Polycystic Ovary Syndrome (PCOS) - Causes, Symptoms and Therapy

Do you suspect you are suffering from a hormonal imbalance? If your complaints include acne, irregular periods, or fertility problems, it is possible that they are due to polycystic ovaries. 

In fact, polycystic ovary syndrome (PCOS) is the most common form of hormonal imbalance among women of childbearing age. 

PCOS is such a common endocrine disorder that it affects one in seven women between the ages of 20 and 50. Unfortunately, the overuse of the term “hormonal imbalance” has diluted its meaning to the point that many women don’t even seek medical attention.

Meanwhile, polycystic ovary syndrome is a serious hormonal condition that is associated with weight gain. It can also cause infertility and even lead to the development of diabetes.

In the following lines, you will discover everything about the condition, including what polycystic ovary syndrome is, what causes it, and whether you can be cured of polycystic ovaries. 

What is polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. Studies have reported that the incidence among women of this age reaches about 181% (181% of women) [1].

Furthermore, according to the World Health Organization, PCOS affects almost 41% of all women. [2].

The disease affects multiple organs and systems, but most notably ovarian function, which leads to infertility. 

Affected women complain of irregular, prolonged, and sometimes painful menstrual cycles. These symptoms are often combined with signs of elevated male sex hormones and the inability to conceive.

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What are the criteria for diagnosis?

To be diagnosed with polycystic ovary syndrome, your doctor must make sure that you meet at least 2 of the following three criteria:

• lack of ovulation
  
• presence of ovarian cysts
  
• promoted androgen levels (male sex hormones).

And although it sounds simple, there are actually many subtleties involved in a specialist correctly assessing whether the relevant criteria are truly present.

Increased levels of male sex hormones

The main criterion for diagnosis is the presence of elevated male sex hormones.

The most important androgen that can be used to diagnose polycystic ovaries is testosterone, and more specifically free testosterone. In fact, most of the testosterone in women is bound to proteins that deactivate it.

However, direct measurement of testosterone is quite inaccurate unless the “double equilibrium dialysis” method is used, which is quite expensive.

Therefore, a more accurate and economical method than direct measurement is to measure the levels of total testosterone and the proteins that bind to it. The level of free testosterone can be calculated using a formula.

Free testosterone levels in women below 0.42 ng/dL and total testosterone levels below 60 ng/dL are considered normal.

Rare (about 51% of cases) are cases of polycystic ovary syndrome in which free testosterone is normal and at the same time other androgens such as dehydroepiandrosterone, hydroxyandrostenedione or androstenedione are elevated. [3], [4]. 

For this reason, official medical recommendations are that there is no point in testing for androgens other than those for testosterone levels. [5].

In adults (but not in teenagers), complaints such as hair loss, acne, or the appearance of male-pattern body hair (hirsutism) are some of the main symptoms of elevated testosterone levels in women.

Lack of ovulation and anovulatory cycles

In polycystic ovary syndrome, their function is often impaired, making it difficult for eggs to be released normally during ovulation.

In fact, there is no ovulation at all, which means that the follicles in the ovary that normally mature during the first 2 weeks of your cycle do not burst and release the egg.

Anovulatory is defined as any cycle that is longer than 35 days. However, if your cycle is shorter, your doctor will need to measure your progesterone levels during the second half of your cycle to confirm whether or not you are ovulating.

Progesterone is a hormone that can only be released if ovulation has occurred. This is because it is produced by cells that are released along with the egg only if the follicle has ruptured.

Therefore, its levels on days 21-22 of the cycle should be at least 2.5 ng/mL. In addition, the arithmetic mean of 3 consecutive measurements (on different days - for example, the 21st, 22nd and 23rd) should be at least 5 ng/mL.

The reason for the lack of ovulation in polycystic ovary syndrome is most likely due to the hormonal imbalance caused by the high levels of insulin and testosterone in PCOS.

In addition, patients often have a change in the balance between luteinizing hormone and follicle-stimulating hormone. These are hormones that are secreted by a gland in the brain (pituitary gland) and control ovarian function.

Normally, the levels of these two hormones should be approximately the same. However, in polycystic ovaries, luteinizing hormone is significantly higher than follicle-stimulating hormone, which negatively affects ovulation and fertility. [6].

Presence of cysts in the ovaries 

An objective assessment of the presence of ovarian cysts cannot be made with a simple ultrasound. Instead, your doctor will use transvaginal ultrasound to detect even the smallest cysts.

In addition, the result of the ultrasound also depends on the sensitivity of the device. It is assumed that when using older devices, we can consider the ovaries to be polycystic if there are at least 12 follicular cysts measuring 2 to 9 mm, or an ovary size of more than 10 ml.

But with the use of new and more sensitive devices, the latest recommendations from the Androgen Excess Society are to have at least 25 follicular cysts to correctly diagnose polycystic ovary syndrome. [7].

If the specialist is not sure about the sensitivity of the equipment he is using, it is best to consider only the size of the ovary as a criterion.

Types of Polycystic Ovarian Disease

Polycystic ovary syndrome is divided into 4 types (phenotypes) according to which of the 3 criteria already mentioned are present. [8]:

• phenotype A: all 3 signs of the disease are present
• fenovip B: high androgens + lack of ovulation
• phenotype C: high androgens + presence of cysts
• phenotype D: lack of ovulation + presence of cysts

Currently, this is the only medical classification of the different types of polycystic ovary syndrome. 

Unfortunately, there are also pseudoscientific classifications that create a wrong impression in most patients about the causes and treatment of PCOS. 

Such is, for example, the following misleading classification: PCOS with insulin resistance, adrenal PCOS (after stress), inflammatory PCOS, and PCOS after taking contraceptives. 

Such classifications are most often spread by sources that, in addition to being non-medical, claim to offer an all-natural, harmless, and effective solution. In fact, what they most often offer are their own dietary supplements and regimens.

In short:

Polycystic ovary syndrome (PCOS), also known as polycystic ovary syndrome (PCOS) or polycystic ovary syndrome (PCOS), is a common condition that affects women of reproductive age and includes at least 2 of the following 3 typical symptoms: high testosterone, lack of ovulation, and ovarian cysts.

Causes of polycystic ovary syndrome development

The exact cause of PCOS is not yet known, but scientists believe that a combination of genetic factors and high insulin levels (hyperinsulinemia) play a role. 

These factors lead to increased testosterone levels, which in turn leads to ovarian dysfunction, anovulatory cycles, and cyst formation.

According to scientific data, excess insulin can lead to increased testosterone levels through two mechanisms – direct and indirect [9]. 

The direct consists in the fact that insulin stimulates the function (and probably the growth) of the so-called theca cells in the ovaries. Theca cells are the main factor producing testosterone and other androgens in the female body.

Indirect is bound to a protein in the blood called GSPH (sex hormone binding globulin) or SHBG (sex hormone binding globulin) – sex hormone-binding globulin (SHBG).

Normally, the function of GSH is to bind to sex hormones such as testosterone and estrogen and inactivate them. GSH binds primarily to testosterone because it is much more sensitive to it than to estrogen.

But if insulin levels are chronically elevated, hyperinsulinemia leads to lower GSH, and a greater percentage of testosterone in the female body remains free and active.

It is free testosterone that actively binds to testosterone receptors, leads to hirsutism, and suppresses ovarian function.

Insulin resistance and polycystic ovary syndrome

Excess insulin, which stimulates the ovaries to produce more testosterone, is usually due to: insulin resistance.

Insulin resistance is a condition in which the body produces more insulin to overcome the resistance of the insulin receptors in the body and maintain normal blood sugar levels.

Insulin resistance is the main risk factor for developing type 2 diabetes.

The causes of insulin receptor resistance are also not fully understood. The condition is most likely due to a combination of factors, including obesity, hypokinesia, hypertriglyceridemia, chronic systemic inflammation, etc.

Studies confirm that about 80% of PCOS patients are also obese. [10]. Combined with low physical activity, this can lead to insulin resistance and polycystic ovary syndrome.

Pregnancy is also a time when women are more likely to develop insulin resistance, which can lead to a condition called gestational diabetes.

Accumulating too much excess fat during pregnancy can also lead to the development of polycystic ovaries after childbirth.

In short:

The causes of PCOS are not fully understood at this time, but it is believed that insulin resistance plays a major role. This, in turn, is associated with genetic factors, obesity, low physical activity, chronic inflammation, and others.

What are the most common symptoms of PCOS?

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The most common symptoms of PCOS include hirsutism, acne, and menstrual problems. Ovarian pain is not a typical symptom, but it can occur before menstruation.

Lack of ovulation leads to symptoms such as irregular periods, infertility, soreness and swelling before menstruation, etc. Lack of ovulation means that attempts to get pregnant with polycystic ovary syndrome would be unsuccessful.

However, it is possible for ovulation to occur but not be regular. Accordingly, some patients with PCOS are able to become pregnant when their attempts coincide with the ovulatory cycle.

According to experts, symptoms such as acne, facial and body hair, and male pattern baldness can also lead to psychological symptoms, such as depression. [11].

If left untreated, insulin resistance can progress and lead to other complications, including an increased risk of developing type 2 diabetes. 

Symptoms of diabetes include increased thirst, frequent urination, dry mouth, chronic fatigue, sleep problems, frequent formation of canker sores, difficult healing of wounds, and frequent fungal infections.

In short:

The most common symptoms of PCOS are hirsutism, acne, hair loss, irregular periods, inability to get pregnant, and others.

Can you be cured of polycystic ovary syndrome?

Treatment for polycystic ovary syndrome is complex and includes both drug therapy and lifestyle changes. The most commonly prescribed medications to address the problem are birth control pills and metformin.

The choice of medication depends primarily on whether the patient is planning a pregnancy in the near future or not. In some cases, combination therapy may be used.

But to be truly cured of polycystic ovary syndrome, you need to change many of your habits and lead a healthy lifestyle, as the problem cannot be solved through drug therapy alone.

It is important to make a differential diagnosis between polycystic ovary syndrome and other common causes of high testosterone, such as Cushing's syndrome and hypothyroidism. [12], [13].

Similar symptoms can also be seen in another condition called hyperprolactinemia. There have been cases where high prolactin levels in conditions such as idiopathic hyperprolactinemia (high prolactin with no known cause) have led to suppression of ovarian function similar to testosterone and even the formation of ovarian cysts. [14].

In cases where you have any of these conditions but are instead being treated for polycystic ovary syndrome, you will not experience improvement in your symptoms until you receive a proper diagnosis.

In short:

Curing PCOS is only possible with successful lifestyle changes, and medications and nutritional supplements have mainly a supportive effect.

How is polycystic ovary syndrome treated?

If you are at increased risk of developing hormonal imbalance and polycystic ovaries, it is important to consider regular checkups and testing.

Your doctor will monitor various parameters, such as insulin sensitivity and testosterone levels, to help you take timely measures to keep your hormones in balance.

If you have already been diagnosed with PCOS, there are 3 treatment options available, and they work best in combination. The options include lifestyle changes, nutritional supplements, and medication.

Lifestyle change

If you have polycystic ovaries and insulin resistance, lifestyle changes will certainly be effective in addressing the problem.

There are several lifestyle changes that can reduce the risk of high T, the most effective being reducing belly fat and increasing physical activity.

For example, weight loss is recommended as the first step in treating overweight or obese women with PCOS.

Studies show that losing just 5-10 pounds of body weight can significantly improve insulin sensitivity. It also dramatically reduces the reproductive, metabolic, and psychological symptoms of polycystic ovary syndrome. [15].

There is no specific diet for PCOS – instead, you should diet to eliminate excess fat around your belly, if you have any. This is also the way to improve insulin sensitivity.

Low-carb diets won't help you lose weight or belly fat unless you're in a calorie deficit. This means your daily energy intake is lower than your energy expenditure.

The best way to achieve this is to eat a balanced and varied diet based on unprocessed foods. This will help you stay fuller for longer and consume fewer calories.

Scientists also report that increased physical activity is one of the most successful methods for improving insulin sensitivity in patients with PCOS as well as type 2 diabetes.

Exercise leads to immediate improvements in insulin sensitivity. A meta-analysis of 617 women with PCOS reported that exercise reduced waist circumference, systolic blood pressure, and fasting insulin. [16].

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Nutritional supplements for polycystic ovaries

Some foods and dietary supplements contain antiandrogenic ingredients that may help lower T levels in women with hyperandrogenism and PCOS.

The most commonly used and recommended dietary supplement for PCOS is inositol. Popular dietary supplements such as “picositol” include mainly myo-inositol as well as some vitamins such as folic acid in their composition.

Studies report that when used as a supplement, inositol can improve insulin sensitivity, suppress symptoms, and increase fertility in PCOS. [17].

If you prefer to get it only from food products, whole grains and citrus fruits are great sources of inositol. 

Herbs for PCOS that act as natural testosterone suppressants include peppermint and licorice, as well as sources of inositol and omega 3 fatty acids.

For example, one study in 42 women revealed that drinking peppermint tea every day for 1 month resulted in a significant reduction in T [18].

Another herb that has been shown to lower T in women is licorice. In one study, daily supplementation was able to reduce testosterone levels by more than 30% [19].

Additionally, sources of polyunsaturated fatty acids, such as omega-3s, can also help reduce T levels in women. One study reported that daily consumption of walnuts and almonds was able to increase GSH levels by up to 16% in women with PCOS. [20].

Case studies also report that another popular plant source of omega-3s, flaxseed oil, may be effective in reducing T levels. [21].

Medications for polycystic ovaries

Drug therapy for PCOS usually includes treatment with: low-dose estrogen-based oral contraceptives. Research reveals that it takes up to 3-6 months of low-dose contraceptive therapy for T levels to return to normal. [22].

Oral contraceptives work by increasing levels of CHSG, which binds and deactivates testosterone. 

According to official guidelines, low-dose estrogen-based contraceptives are the most appropriate drug therapy for patients with hyperandrogenism, including those with PCOS and postmenopausal women. [23].

The most commonly used contraceptives are those containing weakly androgenic progestins such as norgestimate. Other progestogens are generally considered unsuitable because they have a stronger androgenic rather than antiandrogenic effect. That is, they do not counteract the effects of testosterone and may even increase them.

Contraindications to their use include a desire to become pregnant, in which case they can be used instead. metformin as monotherapy. Those who would like to remain fertile are also candidates for metformin. 

Scientists reveal that ovulatory function improves within 6 weeks of metformin therapy, and the number of pregnancies increases within 4 months [24].

Metformin is a first-line drug used in type 2 diabetes. It effectively reduces insulin resistance while having an extremely favorable safety profile.

According to available data, metformin is very effective in restoring ovulatory function in women with PCOS. [25].Yet successful treatment in some cases may require a combination of metformin and contraceptives.

Another group of possibilities includes antiandrogens such as cyproterone acetate, flutamide, and spironolactone. They counteract the effects of testosterone such as hirsutism, acne, baldness, etc.

Unfortunately, the response to antiandrogens is slow, taking up to 18 months, and they have a higher risk of side effects than other options.

In short:

The most important lifestyle aspects to address in PCOS are diet to lose belly fat and physical activity. In addition, there are proven effective nutritional supplements and medications.

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