If you’ve been diagnosed with PCOS – polycystic ovary syndrome – you most probably have a lot of questions about what it is, what causes it and how to treat it. A simple Google search turns up a lot of conflicting and confusing information. Further digging, or finding PCOS health coaches who do a lot of the nitty-gritty work of unraveling and interpreting complex clinical research studies, could provide some relief and direction from a range of symptoms that include irregular periods, excessive hair growth, weight gain, thinning hair and oily skin or acne.
But if you’re stuck and wondering what information to digest first, we’ve got you covered. We spoke to Dr Rosalie Sant, consultant in obstetrics and gynecology at Primavera Medical Centre in Dubai, about PCOS, and she’s given us a thorough, detailed, nuanced rundown of this complex and very common condition. PCOS does not have to be something to panic about, or worse, ignore in the hope it will go away. In understanding our bodies, we can work out how to best move forward, take charge of our health and make lasting shifts that benefit the rest of our lives.
Okay, first thing’s first. What is PCOS, and what does it stand for?
PCOS, or PolyCystic Ovary Syndrome, basically means ‘many cysts in the ovaries.’ But actually the ‘cysts’ are not cysts at all, but developing follicles about two millimeters in size that don’t require surgery. These follicles produce hormones that disrupt how the body functions.
So the actual name for the diagnosis isn’t technically correct?
The term ‘polycystic ovary syndrome’ is actually a complete misnomer. It was the name given to the condition originally and the term stuck. In fact, PCOS is a metabolic syndrome. Furthermore, PCOS also occurs in men and men don’t have ovaries, so you can inherit it from your father’s side of the family.
So PCOS is genetic?
Yes, it is a genetic predisposition. PCOS can become activated by lifestyle or the process of getting older. So if you are genetically predisposed to PCOS, it is something that’s going to be there all your life, but it doesn’t need to be activated all through your life. Depending on how much you push the body through eating habits, through lack of exercise, through stress, through getting older, through hormones during pregnancy or other hormonal imbalances, then it will tip the body into developing the symptoms of PCOS, insulin or metabolic syndrome.
What are the main symptoms of PCOS?
The clinical features of polycystic ovary syndrome are extremely varied and very broad. It doesn’t affect people in the same way. The classic, clinical symptoms of polycystic ovary syndrome – the overweight woman with a receding hairline, face full of acne and hair and very irregular periods – is an extreme example. But not all people who have PCOS have these symptoms. We do see menstrual irregularity very often as a presenting feature, or difficulty getting pregnant. It’s not that the woman is completely infertile, but it just takes them a bit longer to conceive.
There are three “required” characteristics according to international medical consensus. The first characteristic is clinical features, the second is ultrasound features, and the third is biochemical indicators – specifically an increased level of androgenic, or male, hormones in the body. But even though that is the latest consensus of clinical diagnosis, we know that the spectrum is extremely broad and that we can’t actually fit patients into just these three criteria.
So the international medical consensus doesn’t give us the whole picture when it comes to PCOS. It’s much more complex than that.
Because of the inadequacy of the criteria set out by international recommendations, we’re always looking to see if there’s anything more reliable that we can work with. If you had to wait for the androgenic hormones to rise for you to diagnose PCOS, as the international criteria currently suggest, then we would be diagnosing PCOS only when it has become very active and has quite a grip on the patient’s metabolism.
I find it a lot easier to measure FSH (follicle-stimulating hormone) and LH (luteinizing hormone) levels in the body to diagnose PCOS. These hormones are produced by the pituitary gland. Finding out the FSH and LH ratio allows you to suspect PCOS and treat it much earlier.
What are FSH and LH, and what do they do in our bodies?
The pituitary gland is one of the master glands, which is located at the base of the brain. It produces Follicle-stimulating hormones (FSH) and luteinizing hormones (LH), among many others.
FSH makes a few follicles in the ovary mature, one of which will eventually ovulate that month. This mature follicles is required for conception. Normally, LH levels spike just before ovulation in order to trigger ovulation. So if the LH is very high throughout the cycle, the LH doesn’t seem to allow the egg to be released even though the FSH is doing its job and maturing those follicles. You need LH to be low, and then you need it to spike in order for it to work. In people who have PCOS, the LH levels stay high, so you don’t get ovulation every month.
Let’s get into the metabolic side of PCOS. I read that women with PCOS are five to seven times more likely to develop Type 2 diabetes later in life if the condition is left untreated.
Endocrinologists like doing insulin resistance tests, but there’s controversy around this method because it is a difficult test to do and to interpret unless it is very obviously abnormal.
The metabolic effect of PCOS is through causing a situation of insulin resistance, which means that to digest a certain quantity of carbohydrates, you require a lot more insulin than usual because your body is not utilizing insulin efficiently. Because of that, you end up having to overproduce insulin, which means your pancreas has to work overtime. And that’s the reason why someone with PCOS has burst of energy (glucose rush) followed by wipe out and a foggy head (glucose falls) and then cravings starts. .Also insulin is a storage hormone, so while it is high in the circulation, you are going to hold onto your fat, making losing weight difficult. In addition, PCOS can be regarded as prediabetic. This is because one day, if nothing is done to change the situation, the pancreas is not going to be able to cope with the increased demands for insulin. You will end up with sugar levels that aren’t coming back down to normal just like you have in prediabetic patients.
We don’t fully understand the biochemistry behind how exactly this happens, but we do know that there is a link through scientific evidence and through clinical outcome. If you try to control the amount of carbohydrates in somebody who has PCOS, they improve. This does not mean that an extremely low carbohydrate diet is advisable. Just a sustainable diet with a measured amount of healthy, low glycaemic, unrefined carbs together with heaps of vegetables and some protein.
Does hormonal birth control affect PCOS positively or negatively?
So when you put people on the contraceptive pill, you are stopping the function of the ovaries. So those hormones coming from the ovary causing the metabolic imbalance are stopped and are not being fed into the system. So hormonal birth control does actually allow you to control PCOS.
Unfortunately, people think that the only reason why we give the pill is because we want regular periods, which are actually fake periods and not your own periods. And people also think that giving you the pill will cure your PCOS because periods become regular, but that’s not the way it goes. The lifestyle changes are the most important ways of dealing with the condition; otherwise as soon as you stop the pill your periods will go to exactly what they were before you started.
What are the lifestyle changes someone with PCOS should make in order to regain balance in the system and to heal?
I think basically the most important aspect of managing PCOS is learning about nutrition — please note I did not say ‘diet’. What I always tell patients is, I am not a nutritionist and we are not going to count calories or weigh food. What we need to do is know what constitutes protein, and make a list of the ones we like; what constitutes healthy, low glycaemic index, unrefined and unprocessed carbohydrates and make the right choices; and finally what vegetables and fibre containing food we like. As we said, this is not a diet but a lifestyle change that needs to be sustainable so we need to like the food. Educating ourselves about macronutrients is the answer. Make sure you’re eating enough protein and make sure you’re eating the right types of carbohydrates because there’s so much processed food that we eat without even realizing it. And then, every so often we can have a bit of a ‘cheat’ as we know how to combine food for the ‘cheat’ not to have an impact. The changes need to be sustainable as the PCOS will become active again if we start to eat unwisely again.
It is quite a commitment and in a busy lifestyle, sometimes unfortunately we do not give health as much importance as we should. And to eat healthily has become more and more…not difficult per se, but it’s a process. It’s an evolution. We can’t just assume that anything we’re going to eat, even if it is organic, is healthy.
There are certain medications like Metformin or other oral hypoglycemic drugs that women I know have been prescribed to treat their PCOS, and they weren’t given anything else. No information, nothing.
I personally prefer to try and educate the patient and get them to try and do things naturally, because it is very possible to ‘cure’ things naturally. Some people of course will still need the medication because they are so prone to PCOS that it is not going to be enough to change your lifestyle. Because ultimately we’re all going to grow old and we just can’t control all the stress in our lives and both these factors predispose us to insulin resistance and prediabetes. My first line of management is never medication. If possible, I prefer to go the nutritional route because, well, if you take medication it’s going to go fine for a while, but after you stop them it’s going to come back because you haven’t changed your lifestyle. It’s not a long-lasting management.
Have you noticed an increase over the years in PCOS in the UAE? How many women per month do you diagnose, on average?
Oh, many. I don’t know the numbers but unfortunately it’s becoming very common, for two reasons:
Number one, this region [the UAE] and the Mediterranean for that matter, has a much higher genetic predisposition to PCOS as opposed to northern Europe, for instance. Number two, we’re all very busy. We can’t depend on mummy to cook for us and we sometimes don’t have time to devote to making good, wholesome food. Our body and metabolism likes grandma’s cooking a lot more than what we’re eating nowadays, because it was more wholesome and much less refined.
Until one or two generations ago, all this variety of fast food was simply not available to the local population. It takes a while for the body to adapt. In fact, our bodies are not adapting very well to the type of food that is available now. Thankfully, a lot of the local women have become very health conscious and body-aware. So through exercise and all the adaptations to their diet, a lot of them are managing beautifully.
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