Cases are Presenting More Frequently
By Jane Ehrhardt
“I see this syndrome frequently in my office, at least three to four times a week, sometimes in a single day,” says Mackenzie Woodson, MD, an OB/GYN with Complete Women’s Care of Alabama. Affecting about five million women in the United States, polycystic ovary syndrome (PCOS) is one of the most common causes of female infertility, according to the CDC.
Typically, PCOS is seen in women ages 18 to 35 with the hallmark symptom of irregular periods. The cause of the syndrome is unknown, though the problem rests with abnormal androgen hormones with small cysts forming on the outer edge of the ovary that fail to regularly release eggs.
“PCOS comes up a lot in other specialties, not just obstetrics because those with the syndrome often have metabolic syndrome as well,” Woodson says. “Those symptoms lead them to their primary care provider or an endocrinologist who may not immediately think to suspect the presence of PCOS.
“If a provider notices skin changes on the back of the neck, this can be a clue to ask for more information about the patient’s menstrual cycle and even check for prediabetes, which are all signs of PCOS and metabolic syndrome.”
On lighter skin tones, the changes on the back of the neck, called acanthosis nigricans, appear as a darkened area as if tanned in that spot. On darker skin tones, the dark patches present more as a thickened, velvety texture. Besides the neck, these anomalies may be found in the armpits, groin, or under the breasts, as well.
A diagnosis of PCOS requires the presence of at least two of these three conditions: irregular periods, high levels of androgen, and polycystic ovaries. An irregular period would be more than 60 days apart, often as rarely as three times a year. The excess hormone levels may show as acne or excess hair growth such as on the face, and can be determined with a blood test for testosterone.
The third criteria of ovaries appearing polycystic requires only an ultrasound to confirm. “We actually don’t need imaging to confirm two of these conditions” Woodson says, stressing how simple the diagnosis can be. “But even if I see those first two, I usually corroborate it with a pelvic ultrasound. I also recommend that the blood test cover all hormones, which can be tricky to assess so this sometimes requires an OB/GYN or an endocrinologist. And providers should test the A1C, which can diagnose metabolic syndrome. Most of women who have metabolic syndrome will also have PCOS, but those with PCOS do not always have metabolic syndrome.
“The sneakiest people to diagnose are the thin women who come in with infertility, and it turns out they have polycystic ovaries, so are not ovulating. They’re tricky because most medical training pushes doctors to assume obesity is a prime condition of polycystic ovary syndrome. Even normal BMI woman can have PCOS. It comes down to menstrual history and physical features, such as the skin changes or excess hair.”
Undiagnosed, the syndrome can lead to endometrial cancer. “When you’re not having a period, you have low progesterone which makes higher estrogen that can place the uterus endometrium at risk for cancer, especially if you have a BMI of 40 to 60,” Woodson says. “The obesity component can put even younger women at risk for the cancer.
“We want to get women diagnosed for PCOS to be preventive. We can protect her uterus and endometrium by giving progesterone, if her natural levels are low.” Generally, that requires only a prescription for tablets, an IUV, or birth control.
When PCOS is diagnosed, the treatment tends to be individualized depending on the patient’s stage of life and fertility desires. She may have infrequent ovulation, but no problems with extra hormones. Or she may or may not have metabolic syndrome.
“There are so many nuances, and because we’re getting a wider variety of treatment options we really can individualize our approach,” Woodson says. “If a woman has PCOS as well as metabolic syndrome, we get them on metformin.” Metformin, a biguanide, decreases glucose absorbed from food and produced by the liver, which helps prevent the progression into diabetes among this younger demographic.
For overweight patients, weight loss by itself can greatly improve or sometimes completely resolve their PCOS problem, making weight loss a viable treatment. “As little as a five percent body weight loss can help get a PCOS patient to ovulate spontaneously on her own with more regularity and fertility,” Woodson says.
Woodson has been seeing more women coming in with infertility or irregular menstruation issues. “It feels like a movement among women wanting to be in tune with their bodies,” she says. “They no longer want to be on anything hormonal, so they stop their birth control and start tracking their cycle closely with apps. They’re finding it empowering to know about their reproductive health, which is exposing more PCOS cases and this is why primary care providers and specialists should keep PCOS on their diagnostic radar.”