What is PCOS?
Polycystic Ovarian Syndrome (PCOS) is the most common hormone disorder in women of reproductive age. (1) Increases in hormones like testosterone, insulin and luteinizing hormone impact many of the symptoms that we see with PCOS.(2) High amounts of male hormones cause many of the common physical symptoms we see in PCOS. The thing no one talks about is that high testosterone and other male hormones affect things going on inside your body that you might not see outwardly.
Symptoms of PCOS can present themselves as early as puberty after a young girl has her first period bleed. While PCOS affects somewhere between 1 in 5 women or 1 in 10 women, it goes undiagnosed in up to 70% of women. (1)
Learning what symptoms are common can help you determine if it’s likely you have this syndrome. This is especially so because these symptoms can check off 2 of the 3 requirements of diagnosis - ovulation irregularities and signs of high male hormones like acne, hair loss or hair growth in areas of the body that aren’t common for women.
Beyond diagnosis, narrowing in on which symptoms are most frustrating helps determine which interventions to consider focusing on first.
What are the symptoms?
Anovulation and Menstrual Cycle Irregularity
In your ovaries, you have follicles, or fluid-filled sacs where eggs are stored and grow in size to the point one gets chosen for ovulation. When high amounts of androgens like testosterone are present in the ovaries, those follicles are unable to mature and cannot release the egg, we call that ovulation. (2) Ovulation and menstrual cycles go together, so if you do not ovulate, you will not truly menstruate either. Now this can get tricky because there are definitely other health conditions that can make you bleed that have nothing to do with PCOS, but a true menstrual bleed will ALWAYS follow ovulation unless you are pregnant(this is a blog topic for another day).
Some women with PCOS don’t ovulate at all. This means they are not cycling or having any period bleeds. Others do not cycle and ovulate as often as women that do not have PCOS. It’s common for women with PCOS to say things like “I only have one to two period bleeds per year.”
If you aren’t ovulating or are ovulating infrequently you meet the one of the diagnostic criteria for PCOS. If you have questions on if you ovulate, check out my mini course called PCOS + Cycle Tracking. A topic for another post on another day, but it is important for women to ovulate and not just for pregnancy. Ovulation means your body is making progesterone which has essential jobs in your body.
Acne
Excessive amounts of male hormones like testosterone or a lesser known male hormone called DHEA-S (made in your adrenal glands) trigger oil production in the skin, which can clog pores and lead to acne breakouts, especially on the face, chest, and back.(3) In PCOS patients testosterone becomes a more potent form of testosterone called DHT (this happens in the skin cell or hair follicle itself so it isn’t a great lab marker to test for). This overproduction of DHT happens in the cells where acne is made. There are many ways we can target this conversion process and improve this symptom.
Inflammation can also contribute to acne symptoms. A good trick to consider if this is a piece of your acne frustrations, pay attention to how your skin feels where you get most of your acne after eating a food or drink with a lot of concentrated sugar.
Gut health and certain dietary triggers can also be a huge part of acne production - so it may not be related to high levels of male hormones, getting to the root cause can be helpful in treatment options.
Hair Loss
The same issue with higher levels of testosterone, DHEA-S and DHT (all androgens/male hormones) contribute to hair loss. This happens when the androgens shrink hair follicles and stunts regrowth of new hair. DHT is one of the main contributors to male-pattern hair loss, which often starts as a bald spot or receding hairline.(4) However, women with PCOS also experience thinning where the hair is parted.(4)
Hair loss that may not be apart of PCOS can also be caused by things like thyroid dysfunction, under-eating, or nutrient deficiencies.
Hair loss and hirsutism can be some of the most frustrating symptoms of PCOS and affect our self esteem and sense of beauty. Because of this I see tons of products promoted to women with PCOS that really do very little to treat the root cause of the symptoms. It’s okay to try serums, creams, conditioners, but don’t neglect the hormonal abnormalities that are driving the condition, because it will take addressing that to see long term improvements.
Excessive Hair Growth (Hirsutism)
Hair follicles can be sensitive to excess testosterone in the opposite way too. Testosterone can trigger your thin body hair (peach fuzz) to turn into terminal hair (scalp hair), which is thicker and longer.(3) This can happen in many areas of the body that normally do not have terminal hair, like the upper lip, chin, neck, chest, back, and inner thighs.
This symptom of PCOS is one of the reasons we understand that this syndrome is not new but has been around for thousands of years as philosophers have documented women with larger more muscular builds and an ability to grow facial hair like that of male counterparts.
Weight Gain and Abdominal Fat
Most women with PCOS have some level of insulin resistance.(2) Insulin acts as a key to trigger the cells in our body to absorb energy from the bloodstream. However, insulin resistance is when cells are not responding effectively to insulin and sugar is still abundant in the blood. As a result, that excess sugar can be stored as fat, which is why many women with PCOS may struggle with extra body weight especially in the abdominal region.
Meanwhile, insulin-resistant cells haven’t received enough energy from sugar, leading to more cravings and hunger that will make it harder to lose weight.(2) PCOS is also linked to hypothyroidism, or inadequate thyroid hormone production. Without enough thyroid hormone, your body’s metabolism will slow down and weight may become more difficult to lose.(5)
Dark Skin (Acanthosis Nigricans)
This is where a lot of skin pigmentation (the things that help give our skin color) concentrates in the skin around the folds of the neck, armpits, and breast areas. This is a common sign of insulin resistance and may be more common in those with darker skin tones.(3) Insulin activates certain growth factors in the skin, which increase skin cell production and lead to these dark areas on the skin. Skin tags are also common in PCOS for a similar reason. These tend to develop in similar areas: under the arms, on the neck, in the groin area.
Fatigue
Since those with insulin resistance are not getting enough energy into their cells, they may feel tired often.(3) The association between hypothyroidism and PCOS may play a role here as well since low levels of thyroid hormone are associated with fatigue.(6) Stress and poor sleep are other common contributors to fatigue in women with PCOS. This isn’t surprising for reasons listed next!
Disrupted Sleep
PCOS is associated with poor sleep patterns and sleep apnea.(3) This may be in part due to some PCOS women being overweight or obese and these conditions are associated with obstructive sleep apnea. While being in a bigger body can make sleep apnea more common, there are studies showing irrespective of weight and BMI, women with PCOS are more likely to suffer from sleep apnea. So no matter what your body size, having a PCOS diagnosis makes it more likely that you could suffer from sleep apnea. Discuss this with your doctor if you struggle to lose weight or feel tired all the time, taking part in a sleep study could be very informative for you.
Women with PCOS also commonly have low levels of estrogen and progesterone. Some preliminary research in postmenopausal women shows that these female sex hormones have sleep-regulating effects. We know that progesterone in particular can help improve sleep quality, and progesterone is something that will be difficult to benefit from if you aren’t ovulating as it is only made after ovulation.
Infertility
When the pituitary gland releases abnormally high amounts of luteinizing hormone, follicles cannot mature and release an egg.(2) Testosterone and insulin resistance also play a central role in ovulation not being favorable with PCOS. Without ovulation, the egg will not travel into the fallopian tube and cannot be fertilized. Without ovulating, there is no way to get pregnant without the help of fertility treatments. Thankfully, diet and lifestyle changes can improve chances of conception. I have helped hundreds of women become mom’s in my online course: Find Fertility with the PCOS+ Method.
What are lesser-known symptoms that we should be aware of?
Gut Health
Women with PCOS have lower gut biodiversity.(7) This means that we have lower levels and varieties of good bacteria in our gut, which is linked to the high amounts of male hormones(androgens) in our bodies. This increases the risk of gut microbial imbalance, which may cause gastrointestinal problems and worsen the severity of our PCOS symptoms.(7)
Mental Health
PCOS is characterized by hormonal imbalances and fluctuations, which can affect emotional and mental well-being. PCOS is associated with a greater risk of developing depression, anxiety, and obsessive-compulsive disorders.(8) Certain symptoms, like weight gain, excessive hair growth, and infertility, may worsen mental distress. These symptoms may also make a woman feel unfeminine, leading to a difficult relationship with food and body image. Many of the treatments for PCOS revolve around hormonal contraception which increases the risk of suffering from anxiety and depression. This is something to discuss with your health care professional if you are considering this medication or already suffer with anxiety or depression.
Can we manage these symptoms of PCOS?
The good news is that you can manage PCOS through various treatments. And hopefully, that’s why you are here! Lifestyle changes like sufficient sleep, stress management techniques, a well-balanced diet, and movement can improve many of these symptoms. Medications and complementary medicine are available to regulate insulin, blood sugar, and male hormones.
Sources
1 https://academic.oup.com/humrep/article/25/2/544/673002?login=false
2 https://www.nichd.nih.gov/health/topics/pcos/conditioninfo/causes#
3 https://www.pcosaa.org/pcos-symptoms
4 https://www.mountsinai.org/health-library/diseases-conditions/female-pattern-baldness
5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287775/
6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6553506/
7 https://pubmed.ncbi.nlm.nih.gov/30066285/
8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276580/