What is PCOS?
What is PCOS? What causes it?
Polycystic Ovarian Syndrome. PCOS.
I talk about PCOS every day in my clinic. There are entire podcasts devoted to PCOS. This is my take on what PCOS is, how we treat it, and what we can do about it.
First, I hate the name. It is a terribly named disease. It makes you think that the cysts are the problem. But the cysts are not the cause of not ovulating, they are the consequence of it. The disease is named polycystic ovarian syndrome because there are lots of small “cysts” on the ovaries. But really - a cyst is a fluid filled structure on ultrasound, and in context of PCOS you have many small follicles - and technically, each follicle is a cyst. When you are about to ovulate and you have a follicle, that is a cyst. So if you have PCOS you have lots of follicles that are not responding to hormones. So the cysts are not the problem but the real problem is hormone dysfunction.
What is PCOS?
I like to consider PCOS to be a stubborn ovary. Basically the communication between the brain and the ovary is dysfunctional. So you probably know that the brain sends out two hormones, LH and FSH. They do different things. FSH (a well named hormone, follicle stimulating hormone) controls a follicle growing, which happens as an egg matures. LH (luteinizing hormone) helps trigger ovulation (egg release) and stimulate progesterone production in the luteal phase. LH is also very important in the production of hormones.
In short - the ovaries are a hormone making factory.
In PCOS the ovarian response to the brains hormones is abnormal (ovarian dysfunction).
Remember my analogy about the ovarian vault? A woman is born with all the eggs she is ever going to have, they are trapped in a vault inside her ovary, and at the start of every month a group of eggs is released from the vault. These eggs are waiting to get a signal from the brain which is your FSH. In PCOS the number of eggs released is really high and the FSH signal is normal. So the signal gets sent to all of the follicles which causes it to be faint (or diluted). The signal is not strong enough to get one follicle to respond. The follicles are making just enough estrogen to prevent the brain and ovary from communicating properly. However, the ovary is a powerhouse hormone making machine and it likes to do its job right. When it can’t make enough estrogen - it makes testosterone. The pathway for the LH to androgen production becomes the preferred pathway and male hormones are made at a much higher rate than estrogen creating a hormone imbalance.
If this is confusing to you, and trust me you are not alone, go listen to my podcast The Menstrual Cycle, Period.
Insulin is extremely important and it’s important that we understand it. Insulin helps your body do two things: use glucose or store glucose. Insulin resistance is when the cells are no longer up taking the glucose. So the cells feel like they have low glucose levels and the liver starts to breakdown glucose to give you more sugar. The pancreas begins working overtime to get more insulin because the body is saying they need more sugar in your cells. Insulin stimulates increased ovarian androgen production. This means it is causing the body to make more LH and the ovary is being shifted to make even more androgens. It is also preventing the liver from creating sex hormone binding globulin (SHBG). SHBG floats around your blood and binds to your free hormones like testosterone. Your body can’t use hormones that are bound to SHGB. So when SHBG levels are high, you can’t access this testosterone. When SHBG levels are low that means there is less testosterone bound and more that is circulating free and causing an impact on your cells. So insulin is causing your ovaries to make more androgens and making them free in your bloodstream. Not everyone with PCOS has insulin resistance, but 60-70% will. It is a large contributor to making the disease worse although it is not a cause of PCOS
Women with PCOS can have any body type as it is an ovarian problem. However, some women develop PCOS as they gain weight. Obesity predisposes you to PCOS and it also makes the disease worse. Your fat cells are also hormone factories making a form of estrogen called estrone. Estrone can turn into testosterone. That high estrogen level is also contributing to that feedback to the brain saying don’t send out more FSH because the ovary is making enough estrogen. Also, with increasing obesity, your liver makes less SHBG. Obesity makes insulin resistance worse. Not every woman who is overweight or obese has PCOS, and not everyone with PCOS is overweight or obese. That’s hard because there is a lot of misguided information floating around in the world.
The diagnosis
The diagnosis is made by having two out of the following three symptoms. These are called “Rotterdam criteria.”
Hyperandrogenism that can be diagnosed by blood levels or clinical signs of high androgens such as facial hair, acne, losing hair near your temporal area.
Irregular or absent periods which is the hallmark of the clinically significant disease on fertility.
Polycystic appearing ovaries on ultrasound. The criteria say its about having a certain number of antral follicles that is higher than normal. There is a very consistent pattern that is more than just egg count. We see a thick central part of the ovary with small antral follicles pushed to the outer surface called the “ring of pearls.” Many young women with high ovarian reserve will meet the official diagnosis just by counting the antral follicles. However, most do not actually have PCOS.
Why are my periods irregular? Because of the hormone dysfunction. Your body is not making enough estrogen to thicken lining. Then there is no drop in progesterone signaling to the body that it is time to bleed. Sometimes you will still bleed, but it is not like a regular period because you are not ovulating. While we are on this subject, I am going to tell you my biggest pet peeve. Patients are told that there is an estrogen to progesterone imbalance, and I need to give you a progesterone pills to fix it. Also known as “estrogen dominance.” But this is misguided. The reason there is no progesterone because you are not ovulating, and if I put you on a compounded progesterone pill, cream or drop, it will not fix your problem. That is just a form of birth control. You are not going to get pregnant by giving yourself progesterone. You may get those pills to cause a period so you do not help uterine cancer. You don’t need more progesterone - you need to ovulate. You don’t need to clear estrogen from your system with expensive cleanses and pills, you need to ovulate.
Other findings that are common with PCOS but not part of the official diagnosis.
Insulin resistance
High cholesterol
Thyroid or prolactin abnormalities.
Metabolic syndrome
To save you from information overload, I will continue the topic of PCOS in my next blog post discussing the treatments for PCOS.