What is PCOS? Other than “nasty but not the worst thing in the world”?
PCOS stands for Polycystic Ovarian Syndrome. Though it’s hard to define because the symptoms people suffer vary widely, roughly four percent of women still have it worldwide. Up to 15 percent of women in the states. PCOS is the leading cause of infertility in the Western world.
PCOS is a disorder of the endocrine system. It is characterized by the appearance of multiple small cysts on the ovaries, which is almost always accompanied by elevated male sex hormone levels and decreased female sex hormone levels. The male sex hormones, called androgens, are testosterone, the many varieties of testosterone, and DHEA-S. The female sex hormones are all of the varieties of estrogen and progesterone. This imbalance results in a number of problems. These include :
-Oligo- and anovulation
-Irregular or absent menstruation
-Increased risk for metabolic symdrome, diabetes, heart disease, and ovarian and endometrial cancers
-Male pattern hair growth (hirsutism)
-Male pattern hair loss (alopecia)
-Weight gain and increased difficulty in losing weight
In order to understand how menstrual dysfunction occurs, it is important first to review normal menstruation:
The first day of a menstrual cycle is the first day of bleeding. During this period, the lining of the uterus is shed. This bleeding constitutes the first 3-8 days of the first half of the menstrual cycle, which lasts about two weeks and is called the follicular phase. During the follicular phase, levels of estrogen rise and make the lining of the uterus grow and thicken.
Detecting elevated estrogen levels, the pituitary gland increases its production of follicle-stimulating hormone throughout the follicular phase. This hormone stimulates the growth of 3 to 30 follicles. Each follicle contains an egg. With time, the levels of FSH decrease, so only one of the follicles continues to grow. It produces estrogen, and other stimulated follicles break down.
Detecting this shift, the pituitary now releases luteinizing hormone. This makes the follicle bulge and rupture, releasing its egg. This is ovulation. During ovulation, testosterone, that is otherwise constantly produced at low levels by the ovaries, surges, and estrogen drops. Estrogen is required for serotonin production, which is why many women might experience depression during this time.
After ovulation comes the luteal phase. Here the ruptured follicle closes and forms the corpus luteum. This makes the endometrium thicken, which produces progesterone. Estrogen is on the rise again, too, after ovulation. But if the egg is not fertilized within about two weeks, progesterone levels fall, which triggers shedding and bleeding. Here the cycle begins again. Cycles are generally “known” to be 28 days long, but the length of a regular, healthy cycle can vary from ~20 to ~35 days.
Doctors are not sure where the problem enters into the picture with PCOS, but it probably varies. Some options are as follows:
-Low levels of the hormone sex-hormone binding globulin, a “result” of PCOS, decreases the rate of conversion from testosterone to estrogen. This might make estrogen too low to send the proper signals to the pituitary.
-High androgen levels coming right from the ovary or from the adrenal glands can block estrogen and progesterone activity.
-Insufficient pituitary signaling with LH or FSH could be the primary problem. In PCOS, the ratio of LH to FSH is typically around 2:1, instead of the more normal 1:2. This is presumably because the PCOS patient’s pituitary gland wants her to menstruate but she simply is not.
-Finally, the one hormone that is absolutely crucial for menstruation is progesterone. When looking at all of these issues, it is a break in the line towards progesterone production that is the likely cause of disordered menstruation. Without progesterone, the corpus luteum never “knows” when to shed.
In all cases, it’s all very complicated. The question is a tricky one. Therefore, it’s important to test testosterone, DHEA-S (the testosterone precursor, an androgen), estrogen, progesterone, LH and FSH at the very least when trying to figure out an endocrine problem. A liver panel, fasting glucose levels, thyroid tests, micronutrient levels, and adrenal hormone such as cortisol are all important for background endocrine understanding.
Some people in the world of evolutionary medicine posit that PCOS is present in the world today because it was evolutionarily advantageous in a hunter-gatherer environment. This hypothesis falls in line with the “thrifty gene” hypothesis, which states that those humans who are best at conserving energy are the best at reproducing. In this instance, an obese woman, or a woman with PCOS, would be able to always have babies during a famine because she is so good at storing and using fat. The “famine” stage for her makes her fertile. The times of plenty, on the other hand, would make her infertile. This hypothesis might work with overweight PCOS patients, but it doesn’t account for the million PCOS patients who aren’t overweight.
And most importantly, just like with diabetes, solely because PCOS may have provided an advantage in evolutionary times does not mean we do not want to treat it as a medical problem in contemporary society.
In the next post, I’ll cover the apparent causes of and influences on PCOS.
For more information on PCOS, why you have it, and how to overcome it, check out PCOS Unlocked: The Manual, the multi-media resource I created in order to share all the PCOS information and experience I’ve amassed in my brain, and apply it to solving the unique case of your PCOS.