PCOS: A Medical Mystery - National University of Natural Medicine

NUNM students have many opportunities to explore topics, research and areas of practice that interest them. From broad elective choices to research study participation and self study, our students choose the doctor they want to become. Rachel Peterson, naturopathic doctoral student, shares her research and perspectives on polycystic ovarian syndrome (PCOS).

One in ten women in their childbearing years may suffer from a hormonal disorder called polycystic ovarian syndrome (PCOS) and may not even know it. A total of five million women have PCOS worldwide.^[1] What exactly is this disease? If it is affecting so many women, why is there a severe lack of knowledge about it?

PCOS has eluded health care providers for decades. Difficult to diagnose, this mysterious condition has a complex history. In 1935, doctors coined the name, “Stein-Leventhal Syndrome,” to diagnose larger women with male-pattern facial hair, large cystic ovaries, and irregular menstrual cycles. The National Institutes of Health brought awareness to the condition in 1990 by changing its name to PCOS and listing three diagnostic criteria: delayed ovulation, excess androgen hormones, and polycystic ovaries.^[2]

Even with a new understanding of PCOS doctors remained perplexed, as women seemed to present with certain symptoms but not others. Finally, in 2003, the Rotterdam criteria was created, stipulating that a woman with PCOS only needed two of the three criteria to be diagnosed. This created the idea of four PCOS “types,” allowing women with completely different symptoms to be diagnosed with the same condition. The fact that there are many phenotypes, or expressions, of this disease explains why it has been a medical mystery for so long and why there is a huge lack of research, education, and publicity.^[2]

First and foremost, PCOS is a diagnosis of exclusion, meaning that other disorders must be ruled out first. Other imbalances that involve similar symptoms include hypothyroidism, hyperprolactinemia, hypothalamic amenorrhea, and non-classical congenital adrenal hyperplasia. Once these possibilities have been ruled out, possible PCOS causes of symptoms are explored.^[1]

The first cause is anovulation, delayed or absent ovulation or menses.^[3] This is defined as fewer than ten menstrual cycles per year, or cycles that last around 35 days in length (as opposed to the average 28 day cycle).2 Whether these longer cycles are regular or not, they are an indication of a hormonal imbalance, especially if they have been happening since a young age.^[3]

For many women, a second factor in their PCOS symptoms is hyperandrogenism, or excess androgen hormones. These hormones include testosterone, DHEA, and androstenedione, and are responsible for male sex characteristics. An excess of androgens in women can cause male-pattern hair loss, hirsutism, or hair growth on the face, chest, and neck, and moderate to severe acne on the jawline or back. An excess in androgen hormones can be a clinical finding or can be confirmed by bloodwork.^[3]

The third criteria to denote PCOS is the actual presence of polycystic ovaries on ultrasound. This can be misleading, as many women have experienced ovarian cysts who do not have PCOS, and many women who have PCOS do not have ovarian cysts. The type of ovarian cyst confers an important designation. Common non-PCOS cysts tend to be fluid filled sacs that resolve on their own.^[1] PCOS-type cysts are actually not cysts at all, but are follicles that have been stalled in development. In a healthy ovary, follicles are the structures in the ovary that hold the eggs. Over time, follicles grow slowly until an egg is ready to be released in ovulation. High levels of testosterone and insulin, related to PCOS, can cause these follicles to stop growing and accumulate in the ovaries.^[3] On ultrasound, these follicles look like a string of pearls. To meet the definition of a polycystic ovary, at least one ovary must have twelve or more follicles present and have an ovarian volume of ten centimeters or larger.^[2] Age drastically affects the follicle count, so other factors must also be considered in diagnosis.^[2]

Outside of these three criteria, there are additional factors contributing to PCOS. Many women with PCOS have insulin resistance, associated with weight gain (especially around the belly) and diabetes. Low functioning thyroid can also be a factor, which may amplify any insulin resistance and slow down metabolism. Inflammation and environmental factors are also significant contributors.^[3]

The complex and varied presentation of symptoms involved in PCOS has made this disease a difficult one for healthcare providers. As research continues, the definition and understanding of PCOS continues to evolve. With the recent knowledge on diagnosis, doctors are providing treatment plans to improve the quality of life for women with PCOS. Stay tuned for the next article to learn about the treatment of PCOS.

References

Polycystic ovary syndrome. womenshealth.gov. https://www.womenshealth.gov/a-z-topics/polycystic-ovary-syndrome. Published October 22, 2018. Accessed December 1, 2018.[1]
McCulloch F. 8 Steps to Reverse Your PCOS: a Proven Program to Reset Your Hormones, Repair Your Metabolism and Restore Your Fertility. Austin, TX: Greenleaf Book Group Press; 2016.[2]
Vitti A. What kind of PCOS do you have? Flo Living. https://www.floliving.com/what-kind-of-pcos-do-you-have-my-treatment-guide-for-the-pcos-spectrum/. Published December 20, 2016. Accessed December 1, 2018.[3]