8 signs you may have PCOS
Polycystic Ovary Syndrome (PCOS) is a medical condition causing elevated androgen hormones in women. It affects up to 10 percent of reproductive age women1 and is the cause of infertility in 30 percent2 of these women. PCOS puts menopausal and postmenopausal women at higher risk for Type II diabetes, cardiovascular disease, and stroke.
PCOS symptoms can appear unrelated and even conflicting. One woman with PCOS may not menstruate at all (amenorrhea) while another may experience extra-heavy bleeding (menorrhagia) for a week! Or PCOS can cause hair loss at the scalp along the part and the overgrowth of hair on the chest, abdomen, upper lip, chin, and back. Hair loss at the part is called Female Pattern Hair Loss (FPHL). Hair growth in atypical feminine areas is called hirsutism, or male pattern hair growth. Also frustrating, PCOS can cause especially stubborn acne that may resist standard acne treatments. Research also shows a strong tie between insulin resistance, a key risk factor in diabetes.
Ok, that's pretty intimidating. The good news is the signs and treatment options for PCOS are well-studied by the medical community. Learn how to identify PCOS symptoms and communicate with your physician. Take control of PCOS!
What is PCOS?
PCOS is a chronic condition that causes high levels of male androgen hormones in women. Many PCOS symptoms stem from the ovaries but not all. Some studies show the hormonal imbalance can begin in the adrenal gland. How women get PCOS is not fully understood, but there's no argument that it can wreak havoc on a woman's body and create emotional and psychological pain. The symptoms of PCOS are well-studied.
How is PCOS diagnosed?
Using the Rotterdam criteria, PCOS is diagnosed if a woman has at least two of the following three symptoms:
- Hyperandrogenism (abnormally high androgen levels)
- Ovulatory dysfunction (infrequent ovulation)
- Excessive cysts in egg follicles diagnosed as polycystic ovaries
Other common symptoms of PCOS:
- Amenorrhea (No menstrual periods)
- Menorrhagia (Heavy menstrual periods)
How is PCOS tested?
If you have any of the above 8 signs of PCOS talk to your medical provider. You may have PCOS. Following are tests for PCOS:
- Ultrasound to determine the presence of polycystic ovaries. Twelve to 25 cysts measuring from 2 to 9 mm are diagnosed as polycystic ovaries.2
- Tests to measure follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels. A ratio greater than 2:1 is a strong indicator of PCOS.3
- Tests for "free testosterone"* and dehydroepiandrosterone (DHEA) hormone levels. 4
- Physical exam to check for symptoms of PCOS such as hyperandrogenism, acne, FPHL, and hirsutism.5
- Perform a detailed review of medical history6
- Test levels of Anti-Mullerian Hormone (AMH). AMH is a hormone secreted by developing follicles. Low AMH signals improperly functioning ovaries and is a sign of PCOS.7
*Note: high testosterone isn't enough to diagnose elevated testosterone. The amount of testosterone that is available for use by the body (bioavailability) is the benchmark. High bioavailability, or high free testosterone, can indicate PCOS.
Women with PCOS have 4x the risk of developing Type II diabetes
Can I get pregnant if I have PCOS?
It is possible to get pregnant if you have PCOS. Clomiphene (Clomid) is FDA-approved to treat ovary dysfunction. Clomid works by stimulating ovulation.
Metformin also stimulates ovulation and is a top off-label prescription to restore normal menstruation. Due to its success in restarting ovulation, metformin is also prescribed off-label to women whose infertility stems from ovary dysfunction.8
Metformin is sold under the brand names Glucophage, Glumetza and Riomet, and Fortamet.
Laparoscopic ovary drilling (Ovarian Diathermy) can restore ovary function. As many as 50 percent of women get pregnant within a year of ovary drilling, according to the American Society for Reproductive Medicine.
How can I lose weight if I have PCOS?
Women with PCOS and insulin resistance show benefits with metformin as an off-label medication. A six-month study using metformin to treat obesity in non-diabetic adults showed participants lost up to 13 pounds.9 Patients with insulin resistance lost more weight than patients with insulin sensitivity.10 Insulin resistance is the ineffective use of insulin by the body. Insulin resistance results in high glucose and may lead to dependence on insulin therapy. Metformin is also prescribed off-label to treat insulin resistance in men.
How common is PCOS?
- Up to 5 million women, 1 in 10, of reproductive age have PCOS
- PCOS is the #1 endocrine disorder in reproductive age women12
- 70 to 80 percent of women with hirsutism have PCOS, compared to 4 to 11 percent of average women13
- 83 percent of women with acne have PCOS14
- Daughters of mothers who have PCOS have a greater chance of mild symptoms of follicle irregularity and hormonal imbalance beginning in infancy15
- Sisters of women with PCOS have a 50 percent chance of developing PCOS16
What are the health risks of PCOS?
- 30 percent of infertility in women is caused by PCOS17
- Women with PCOS have 4x the chance of developing Type II diabetes.18
- PCOS is characterized by insulin resistance (an indicator of pre-diabetes) and a key factor in Type II diabetes19
- Decreased estrogen levels in menopausal women and post-menopausal are linked to elevated androgen levels (hyperandrogenism) and PCOS20
- Lack of ovulation (anovulation) in PCOS can cause continuous high levels of estrogen and low androgens.21 Without treatment, prolonged high exposure to estrogen can lead to endometrial cancer.22
- Anovulation can cause heavy and/or irregular bleeding, referred to as abnormal or anovulatory uterine bleeding. 23
Do high DHT and DHEA cause PCOS?
Yes, elevated DHT and DHEA are related to PCOS. The imbalance may start with overproduction of DHEA by the adrenal gland.24 DHEA has the ability to convert to estrogen or testosterone. In women with PCOS, the majority of DHEA is converted to testosterone, instead of estrogen. This leads to high testosterone (hyperandrogenism) and low estrogen.25 The next step in the female metabolic process is for testosterone to convert to DHT. However, an imbalance of testosterone leads to overly high DHT. Elevated levels of DHEA, DHT, and testosterone all contribute to PCOS.
Can I reverse hair loss from PCOS?
Yes, spironolactone*, a popular off-label medication for acne is also prescribed off-label to treat hair loss in women. Elevated 5-AR, the enzyme responsible for the conversion of testosterone into DHT, has been detected in women with PCOS. In the presence of high AR-5 and elevated testosterone, women with PCOS will experience excessive testosterone to DHT conversion. During the synthesis of testosterone to DHT, hair follicles are permanently damaged26 causing hair to fall out and unable to regrow. This type of hair loss occurs in both women and men.27 Testosterone DHT, and DHEA, also cause overactive sebaceous glands (oily skin) and sticky skin cells (retention hyperkeratosis). Both sebaceous glands and retention hyperkeratosis lead to plugged hair follicles that are the basis of acne.
High testosterone and DHT cause female pattern hair loss at the top of the scalp along the part. The part continues to widen as more hair is lost. Male pattern hair loss caused by high DHT and testosterone causes hair loss at the top of the scalp and along the hairline. Female hair loss may be successfully treated with spironolactone. Spironolactone reduces DHT, and Rogaine (minoxidil) stimulates new hair growth.
Due to its feminizing effects, spironolactone is not prescribed to men for skin and hair related conditions. However, finasteride (Propecia) and minoxidil (Rogaine) are both FDA-approved to treat male pattern balding.
What does off-label use mean?
According to the US Department of Health and Human Services, physicians may prescribe medications for uses other than their FDA-approved indication. Off-label prescribing is legal. In fact, one out of five prescriptions written today is off-label.
Outlook for women with PCOS
Even though the symptoms of PCOS are difficult for women, it is heavily researched and off-label use of spironolactone and metformin are highly effective. Infertility treatment with clomid and metformin are inexpensive and demonstrate promise for women with infertility due to PCOS.
*Because of the potential risk to the male fetus due to anti-androgenic properties, spironolactone should not be used by women who are pregnant or trying to become pregnant. Additionally, women who are breastfeeding should not use spironolactone. Spironolactone may cause dangerously high potassium levels called hyperkalemia. Its use should be monitored by a physician. For full warnings and prescribing information, refer to prescription inserts and follow instructions provided by your doctor and pharmacist.
1. Barthelmess EK, Naz RK. Polycystic ovary syndrome: current status and future perspective. Front Biosci (Elite Ed). 2014;6:104–119. Published 2014 Jan 1.
2-6. Williams, Christi, MD. Mortada, Rami, MD. Porter, Samuel, MD. Diagnosis and Treatment of Polycystic Ovary Syndrome. Am Fam Physician. 2016 Jul 15;94(2):106-113. https://www.aafp.org/afp/2016/0715/p106.html
7. Grynnerup AG, Lindhard A, Sørensen S. The role of anti-Müllerian hormone in female fertility and infertility - an overview. Acta Obstet Gynecol Scand. 2012 Nov;91(11):1252-60. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1600-0412.2012.01471.x
8 Howard Craig Zisser. MD. "Polycystic Ovary Syndrome and Pregnancy: Is Metformin the Magic Bullet? Diabetes Spectrum https://doi.org/10.2337/diaspect.20.2.85
9,10. Seifarth, Christian & Schehler, B & Schneider, Harald. (2012). Effectiveness of Metformin on Weight Loss in Non-Diabetic Individuals with Obesity. Experimental and clinical endocrinology & diabetes: official journal, German Society of Endocrinology [and] German Diabetes Association. 121. doi: 10.1055/s-0032-1327734.
11. Kim GK, Del Rosso JQ. Oral Spironolactone in Post-teenage Female Patients with Acne Vulgaris: Practical Considerations for the Clinician Based on Current Data and Clinical Experience. J Clin Aesthet Dermatol. 2012;5(3):37–50.
12. Fernand Labrie, Van Luu-The, Claude Labrie, Jacques Simard. DHEA and Its Transformation into Androgens and Estrogens in Peripheral Target Tissues: Intracrinology. Frontiers in Neuroendocrinology. Volume 22, Issue 3, July 2001, Pages 185-212
13,14. Kim GK, Del Rosso JQ. Oral Spironolactone in Post-teenage Female Patients with Acne Vulgaris: Practical Considerations for the Clinician Based on Current Data and Clinical Experience. J Clin Aesthet Dermatol. 2012;5(3):37–50.
15,16. Corrine K. Welt, Enrico Carmina. Lifecycle of Polycystic Ovary Syndrome (PCOS): From In Utero to Menopause, The Journal of Clinical Endocrinology & MetabolismVolume 98, Issue 12, 1 December 2013, Pages 4629–4638. https://doi.org/10.1210/jc.2013-2375
17. Kim GK, Del Rosso JQ. Oral Spironolactone in Post-teenage Female Patients with Acne Vulgaris: Practical Considerations for the Clinician Based on Current Data and Clinical Experience. J Clin Aesthet Dermatol. 2012;5(3):37–50.
18,19. Giudice LC. Endometrium in PCOS: implantation and predisposition to endocrine CA. Best Pract Res Clin Endo- crinol Metab. 2006;20(2):235–244. https://doi.org/10.1016/j.beem.2006.03.005
20. Fernand Labrie, Van Luu-The, Claude Labrie, Jacques Simard. DHEA and Its Transformation into Androgens and Estrogens in Peripheral Target Tissues: Intracrinology. Frontiers in Neuroendocrinology. Volume 22, Issue 3, July 2001, Pages 185-212
21-23. Giudice LC. Endometrium in PCOS: implantation and predisposition to endocrine CA. Best Pract Res Clin Endo- crinol Metab. 2006;20(2):235–244. https://doi.org/10.1016/j.beem.2006.03.005
24,25. Labrie F, Luu-The V, Labrie C, Simard J. DHEA and Its Transformation into Androgens and Estrogens in Peripheral Target Tissues: Intracrinology. Frontiers in Neuroendocrinology. Volume 22, Issue 3, July 2001, Pages 185-212
26,27. Causes of Hair loss. American Hair Loss Association. https://www.americanhairloss.org/women_hair_loss/causes_of_hair_loss.html