A Conversation with Christine Burt Solorzano, MD
Polycystic Ovary Syndrome (PCOS) is a hormone disorder that is a common cause of infertility and raises the risk of developing diabetes, obesity, and other metabolic health problems. PCOS affects 7-10% of women of childbearing age. Women with PCOS have at least two of these signs:
We spoke to expert Christine Burt Solorzano, MD, about the signs and symptoms to help you spot PCOS.
PCOS arises from the interaction of genetic and environmental factors, often starting around the time of puberty. Of all women with PCOS, 25% have a mother with PCOS. If you are a daughter of a woman with PCOS, your chance of having elevated testosterone levels is about 50%. Most adolescents with PCOS have either a mother with polycystic ovaries or a parent with metabolic syndrome. Half of sisters of PCOS women also have elevated testosterone levels, but only half of these have menstrual problems.
Many genes are linked to PCOS, related to hormone production, insulin sensitivity, or obesity, and may lead to the development of PCOS by different paths. Weight gain is the most common cause of insulin resistance, when the body does not use insulin well, and insulin resistance is a risk factor for PCOS. Childhood obesity is a risk factor for adult PCOS. Women with excess androgen hormones, including testosterone, due to classical or non-classical congenital adrenal hyperplasia are also at risk for PCOS.
Women with PCOS are at a higher risk of developing metabolic problems, including weight gain and obesity, insulin resistance (even with normal weight), non-alcoholic fatty liver disease, elevated glucose levels, and type 2 diabetes mellitus.
Cardiovascular risks can include abnormal lipid levels such as low HDL (“good” cholesterol), elevated triglycerides and LDL (“bad” cholesterol), as well as elevated inflammatory markers that are associated with heart attacks and stroke. The severity of PCOS may correlate with risk of cardiovascular events.
Common reproductive issues associated with PCOS include abnormal uterine bleeding such as heavy periods, irregular periods, and absent menstrual cycles, infertility with a decreased response to fertility medications compared to other women, and pregnancy complications. We also see cases of endometrial cancer due to low progesterone levels, albeit a very small risk (1.3 per 10,000 women age <50 years old).
Women with PCOS are at a higher risk of a decreased quality of life and mental health concerns. For example, many suffer from obstructive sleep apnea or poor-quality sleep with a higher risk even when taking excess weight into account. They also suffer from anxiety and depression even when taking excess weight or hirsutism (facial hair) symptoms into account, as well as eating disorders (binge eating and bulimia nervosa) and decreased sexual satisfaction.
Researchers are actively investigating PCOS’ causes, treatments, and related medical conditions. Since many pathways may lead to PCOS, researchers are trying to sort out which women and girls are at risk, how PCOS develops in the different pathways, and individualized strategies for preventing progression to PCOS based on risk factors. They also are studying the best ways to help women with PCOS have successful pregnancies and to protect against metabolic problems.
There are many other questions about PCOS that still need to be addressed, including:
For teens, PCOS can lead to acne, hirsutism (growth of facial hair and hair in other areas typical for men), irregular periods, anxiety, depression, weight gain, and eating disorders. Young adults can expect the above complications as well as issues conceiving children, pregnancy complications, and metabolic complications.
Older adults are subject to metabolic and cardiovascular issues and are at increased risk of endometrial cancer. They also tend to suffer from persistent hirsutism and male-patterned hair loss. Unfortunately, once a hair follicle starts producing dark hair in male-patterned areas, the hair stays dark. Hair removal can be costly and only partially effective. Medical treatments may help the hair grow more slowly and decrease the amount of it. Male-patterned hair loss may be difficult to treat.
Infertility in women with PCOS may be related to insulin resistance and excess androgen. It is important to be metabolically fit, meaning that your body can respond to food in a beneficial way that reduces your risk of conditions. A healthy diet and regular exercise is helpful to lower insulin and androgen levels in women with PCOS.
Modest weight loss (5-10% of body weight, over 3-4 months) before starting ovulation induction therapy has been shown to restore normal ovulation and improve pregnancy rates in some women. Medications we use to induce ovulation in women with PCOS include letrozole, clomiphene, and, rarely, metformin (in women with glucose intolerance).
Women with PCOS have a higher risk for pregnancy complications, including miscarriages, gestational diabetes, pregnancy-induced high blood pressure (three-fold higher risk), pre-eclampsia, and premature delivery (two-fold higher risk). Obesity likely plays some role in these complications, but any woman with PCOS has higher risks.
One of the easiest diet changes to make is focusing on eating green vegetables, fruits, and lean protein. It is important to avoid refined carbohydrates, sugar-sweetened beverages, eating out, and processed food. High protein/low carbohydrate (30% fat) and low protein/high carbohydrate (30% fat) diets appear to be equally effective in a recent study. Having an active lifestyle with regular exercise, including cardio and strength training, also helps.
There are some medications that can help treat PCOS, including estrogen-progestin oral contraceptive pills, or progestin-only contraceptives, weight loss medications, spironolactone or other androgen blocking medications (used if cosmetic response is suboptimal after 6 months of estrogen-progestin oral contraceptive), and medications to improve the body’s responsiveness to insulin (e.g., metformin, liraglutide). Bariatric surgery also can be beneficial.
However, we no longer recommend metformin as a first-line therapy in adult women with PCOS, as it lowers androgen levels only modestly and is less effective for achieving regular menstrual cycles. Yet, we may use metformin if there is a contraindication (any reason for a person to not receive a particular treatment because it may be harmful) to the first-line treatments or in addition to combined estrogen-progestin oral contraceptive therapy.
Metformin can help lower blood pressure, LDL-cholesterol, insulin levels, and possibly delay onset of type 2 diabetes mellitus in those at risk. However, it cannot protect against endometrial cancer, reduce weight significantly, or improve hirsutism. Metformin also does not reduce the risk of gestational diabetes mellitus, early miscarriage, pre-eclampsia, or preterm delivery in pregnant women with PCOS.
Healthy diet and active lifestyle can mitigate problems for all women with PCOS, regardless of weight, and should be implemented early and maintained. Women with excess weight can find hope in the evidence that even modest reductions in weight (5-10% of body weight) can lead to improvement in PCOS.
Christine Burt Solorzano, MD, (pronouns: she/her) is a pediatric endocrinologist and a clinical investigator studying early etiologies of polycystic ovary syndrome in girls, and is involved in multi-center studies for types 1 and 2 diabetes in children. She is medical director of the UVA Children’s Fitness Clinic and co-director of the UVA Children’s Hospital Transgender Health Clinic.
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