Polycystic ovary syndrome (PCOS) affects 5 to 26 percent of women and 75 percent of women attending infertility clinics, but my personal experience is that many women who are diagnosed with this disease actually may not have PCOS.
It’s typically characterized by three overriding symptoms: elevated androgens (male sex hormones, especially testosterone), cystic ovaries on ultrasound and menstrual irregularities (most frequently lack of ovulation). Other signs include insulin resistance, weight gain and increased systemic inflammation.
Although these signs and symptoms are typical, some 20 to 25 percent of patients don’t have significant weight gain and may not have elevated androgen levels.
The diagnosis usually relies upon the so-called Rotterdam Criteria, set down in 2003, which claimed that if two of the following criteria were met, one could make a PCOS diagnosis:
The Rotterdam Criteria also noted that there were two recognized profiles of PCOS: 1) women with polycystic ovaries and clinical or biochemical evidence of androgen excess, but without ovulatory dysfunction and 2) women with polycystic ovaries and ovulatory dysfunction, but without problems of too much androgen or having excessive hairiness—another sign of androgen excess.
Another important sign of PCOS is the ratio between the amount of two important female hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
Normally the ratio of FSH to LH is close to 2:1, but in patients with PCOS that ratio is more or less reversed to 1:3.
Because of the various presentations of PCOS, diagnosis is often difficult. Many women are either misdiagnosed as having PCOS or simply diagnosed with anovulation when they actually do have PCOS.
In 2022, it’s debatable whether the Rotterdam Criteria are now outdated.
With PCOS, a physician needs to listen to the patient and, with the help of labs and ultrasound along with patient history, carefully make the diagnosis. In my view, rather than sticking to rigid criteria, doctors would benefit from looking instead at a patient’s insulin and glucose levels, because there is a strong metabolic component to PCOS.
The problem with overdiagnosis of PCOS, besides it being technically incorrect, is the usual drugs given for it, which have their own set of potential risks and complications.
Most allopathic and osteopathic physicians treat PCOS with oral contraceptive pills, usually a pill containing a combination of ethinyl estradiol and progestin.
While the pill may very well help overcome symptoms by interrupting the mismatch between the brain and ovaries and turning down hormones, it is not likely to cure the syndrome itself.
Birth control pills shut down ovarian production by interrupting the communication of the hypothalamic-pituitary axis, which in turn decreases androgen production by the ovaries and takes over the menstrual cycle.
Most providers say the patient will go back to regular periods; however, technically, this is a chemical withdrawal bleed, not a true menstrual period, and the patient could still suffer from the other issues of PCOS like weight gain and insulin resistance.
Metformin, also regularly prescribed, improves insulin resistance, but it has the potential for serious side-effects such as bone marrow issues and diarrhea or abdominal pain.
Low-dose naltrexone, a competitive nonselective antagonist of opioid receptors, is also prescribed, based on the evidence that PCOS involves increased activity of the sympathetic nervous system, altered central opioid tone and elevated beta-endorphin release.
There is some evidence that beta-endorphins affect insulin release, but no evidence naltrexone has a significant effect on lipid profile, systemic inflammation or blood vessel function in women with PCOS.
In my practice, I find that most patients with PCOS benefit from a nutrition and exercise program.
In many cases, a 5 percent reduction in weight can help with symptoms and even reverse the disease process, although this is not true for all patients.
For patients who desire to lose weight, I recommend intermittent fasting and a lower-carbohydrate nutritional plan, focusing on carbohydrates from a limited number of fruits and vegetables. In my experience, this type of diet plan plays a major role in helping patients recover from PCOS.
I also recommend supplements with inositol. Inositol is a type of sugar (carbohydrate molecule) that naturally occurs in some fruits and vegetables including citrus, beans and brown rice. Sometimes referred to as vitamin B8, inositol acts as a second messenger for insulin. A deficiency of inositol contributes to the various features of PCOS, especially insulin resistance.
Correction of the deficiency may help in alleviating metabolic and menstrual/ovulatory symptoms of PCOS, along with the effects of elevated androgen levels on the skin (known as cutaneous hyperandrogenism) such as excess hair growth and acne.
There’s also evidence of a direct relationship between milk consumption and risk of PCOS, so I often recommend that patients consuming lots of dairy cut back.
And while there are no placebo-controlled trials utilizing vitamin D and PCOS, in my practice I’ve found that vitamin D can improve insulin sensitivity.
PCOS is a complex and difficult to diagnose condition. But in my view, it makes good clinical sense for patients to be treated with a multidisciplinary approach rather than a one-size-fits-all strategy of using oral contraceptives.
What do you think? Start a conversation over on the... WDDTY Community
Great news! Discounts are available based on your cart total. Check the details below:
