How is it that a condition that affects about 10% of women is so poorly understood? What is PCOS? Why is it so confusing and how do we treat it?
A huge part of the PCOS mystery is in its diagnosis. Unfortunately there is no “classic” PCOS presentation. Women can be diagnosed at any age, at any weight, with or without periods, and the degree of symptoms can be from mild to life altering.
Ok, so let’s break this down. What is PCOS? The simplest definition is having at least two of the following:
Signs or symptoms of androgen excess (aka male sex hormones)
That sounds simple, but each criteria is so vague that it can be challenging to determine who fits these criteria.
Irregular periods, what qualifies? PCOS patients can have menses every 21-35 days or can have no periods at all in a year. See where the confusion starts? About 30% of women with PCOS have periods every month and do not present with menstrual irregularities. An estimated 85% of women with PCOS will have oligomenorrhea.
Now let’s add to the confusion, shall we? Oligomenorrhea. Few or scant periods, less than 6 to 8 periods per year. First, you should have had normal cycles BEFORE becoming irregular as a part of the diagnosis. Early in a woman’s reproductive days, menarche, it’s is normal to have irregular menstrual cycles. When women are in perimenopausal state, they too are expected to have irregular menses. So what is considered a regular menstrual cycle? Basically if your period’s cycle is longer than 35 days OR you have less than 6-8 cycles per year this is considered oligomenorrhea.
Ok, so we kind of understand the number of periods game. Now let’s tackle the idea of what’s actually considered a cycle or period. There’s a hilarious but amazing video that shows the fun progression of a period. Take a quick break to watch, laugh, and return for more education.
What’s a period?? A period is when we shed the lining of the uterus and have visible blood discharged from the vagina. What’s the average period length? 3-5 days. But what’s considered “normal“ period length? 2-7 days or some say even just one day.
Periods. That’s a wrap on that. At least 6 per year, about 21-35 days apart and lasting somewhere around 1 day and more. Let’s move on, shall we? Androgen excess!! This topic can get a little hairy.
What are androgens and how do I know if I have too much of them? Do I need labs? How much is too much?
Androgens broken down. Basically sex hormones that are associated with male characteristics. They can be made in the ovary AND in the adrenal glands. Most popularly hated is good old testosterone. Other hormones such as DHT (bye bye hair), androstenedione, and DHEAS are less talked about but have an important role.
Testosterone explained: this is one of the most potent (strongest) male sex hormones. When it’s elevated it disrupts the regular cycle and produces hirsutism. The tricky part is, for some women they can have hirsutism even with testosterone in the “normal range.” We will talk about hirsutism in a few.
DHT reviewed: the second most potent androgen, but much less talked about. This bad boy is also produced in gonads (ovaries and testicles) and is a huge focus in men’s health, but over looked in women’s health. DHT is essential for growth of pubic hair (armpits and genitalia), BUT at higher than normal levels it causes the hair follicles in our scalp to shrink. This will overtime lead to male pattern baldness. This high DHT is also responsible for acne and hirsutism.
Hirsutism, do I have it? Dark and coarse hair growing in “unexpected” areas. BUT hirsutism can be caused by genetic and other factors. It does not have to be only in PCOS. Generally we ask if the same pattern of hair is seen in other females in the family to see if there’s a genetic component. We can use a scale to score the severity of hirsutism which can be helpful in determining if the treatment is working and if it’s progressing.
Androstenedione and DHEA-S, what’s the deal? These are adrenal mediated sex hormones. They can be elevated or normal in PCOS. Generally speaking we check them to rule out other adrenal disorders that can lead to irregular periods and androgen excess.
Now the question, do I need to have labs? Maybe. All that is required for diagnosis of PCOS are signs or symptoms of androgen excess, irregular periods, and/or findings on ultrasound. PCOS, however, is a diagnosis of exclusion. This means that we usually do run labs to rule out other causes of irregular periods AND hirsutism. Labs can also be helpful to evaluate presence of complications from PCOS and guidance/efficacy of therapy.
String of pearls?? Finally, the pelvic ultrasound. Classically NOT required for diagnosis of PCOS AND can be seen in non-PCOS patients. Patients with early and mild PCOS may also have completely normal ultrasound. Recently there were debates over what are qualifications for PCOS findings on ultrasound. Currently the requirement is 12 or more follicles on at least one ovary.
Phew, we have covered a LOT here. I hope this was beneficial and you‘ve learned from this blog. Want more? Follow me for more fun and educational material along with tips and tricks to treat PCOS. Visit my website to learn about my holistic services and keep your eyes open for my part 2 (PCOS causes and physiology) and part 3 (PCOS therapies reviewed) blogs. And subscribe to my newsletter for updates on more upcoming content and freebies.