Polycystic ovarian syndrome (PCOS) is the most common cause of menstrual irregularities and infertility. It has been described in the medical literature from as far back as the early 1800s; however, we weren't able to get a formal way of diagnosing it until the early 1990s. The problem with PCOS lies in the fact that it is not a specific disease. Specific diseases are straightforward, we can define exactly what it is, and most often we can determine what causes it and in turn how best to treat it. Take hypertension, for example. We know what levels are normal and abnormal, we know exactly how to check for it, and therefore we can start treatment plans based on what we find. PCOS, on the other hand, as the name tells us, is a syndrome rather than a specific disease. That literally means it's a bunch of signs and symptoms grouped together that sounds like it could be something, but we are not really sure what causes it. (It took us almost 200 years just to come up with some sort of a definition).
So… what is PCOS?
Classically, this syndrome is characterised by three things: irregular periods, excess male hormones and specific ultrasound ovarian features. These irregular periods involve missed periods or cycles longer than 35 days. The excess male hormones can either be diagnosed via blood tests or by symptoms such as acne and facial/chest hairs. The ultrasound features can involve your ovary (or both ovaries) having the classic “polycystic” appearance, or it could just be a large ovary.
The most common criteria for diagnosis states you only need to have two out of the three to have PCOS. Which means that, PCOS, the most common cause of irregular periods, can be diagnosed in someone with regular periods. This also means that your ultrasound can be completely normal with no polycystic ovaries, and you still have PCOS. If that's not confusing enough, adolescents often have irregular periods and male hormone level fluctuations. So when a 15-year-old girl presents with irregular periods and acne, is it really PCOS, or is this just puberty? We often have to wait years before being able to make the diagnosis in adolescents. Even in adults the diagnosis isn't as straightforward. Many other conditions can mimic what PCOS looks like. If you have abnormal thyroid function, high prolactin levels or a tumour producing excess male hormones you may present with the same symptoms. With that being said, there's also another diagnostic criteria that states you must have excess male hormones to diagnose PCOS. This wide variability causes PCOS to be both over and under diagnosed, often frustrating patients.
Do we know what causes it?
The exact cause as you can imagine is unknown. Genetics, in utero nutrition and lifestyle all play a role in developing PCOS. What we most recently agreed on, is that in 90 per cent of PCOS patients, the ovary is overproducing male hormones, and over half of patients have some form of insulin resistance. For those with insulin resistance, this results in higher than normal insulin levels which in turn stimulates the ovary to produce even more male hormones. Obesity is a known contributor because excess body fat increases insulin resistance.
How do you treat what you don't know?
The knowledge of what happens in PCOS patients is what directs treatment, and it also explains why not everyone receives the same treatment. If you have excess body fat, then weight loss with dietary modifications and exercise is a good starting point for you. If your body fat percentage is normal, then medications to suppress the excess male hormones may be right for you. Many patients will benefit from medication to help reduce insulin resistance such as metformin. Contraceptive pills can be used to regularise your cycle, especially if you need some form of birth control as well. Some contraceptives can directly reduce male hormone levels, and provide relief of not only irregular periods, but also the acne and male hair distribution. So while we can't exactly tell you what it is or what caused it, we do in fact know a lot about what happens within PCOS patients. It has a wide array of presentations and underlying causes, so it's important for you and your physician to understand “your type of PCOS”, so that your investigations and treatments can be tailored to suit your specific needs.
Dr Ryan Halsall is a consultant obstetrician gynaecologist who operates at ILAP Medical, 22 Windsor Avenue, Suite 2, Kingston 5. He can be contacted at firstname.lastname@example.org or 876-946-0353. Follow him on Instagram: @drhalsall
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