irregular’ periods (between 32 and 35 days apart), your doctor may order a blood test mid-cycle to check your progesterone levels.
- Next, let’s talk about no periods altogether: if you’ve gone 6 or more weeks without bleeding, then this is considered a missed period.
- Higher levels of androgens present in the blood (hyperandrogenism)
- Lutenizing hormone (LH)
- Women with PCOS can have high levels of LH secretion, which can contribute to high levels of androgens. This, along with low FSH levels, can contribute to poor egg development and a consequent lack of ovulation
- Follicle-stimulating hormone (FSH)
- Your FSH levels may be checked to rule out the possibility of primary ovarian failure. In patients with PCOS, FSH levels are usually within normal range or low, and the LH-FSH ratio may be greater than 3.
- Total and free testosterone
- Women with PCOS are known to have raised levels of testosterone which is responsible for excess hair growth and acne, as your skin cells and hair follicles are extremely sensitive to increased levels of this hormone.
- Dehydroepiandrosterone sulfate (DHEAS)
- DHEAS is secreted by the adrenal glands and is converted into either estrogen or testosterone. In women, moderately high levels of DHEAS are associated with hyperandrogenism, and around 20-30% of women suffering from PCOS have elevated levels of DHEAS.
- This is a steroid hormone that has androgenic actions.
- Polycystic ovaries visible on an ultrasound
- Polycystic ovaries are characterized by ovaries that have a high number of follicles on them. These follicles are fluid-filled sacs, and they are not associated with any pain or discomfort
Now that we know what physical symptoms are most commonly associated with ‘androgen excess’, and we understand what researchers are talking about when they refer to the Rotterdam criteria, we can talk about the most recent research in the space.
- This 2018 study suggests there is a “shared genetic architecture for different diagnosis criteria”
- One meta-analysis that studied over 10 million genetic markers across 10,000 European women with PCOS (and 100,000 control participants) found that across self-report, National Institute of Health (NIH) criteria, and non-NIH Rotterdam criteria, the genetic architecture of women with PCOS was much similar. This essentially means that, though academics have debated the efficacy of using the Rotterdam criteria (i.e. asking is this the right diagnostic criteria to use to diagnose PCOS), the women who self-reported having PCOS, had “similar risks to the other cohorts where the diagnosis was clinically confirmed.”
- This study also found “the first genetic evidence for a male phenotype for PCOS,” as well as a “causal link to depression.”
- A 2019 study found that there is “cross-talk” between the fat, muscle, brain, and ovary tissue and supports the idea that PCOS is fundamentally a “systemic” disease
- The authors argue that inflammatory and metabolic implications of PCOS are explained in part by insulin resistance, obesity, and androgen excess all taken together.
- Authors also note that letrozole (a drug used to prompt ovulation) “seems to be more effective than the reference drug CC to treat infertility due to PCOS.” They also argue for lifestyle interventions, not just medication, to support metabolic and reproductive health in patients with PCOS
- A recent study examining the impact of combined oral contraceptives (COCs), anti-androgens (AAs), and metformin found that COCs and AAs together are more impactful for reducing symptoms of androgen excess, although when paired together with metformin, this can have a “positive effect on BMI and glucose tolerance.”
- Speaking of metformin, a study conducted just a few years ago which evaluated the impact of metformin across a cohort of women with PCOS (diagnosed according to the Rotterdam criteria) found that “overweight” and “normal-weight” women had increased menstrual frequency and reduced BMI, as well as testosterone and LH levels, in the first 6 months of use.
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