What exactly is PCOS and how to treat it?

Polycystic ovary syndrome (PCOS ) arouses a lot of emotions and controversy among both patients and doctors.

From our (gynecologists) side, this is due to the fact that every year we receive new guidelines or additional advice, hence different procedures from different specialists. The disease is multidimensional and newer and newer tests provide us with more and more information, and the equipment we use during diagnosis (e.g. ultrasounds) is more and more sensitive and helps us see more and more.

On the part of patients, emotions are caused byovulation disorders , and consequently problems with menstruation, or, even worse, with getting pregnant. On the other hand, PCOS often affects a woman's appearance: hair in places where it shouldn't be or acne. There is a hyperdiagnosis of PCOS (i.e. the disease is diagnosed more often than it actually occurs), which results from the statement during an ultrasound "you have polycystic ovaries", and unfortunately the matter is not so binary, because PCOM ( polycystic ovary morphology ) is not equivalent to the presence of the entire syndrome.

What exactly is PCOS?

The syndrome was first described in 1935 by Stein and Leventhal, and the first name was created from their surnames. The main symptoms are the previously mentioned menstrual disorders, symptoms of excess male sex hormones (hyperandrogenism), i.e. seborrheic skin problems or problems with excessive hair (hirsutism) . Obesity is often added. In the past, all patients with PCOS symptoms were pigeonholed and treated similarly. Due to the development of science, we now know that there are three main phenotypes, in which we have different procedures, but I will talk about this in more detail later. Unfortunately, the problem associated with PCOS is not limited to the reproductive period in a woman's life. In the postmenopausal period, they are exposed to a more frequent occurrence of type 2 diabetes, cardiovascular diseases, endometrial hyperplasia or endometrial cancer. When does PCOS actually begin? There are many theories: some say that it begins in utero, others that it begins during puberty. One thing is certain - long before the first symptoms appear. The disease results from both genetic and environmental factors. It is associated with, among others, intrauterine developmental disorders, low birth weight and insulin resistance. Daughters whose mothers suffered from PCOS are at increased risk of developing this condition, but the search for a specific gene is still ongoing. Recently, much attention has been paid to the environmental factor, which are products used in the production of plastic (mainly BPA, or bisphenol A) contained in food packaging, cosmetics, bottles, water pipes, etc. and advanced glycation -end products (AGEs ). The latter are products of food processing, and if there are not too many of them, the body eliminates them itself. When they are produced in excess, they are deposited in the tissues and can cause broadly understood inflammatory reactions in our body, which lead to lifestyle diseases, such as cardiovascular diseases, diseases of the musculoskeletal system or diabetes. How to avoid AGEs? You've probably heard the recipe many times: we eat the least processed food possible and avoid thermal processing, such as frying. Additionally, AGEs are also present in tobacco smoke. The aforementioned substances are important factors related to our civilizational progress, and links for people who want to expand their knowledge can be found below.

PCOS is considered the most common endocrine disorder among women of reproductive age, and therefore, unfortunately, the most common cause of infertility. Depending on the guidelines we follow, its incidence is estimated at 10-15%, but according to some sources, these values ​​can reach up to 25%. This entire discrepancy results from the criteria based on which we diagnose the disease. Unfortunately, as is often the case in medicine, nothing is black or white, and the boundaries are quite fluid.

How is PCOS diagnosed?

The flagship and most basic criteria for diagnosing PCOS are the so-called Rotterdam criteria from 2003. Proposed by ESHRE ( European Society of Human Reproductive Medicine ) and ASRM ( American Society for Reproductive Medicine ). They include 2 of 3 main points: oligoovulation (infrequent ovulation) or anovulation (lack of ovulation), clinical symptoms of hyperandrogenism or hyperandrogenemia, and the image of polycystic ovaries in ultrasound (at least 12 follicles and ovarian volume > 10 ml). In 2018, we received a new dose of knowledge in the form of the International PCOS Network guidelines. The number of follicles required in an ultrasound examination has increased - to at least 20 (Polish scientific societies suggest even 25). The lack of a dominant follicle is also necessary. The situation is more complicated in younger patients - as in many other disease entities, the procedure here differs from the standard one. In the first year after the first menstruation, up to 85% of cycles are anovulatory, and for comparison, in the third year - 59%. Of course, the more irregular the cycles in a girl, the greater the probability of disorders in reproductive age. But it is still only a probability.

The factors of PCOS in adolescents are early onset of menstruation, puberty, low birth weight at delivery and obesity. When PCOS is suspected in obese girls, the first recommendation should always be weight loss - even a 5% loss can show benefits in improving health. However, we must remember that every body needs time to "get used to" new conditions, in this case - menstruation. In the 2018 guidelines, this time has been extended to 8 years. This means that PCOS should be diagnosed only 8 years after the onset of menstruation. Of course, we should observe the patient beforehand - for at least 2 years.

In addition to assessing the ovaries with an ultrasound, it is necessary to perform hormonal tests. In this case, we either immediately determine free testosterone (that which is not bound to any proteins) or calculate FAI (free androgen index), which is calculated from the concentration of total testosterone and SHBG (androgen binding globulin). Normal testosterone concentration? Let's go further - we determine the remaining androgens. We also determine a lot of other sex hormones, and often also the concentration of glucose, cholesterol, etc. Okay, because I've probably bored you by now, and I just wanted you to know that the whole process is complicated and one visit is not enough to diagnose PCOS. So be patient and don't get upset that your doctor orders a ton of tests without giving you any specifics.

I promised to write more about phenotypes (groups with specific features) associated with PCOS. The dominant phenotype is the metabolic phenotype (otherwise known as classic), i.e. an obese patient with insulin resistance and hyperandrogenism. Unfortunately, abdominal obesity is associated not only with the accumulation of fat in the subcutaneous tissue, but also in the muscles and liver (so-called visceral fat tissue), which entails further consequences. The problem is not "only" menstrual disorders, but of the entire body: through lipid disorders, insulin resistance, to cardiovascular diseases or postmenopausal endometrial cancer. In these patients, weight loss is very important (reducing diet, increased physical activity, sometimes pharmacotherapy - metformin), which has a positive effect on all systems. Unfortunately, it is not that simple, because in these patients, losing weight is simply more difficult than in a population not burdened with hormonal disorders.

The next phenotype is the hyperandrogenic phenotype, which is associated with an excess of male sex hormones or the occurrence of symptoms characteristic of them (both features do not have to go hand in hand). I mentioned the so-called biochemical androgenism earlier in the 2018 guidelines. As for the symptoms that you may observe in yourself, these are skin problems (mainly seborrheic changes, acne), excessive body hair, or androgenic alopecia (rarely). We must remember that an increase in male sex hormones can also occur with many adrenal diseases or tumors. Therefore, it is very important to rule out these diseases, but leave this to the doctor :) The treatment is most often a two-component contraceptive pill. The matter is much more complicated than it seems, but I will not overwhelm you with details - the doctor will take care of you.

The last phenotype is the reproductive phenotype, which basically means everything is great, except that you can't get pregnant. Your testosterone is within normal limits, you have no symptoms, you're slim, you don't have acne, but you have irregular periods. The goal of treatment in this phenotype is to restore ovulation, which is why the drugs used by gynecologists affect your hypothalamus-pituitary-ovary axis precisely. Pharmacological treatment to stimulate ovulation is quite complicated and requires constant medical supervision and sometimes surgery.

Complicated disease

As you can see, PCOS can affect both an overweight girl with excessive hair and a slim one with beautiful skin. This is of course a great simplification, but I wanted to draw attention to the fact that this disease is complex and diverse. Remember also that there are no simple boundaries between patients, we are always talking about the dominant phenotype. It is precisely because of the richness of symptoms that personalized therapy is important. We will not treat patient no. 1 and patient no. 2 in the same way, because their problem lies in a completely different place. Another issue is that we have not yet fully understood the causes of PCOS and we are still treating its symptoms, not the cause. It is important to choose a doctor whom you trust, regardless of the symptoms you come with, and you will be consistent in implementing his recommendations. The worst thing you can do is to change doctors all the time, not giving them a chance to make a full diagnosis. And I am far from saying that you should stick to the first one you go to at all costs, but with the constant change of doctors, the whole diagnostic and therapeutic process will start all over again. And yes, any gynecologist can treat PCOS, but remember that there are also gynecologist endocrinologists, so if you have a history of many visits that did not bring you any improvement in your condition, simply go to a double specialist ;)