What Is PCOS?

PCOS (Polycystic Ovarian Syndrome) is a condition affecting approximately 10% of the female population. It is the number one most common reproductive health concern in women and affects not only fertility, but also emotional and physical well-being due to its far-reaching health implications. High DHEA-S and testosterone in PCOS are common, however what is the difference if any between these two androgenic hormones? Why do some women with PCOS have specific androgens that are high, or high in the normal range and most importantly, what does this mean?

PCOS is a wide umbrella term, describing a common condition of female hormonal imbalance. The Rotterdam criteria for the diagnosis of PCOS are:

• Lengthy menstrual cycles, or delayed ovulation. Also known as oligomenorrhea.
• Androgenicity, either clinical (for example hirsutism, acne, or male pattern hair loss), or elevated androgenic hormones such as DHEA-S, testosterone, bioavailable testosterone or androstenedione in the blood.
• On ultrasound, a polycystic appearance to the ovaries. The ultrasound will reveal an ovary with multiple small follicles present.

2 of the 3 criteria are required for a diagnosis of polycystic ovarian syndrome.

In my upcoming book on PCOS, I will go through the different phenotypes of PCOS and how to treat them effectively. It’s important to note that the understanding of PCOS is not yet complete. That being said, we do have a good amount of information on what makes up the unique variants of this common hormonal disorder.

In women with PCOS, androgens like testosterone are a very problematic part of the disorder. Most women suffer greatly with hirsutism, acne, and hair loss. Excessive androgens are also responsible for inhibiting ovulation and reducing healthy follicle development. High androgens are also associated with an increased risk of cardiovascular disease in PCOS. It has been found that women with elevated androgens have a similar cardiovascular risk profile as men. Cardiovascular disease is something which starts many years ahead, and as such it’s important to head it off before it causes major health problems. As such, it is crucial to determine both the level of and how to reduce the excessive amount of androgens in women with PCOS.

In PCOS, it has been found that there are actually two different sources of androgens.

1. The ovary.
2. The adrenal.

The ovary’s primary androgen is testosterone. Testosterone is produced by specialized cells in the follicles which surround the eggs, the theca cells. In women with PCOS, the theca cells are overactive and proliferate excessively, producing too much testosterone. As the follicles are often poorly developed in women with PCOS, they lack enough of another important component, the granulosa cells. The granulosa cells normally take testosterone and convert it into estrogen, in a process known as aromatization. In women with PCOS, the aromatzation process is not effective due to the poor development of the granulosa cells, and as such, there is a buildup of testosterone which was produced by the ovary.

Unfortunately, in 40-50% of women with PCOS, there is also another source of androgens, which is the adrenal glands. The adrenal glands produce all of the DHEA in the body. It’s important to note that about half of another androgenic hormone, androstenedione, is produced by each of the adrenals and ovaries.

It has been found that women with PCOS might actually have different variants on the “types” of androgens that predominate in their conditions.

Some women are more “adrenal dominant” and others are more “ovary dominant” with respect to androgen production. It appears that there is a clear difference between the two with respect to risk for both inflammation and cardiovascular/metabolic disease risk.

A 2012 study comparing a group of 280 women with PCOS, looking at their adrenal and ovarian androgens. The ratio between DHEA-S (adrenal androgen) and total testosterone (ovarian androgen) were calculated for the group of women. The median value for the study group was 4.40. They then compared body mass index, waist circumference, hirsutism (according to the Ferriman-Gallwey score), inflammatory markers, and menstrual cycle length in the two groups.

Across the board, the group with the higher ratio of adrenal androgens had better outcomes with respect to body mass index and waist circumference, hirsutism and also had a shorter cycle length. The group with higher DHEA also had better lipid (cholesterol) profiles and lower levels of inflammatory markers. Although this study is quite small in size, it is interesting to note that the adrenal “typeology/phenotype” of androgen production appears to be protective in PCOS.

A similar result was found in another study, completed in 2007 on a group of 238 young women with high androgens. In this particular study, the women with the highest levels of DHEA, the adrenal androgens, were found to have the lowest levels of different inflammatory markers. Interestingly, although women with high DHEA-S had higher testosterone levels overall, they also had lower insulin, lower LDL cholesterol and higher HDL cholesterol.

As such it appears that the source of the androgens may make an impact on the metabolic and reproductive outcome of a woman with PCOS. As such it may be useful to test the levels of testosterone (ovarian) and DHEA-S (adrenal) androgens, to be able to predict the phenotype or severity of the syndrome, and as such make adjustments to treatment accordingly.

http://www.whitelotusclinic.ca/blog/dr-fiona-nd/high_dhea_testosterone_pcos/

Ever feel like something is wrong with your hormonal system and curious as to what might be going on? I’d like to tell you about 14 major signs of PCOS – Polycystic Ovary Syndrome – the most common hormone disorder in women of reproductive age. PCOS affects more than 1 in every 10 women – and despite it’s name, it’s so much more than ovarian cysts. In fact, ovarian cysts are not even required for its diagnosis!.

Rather than being specific to our ovaries, PCOS is a complex hormonal and metabolic disorder that lasts a lifetime and even passes through the genes of male relatives in the family.

14 Signs that You Might Have PCOS

1. Irregular periods.
   If your periods are irregular and in particular if they are far apart or if you skip periods altogether, you’ve got a major sign of PCOS. Women with PCOS have high levels of androgens (testosterone is the most well-known androgen). Too many androgens slow our ovaries down, stalling ovulation. When ovulation is inhibited, the period (which comes 2 weeks after ovulation) will also arrive late and in some cases, not at all. For women with irregular periods and PCOS, there is often irregularity right from the start of the periods in the teenage years. In some women, periods may start coming regularly and then after a few years become irregular. Women with PCOS experience irregular periods more often when they have gained weight or have experienced a lot of stress.
2. Hair growth on the chin, upper lip, stomach or chest.
   The aforementioned androgens also cause excess hair growth in the areas of our bodies where hair is typically seen in males. This is known as hirsutism (pronounced HER-Soo-Tism). These hairs can be coarse in texture – removal can be a challenge and a major source of stress. If you are experiencing significant hair growth in these areas, it’s important to be checked for PCOS. It’s been estimated that up to 90% of women with hirsutism have PCOS.
3. Weight gain, particularly around the stomach area.
   Women with PCOS tend to gain weight easily and losing weight can be exceptionally challenging. This is due to insulin and leptin resistance, two of the central factors involved in PCOS. Insulin resistance causes our bodies to store fat more readily, and leptin resistance makes our brains think we are in starvation mode – messing with our hungerand fullness signals. With insulin resistance, weight is easily gained around the abdomen- and we all know that this type of fat is the most risky when it comes to cardiovascular health.
4. Moderate to severe acne.
   Moderate to severe acne is common in women with PCOS. It all comes back to those troublesome androgens again. Androgens cause excess sebum production in the skin, resulting in clogged pores and bacterial overgrowth. If a women has acne that started early compared to her peers as a teen, or if she has adult onset acne, it’s possible that PCOS could be the culprit. Other signs that acne may be related to PCOS: it is resistant to treatment or comes back after strong acne treatments like Accutane (yet another reason not to take this harmful drug – it’s usually not a permanent fix for PCOS acne!). PCOS-related acne is commonly seen along the jawline.
5. Difficulty in conceiving or long time to conceive.
   Women with PCOS may have difficulty in conceiving for a variety of reasons. Firstly, if a woman is not ovulating regularly, it will definitely take a longer time to conceive as the fertile window can be difficult to detect. Ovulation tests are often ineffective in PCOS as the LH hormone it picks up can be too high across the cycle, causing false positives. Also quite simply, there are less fertile periods yearly. Women with PCOS also have egg qualitychallenges due to inflammation and hormonal shifts within the ovaries. The good news is that women with PCOS often have an abundance of eggs so it’s often just a matter of time until pregnancy is achieved, particularly with the right treatment.
6. Hair loss.
   Hair loss is a common problem in PCOS. The pesky androgens once again are involved in this problem. Testosterone is converted into a strong androgen – known as DHT (Dihydrotestosterone) – within the scalp. DHT is the mortal enemy of your hair follicles – it shrinks and damages them, causing hairs to enter the telogen phase where they soon fall out. Hair loss in women with PCOS is often seen at the frontal area, just behind the hairline. It can also be diffuse, with loss all over the head and a widening of the part. Hair loss can also be caused by other common problems as well so it’s important to investigate these, too. Thyroid dysfunction and a ferritin (stored iron) level under 80 can also cause hair loss.
7. Dandruff.
   Oily scalp and dandruff are also commonly seen in PCOS due to elevated androgens and increased oil production. If you have persistent dandruff, and any of the other above signs, ask to be checked for PCOS.
8. Pigmentation in the folds of your skin.
   Known as acanthosis nigricans, this is a dark, velvety discoloration of the skin. It’s most commonly seen in the crease behind the neck, under the arms, or in the creases of the thighs. Acanthosis nigricans can make your skin look “dirty” but it doesn’t wash off – no matter how hard you scrub! Acanthosis nigricans is caused by insulin resistance and can be reversed when insulin sensitivity is improved.
9. Skin tags.
   Little tag-like growths of the skin can often be seen in PCOS. Skin tags are flesh coloured and small. They can appear on the neck, chest or other areas, and are related to insulin resistance.
10. Depression and anxiety.
    Women with PCOS suffer with higher rates of depression and anxiety. Changes in mood are related to a variety of underlying causes including inflammation, emotional suffering due to the stressful symptoms of PCOS and hormonal imbalances.
11. Sleep apnea.
    If you haven’t been getting restful ZZs, PCOS may be involved. Many women with PCOS suffer with sleep apnea and as such do not get the restorative deep sleep that they need. Research has found that women with PCOS who are the most insulin resistant are more likely to suffer from obstructive sleep apnea. Sleep apnea often results in daytime sleepiness and fatigue.
12. Fatty liver.
    This is a particularly unpleasant one. Also known as Non-alcoholic Fatty Liver Disease (NAFLD), the insulin resistance of PCOS can cause excess food energy -particularly carbohydrate-to be deposited as fat within our livers.Fatty liver is typically reversible but if not treated, it can turn into a serious, damaging liver condition. It’s important to take steps right away to control insulin resistance if you have fatty liver.
13. Problems with breast milk production.
    Women with PCOS often have differences in their breast development that can cause difficulty with breastfeeding. During puberty due to the hormonal shifts present, the breasts may not develop fully due to a lack of estrogen. In addition, androgens can interfere with prolactin secretion, reducing the output of milk. If a woman is insulin resistant, this can impair milk production as well.
14. Ovarian cysts.
    It may be a surprise to you that I’ve placed cysts last on the list, given that the name PCOS implies that ovarian cysts are central. Emphasizing cysts can cause many women to remain undiagnosed – so although they are in fact one of the important signs – they are certainly not a required factor. Important to know, the cysts in PCOS are not typical ovarian cysts but are partially developed follicles that have stalled in the process of preparing for ovulation. Younger women are more likely to have these little “cysts” whereas older women may not have them as often. On an ultrasound, they will often be described as “multiple small follicles”.

It’s been estimated that 50% of women with PCOS do not know that they have it. I see women in my clinic regularly who have PCOS and who have remained undiagnosed for their entire lives – sometimes for 20 years! Let’s increase awareness of this condition that affects 1 out of every 10 of us, by knowing and sharing the signs and symptoms. As PCOS is a lifelong metabolic condition linked to diabetes and cardiovascular disease, early intervention can prevent a multitude of health problems and safeguard a woman’s health for years to come.

Do you think you may have PCOS? Which of the symptoms do you have?

http://www.whitelotusclinic.ca/blog/dr-fiona-nd/14-signs-might-pcos/