What is Polycystic Ovary Syndrome (PCOS)?

Polycystic ovary syndrome (PCOS) is a hormonal disorder that leads to menstrual irregularity, ovarian dysfunction and infertility. It affects 5- 15% of all women of reproductive age and is considered to be the leading cause of female infertility.

Most often, symptoms first appear in adolescence, around the start of menstruation. However, some women do not develop symptoms until their early to mid-20s. Although PCOS presents early in life, it persists through and beyond the reproductive years. In PCOS, there is an imbalance in the hormones that control the menstrual cycle, often in combination with insulin resistance, which then prevent ovulation and decrease fertility.

What is the link between insulin resistance and PCOS?

Insulin resistance leads to high levels of insulin in the blood stream (hyperinsulinaemia) as the body attempts to control glucose levels. High levels of insulin lead to a reduction in a hormone called sex hormone-binding globulin (SBHG) in the liver, which results in abnormally high levels of male hormones circulating in a woman’s bloodstream.

What is an ovarian cyst?

An ovarian cyst is any collection of fluid, surrounded by a thin wall, within an ovary. Small ovarian cysts, called follicles, are normal and occur in both ovaries. A follicle that is larger than about 2cm is termed an ‘ovarian cyst’. Such cysts range in size from as small as a pea, to larger than an orange.

The diagnosis of polycystic ovaries is made when there are either 12 or more ovarian cysts, or when one or both ovaries are bigger than 10cm3.

Although 20% of all women have ovarian cysts, it does not mean you necessarily have polycystic ovary syndrome.  These cysts are only one of the three components of PCOS: if you do not have two of the three components, you probably do not have PCOS.

It’s important to note that 30% of women diagnosed with PCOS do not have polycystic ovaries.

What are the symptoms of PCOS?

The following symptoms are common:

  • >90% have fewer than periods per year (called oligomenorrhoea)
  • 30–50% have no periods at all (called amenorrhoea)
  • >90% are infertile
  • >95% have acne
  • 60-95% have unusual male pattern body hair, often on the upper lip, chin, around the nipples and in a line beneath the umbilicus (called hirsutism)
  • Difficulty in falling pregnant
  • Hair loss, especially male-pattern balding (called alopecia)
  • Excess body fat or difficulty losing weight (the weight distribution is usually around the waist)
  • Psychological symptoms such as mood swings, depression and anxiety
  • Sleep disorders
  • Skin pigmentation (may be present and may also indicate insulin resistance)
  • Occasionally masculinisation (including increased muscle mass and a deepening voice; these indicate a severe increase in male hormones)

What is the link between body weight and PCOS?

Approximately 70% of women with PCOS are overweight or obese. Excess weight, especially central obesity, is strongly associated with insulin resistance and systemic inflammation, both contributing factors to PCOS and other health conditions.In teenagers, obesity is the highest cause of anovulation (not ovulating) that continues into adulthood.

What is the link between stress and PCOS?

Stress can be both a contributing factor towards developing PCOS and a complication of the condition. This is because the body produces stress hormones such as cortisol as part of the normal stress response. Cortisol levels that are elevated chronically in response to prolonged stress can produce a wide variety of adverse reactions, including disruptions in ovulation and the menstrual cycle, contributing to infertility and to PCOS.

What complications are associated with PCOS?

Polycystic ovary syndrome, especially in the presence of obesity, increases the risk of both gynaecological conditions and a wide variety of many other diseases.

The gynaecological conditions include:

  • Abnormal  bleeding in the uterus
  • Abnormal thickening of the lining of the uterus (endometrial hyperplasia)
  • Cancer of the uterus (a three times higher risk than those without PCOS)
  • Pregnancy abnormalities
  • Decreased fertility

There is also an increased risk for:

  • Cholesterol abnormalities e.g. elevated triglycerides and LDL-cholesterol and lowered HDL-cholesterol
  • Depression and anxiety
  • Diabetes
  • Chronic, low-grade systemic inflammation
  • High blood pressure (hypertension)
  • Metabolic syndrome
  • Heart attacks
  • Non-alcoholic-fatty liver disease
  • Sleep disorders

What lifestyle measures can I follow to help improve PCOS?

Although polycystic ovary syndrome cannot be cured, there are various approaches available to manage the underlying contributing factors and to alleviate symptoms.

Lifestyle modification should be the focus of treatment for the management of both PCOS as a syndrome, and for the underlying causes or risk factors. This includes dietary changes, weight loss (where necessary), increased physical activity and stress management.

Weight loss and exercise have been shown to improve fertility, psychological symptoms and the metabolic features (insulin resistance and cardiovascular risks) of PCOS and may improve ovulation and pregnancy rates and outcomes too.

The thought of losing a large amount of weight may be demoralising.  While achieving a normal BMI (19 to 24.9) would be ideal, it is important to know that a modest weight loss of as little as a 5% loss of body weight can restore fertility.

Various scientific studies have shown that inositol, a natural phytochemical, improves insulin sensitivity, slows down the formation of fat and increases the rate that stored fat is broken down. Inositol’s insulin-sensitizing action appears to improve ovarian function in many patients with PCOS.

How can stress management improve PCOS?

Our body produces cortisol as part of the normal stress response. Cortisol levels that are elevated chronically in response to prolonged stress can produce a wide variety of adverse reactions, including erectile dysfunction and disruptions in ovulation and the menstrual cycle. These effects may in turn result in decreased fertility.

Managing stress levels could be beneficial not only to the woman struggling with PCOS, but also for her partner when trying to fall pregnant, as the challenge to conceive can be stress-inducing for both parties.

A free online stress self-test is available, which can be used to identify the presence and severity of your own stress levels.

References

  1. Hursting SD, PhD, MPH. Obesity, Energy Balance and Cancer: Trends, Targets and Transgenics. 2003. Department of Carcinogenesis, University of Texas
  2. Linkov F, PhD. Cancer Epidemiology: The Need for Global Information Sharing in obesity and cancer? World Congress of Epidemiology, Aug 2011
  3. Pazaitou-Panayiotou, K., Polyzos, S. A. and Mantzoros, C. S. (2013), Obesity and thyroid cancer: epidemiologic associations and underlying mechanisms. Obesity Reviews. doi: 10.1111/obr.12070
  4. Yehuda-Shnaidman E, Schwarts B. Mechanisms linking obesity, inflammation and altered metabolism to colon carcinogenesis. Obes Rev. 2012 Dec: 13(12): 1083-95. Epub 2012 Sep 3.
  5. Birk S, Peeters A, Mackholder K, O’Brien P, Brown W. A systemic review of the impact of weight loss on cancer incidence and mortality. Obesity Review, Vol 13, Issue 10, pgs. 868-891, Oct 2012
  6. Gallagher EJ, MB BCH BAO MRCPI, LeRoith D, MD, PhD. Epidemiology and molecular mechanisms tying obesity, diabetes and the metabolic syndrome with cancer. Diabetic Care, Vol36, Sup 2, Aug 2013
  7. Messiah SE, Lipschultz SE, Natale RA, Miller TL. The imperative to prevent and treat childhood obesity: why the world cannot afford to wait. Clinical Obesity
  8. The Cancer Association of South Africa. http://www.CANSA.org.  Accessed 16 October 2013
  9. Krygsman, A. Can restriction of carbohydrate and/or omega fatty acids prevent breast cancer development? Dept. of Physiological Sciences, University of Stellenbosch.
  10. Albrecht, C MD. Cancer stakes its Territory- Causes and Link to Stress. Head of research, CANSA, Aug 2012
  11. Herbst MC, Prof. Fact sheet on Colorectal Cancer. Cancer Association of South Africa. June 2013
  12. Donna Kerrigan, M.S. Jeanne Kelly. Brian Hollen.  Understanding Cancer and Related Topics, Understanding Cancer Genomics. National Cancer Institute.
  13. Shmoop Editorial Team. “The Cell Cycle, Cellular Growth, and Cancer” Shmoop.com. Shmoop University, Inc., 11 Nov. 2008. Web. 17 Oct. 2013.
  14. Chow AY, PhD. (2010) Cell Cycle Control by Oncogenes and Tumour Suppressors: Driving the Transformation of Normal Cells into Cancerous Cells. Nature Education 3(9):7
  15. National Cancer Institute at the National Institutes of Health. Fact Sheet: Obesity and Cancer Risk. www.cancer.gov/cancertopics/factsheet/risk/obesity  Accessed 18 October 2013
  16. Nissen MJ, Shapiro A, Swenson KK. Changes in weight and body composition in women receiving chemotherapy for breast cancer. Clin Breast Cancer, 2011 Mar;11(1):52-60
  17. The Cancer Association of South Africa. Breast Cancer – Big & Small Let’s save them all. www.cansa.org.za Accessed 16 October 2013
  18. National Academy of Sciences. The Role of Obesity in Cancer Survival and Recurrence: Workshop Summary 2012