PCOS – Explained
Poly Cystic Ovarian Syndrome – PCOS
This article I am going to write about Polycystic Ovarian Syndrome. I decided to write the article because after taking a quick survey I realized that in my own practice, which focuses on fertility and pregnancy care, almost half of my patients have PCOS. This is a big change from a few years ago when I would have 1 or 2 PCOS patients at a time.
A good place to start this article is with the question “What is PCOS?”. First, it is important to understand that PCOS is a syndrome. A syndrome is a collection of symptoms/signs without a known specific cause. This is code for, it has fuzzy diagnostic boundaries. It is difficult to diagnose and doctors will disagree about who has PCOS. Lately diagnosing PCOS is all the rage, and often any woman who does not ovulate regularly for an unknown reason is labeled with PCOS, but I am getting ahead of myself.
Generally women with PCOS do not ovulate. This is usually what brings women into the doctor’s office, that they only get a few periods a year or less. On an ultrasound, her ovaries most of the time will be packed full of immature follicles. Unfortunately, these follicles usually do not get big enough and mature enough to pop out of the follicle and ovary. The ovaries of a women who has PCOS are like a class of 10 year olds on the last day of school before summer holidays. The kids are bouncing around, dying to get out of school and enjoy the freedom of summer, but can’t because the door is locked. Only no one ever unlocks the door and the kids don’t get to mature into teenagers and adults, a bit like the movie Groundhog Day where Bill Murray gets stuck in a small town in Pennsylvania reliving the exact same day, over and over again, never getting to move on.
In normally ovulating women, ovulation occurs when LH reaches the threshold level needed to pop the egg out. For different reasons, some known and some unknown, this does not occur often or at all in women with PCOS. A possible reason for ovulation not occurring is that often the woman’s FSH (Follicle stimulating hormone) response is blunted, for whatever reason her body is unable to respond to her often-normal range levels of FSH in the usual way. Often women with PCOS will have elevated levels of LH (Lutenizing hormone) though, usually in the range of 2 to 3 times higher than her FSH. Normally the ration of LH and FSH is 1:1. This is because the relationship between LH and FSH is one of positive feedback. Producing more of one induces the production of the other. In a normal cycle her LH and FSH levels should rise in concert with each other, the FSH stimulating her follicles to grow and the LH rising towards the peak needed to cause ovulation. Both are needed because ovulating an immature egg is no good, as is maturing an egg that will not ovulate.
To complicate this further, there are generally two types of women who get PCOS; one heavier and one thinner. Let’s start with the heavier woman because she is less complicated and easier to treat. The heavier type PCOS woman usually has low energy, is on the hypothyroid side, has extra body/facial hair, tends to loose stool and is usually fairly overweight. Her BMI (Body mass index) is usually at least in the low 30’s, tending to very overweight and obese. As well, her insulin and blood sugar are most often high and she is usually on the verge of type 2 diabetes presenting with at least some insulin resistance. They also most often do not exercise much or at all, and eat a lot of sugar and/or refined (white) flour products
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Speaking with a researcher at Queen’s University in Kingston, Ontario, Canada (whose name I can not find or remember), he found with these heavier PCOS women that their BMI’s only had to drop 1 or 2 points before they started to ovulate again, their cycles became regular and their fertility returned. Guessing as to why this happened gives us a clue as to what is going on from a western perspective. To do this first we have to look into type 2 diabetes a bit.
Type 2 diabetes starts because someone eats too much sugar and refined carbohydrates. These simple sugars digest quickly and therefore also cause high levels of glucose in our blood stream. The body responds to these quickly rising levels of glucose by making the pancreas rapidly pump out insulin. The more and the quicker the sugar enters our blood stream the more and quicker the pancreas pumps out the insulin. Of course these now high levels of insulin quickly process the sugar by putting it into our cells to use as energy, and because generally highly processed food snack food that us North Americans seem to love is mostly high glycemic index (an index that measures how quickly and food’s sugar enters the blood stream, higher is quicker) foods, most of the calories from this food enters the blood stream quickly in the form of sugar. So again sugar goes in quickly and to a high level, insulin rises quickly and to a high level, we get a rush or energy. However because the insulin level is so high it quickly metabolizes any calories from the glucose you can not use into fat cells, thereby using up all the sugar in the blood stream and consequently we get tired ½- 1 hour after eating a Mars bar. Then, because we are tired, we crave more sweets thus repeat the cycle. Eventually the cells in the body get used to these high levels of insulin, just like a person gets used to sleeping pills or alcohol and needs to take ever-increasing amounts to get the same effect if taken regularly. Same thing happens to the body with insulin. In people who eat poorly their insulin and blood glucose levels are high so regularly their bodies get numb to these high levels of insulin and the pancreas has to pump out ever increases amounts of insulin to get their cells to respond. As mentioned earlier high levels of insulin lead to decreased fat metabolism and increase of fat depositing. Thus the obesity crisis in North America and the insulin resistance of type 2 diabetes. So women with heavier type PCOS fall into this category, some level of insulin resistance with a type 2ish diabetes presentation.
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Back to the study at Queen’s, the women were asked to start exercising and eating better in order to loose weight and regulate their insulin and blood glucose levels. The exercise and eating better would level out their insulin and blood levels quickly, and they would loose the weight slowly over time depending on the calorie deficit they sustained However, that their periods returned to normal quickly after only loosing a bit of weight is interesting. It suggests that it is not the weight that is the problem, but that the high insulin and glucose levels is. It is like in these women with heavier type PCOS their body’s cells became resistant to the insulin, but their ovaries did not. To her ovaries, her levels of insulin are high and in trying to act on this they become jacked up, and over respond getting blocked up with too many immature eggs and becoming unable to function properly. (Whether or not this is the exact mechanism is unimportant for our purposes, that the analogy works and you can use it for motivation to have a healthier lifestyle is more important clinically). So…. for helping these heavier type PCOS women regulate their periods, start ovulating normally and regain their fertility it is critical to level out their glucose and insulin levels by getting them to eat properly and exercise regularly. This in fact this works very well. Further confirming this is that the drug mostly prescribed by western clinicians for these women is metformin, a blood glucose level regulating medication. Most of the studies out there on PCOS focus on these heavier women because they are relatively easier to treat and some simple lifestyle modifications will often get everything working again.
However for those of you that treat PCOS patients, you know there is a but coming, a large but! Thin type PCOS patients.
These women are thin, tend to have lots of energy/ hyperthyroidish, not so much body/facial hair, tend to more constipation and have fairly normal blood glucose and insulin patients. The above model of the ovaries hyperstimulating to high glucose and insulin levels does not work. They do have ovaries that are full of immature follicles and they also tend to have the skewed FSH/LH ratios. However, these women typical get put on metformin by their western doctors, with usually not much change in their already normal insulin/glucose levels or more importantly much change in their cycle regularity or how often they ovulate. Can you guess which type of PCOS patient I see more in my clinic?
By a massive margin the thin type. These women are frustrated. Generally their family/fertility/OBGYN doctors have not much to offer them other than metformin, which does not work well for them. Once they come to me they are generally frustrated because the only thing that their western fertility doctor has to offer them is an expensive IVF with less than usually success rates because of their finicky ovaries. These women come to see me to try and regulate their cycle before starting their western fertility treatments or to avoid using them in the first place. I also find that it takes longer than the normal 2 – 6 months to treat these women, more likely 4 – 12 months and even up to a year and a half. I will discuss the reasons for this and some treatment methods I have found effective next article.
