Polycystic ovary syndrome (PCOS) is the commonest disorder affecting young women, affecting 5 to 18% of women in different studies.

In simple words, it can be described as a “syndrome” with following manifestations:

1.    Irregular menstrual cycles, usually delayed cycles in “most” women with PCOS

Male pattern hair growth (hirsutism) of different degrees in “some” women with PCOS

Acne in “some” women with PCOS

Male pattern baldness in “few” women with PCOS

Infertility in “some” women with PCOS

6.    Ultrasound revealing polycystic ovaries (PCO) in “some” women with PCOS (Crazy fact no. 1: Not every woman with PCOS has PCO on USG. And notevery woman with PCO on USG has PCOS.)

Not all features will be seen in every woman with PCOS, but at least two or three of the above features should be present before a woman can be labeled as having PCOS. Scientists keep debating as to which one of the above features is essential or more important than others. They also don’t seem to come to a consensus regarding what is the main reason for a woman developing this disorder.

The commonly held view is that insulin resistance leads to high insulin levels in the body, which in turn stimulates male hormone (androgen) formation from the ovary. A less commonly proposed view is high androgen level is the primary cause leading to insulin resistance. A third view is that the master gland of the body i.e. pituitary sends crazy signals to ovary disturbing its hormones.

The difficulty in sorting out this confusion is also because of difficulty in measuring “insulin resistance”. High blood or serum insulin levels do not help. (Crazy fact no.2: the test of serum insulin levels which is not uncommonly ordered is misleading and should best be avoided at least till we have better insulin assays)

When two or more of the above symptoms are present, one can consider the diagnosis of PCOS, but only when we rule out some other hormone disorders. Our body has lots of hormones and disturbance in many of them can mimic PCOS. It is therefore important to exclude the following diseases clinically or through tests before we put the label of PCOS:

Low levels of thyroid hormones (called hypothyroidism) which leads to high levels of thyroid stimulating hormone or TSH

High levels of cortisol hormone (called Cushing’s syndrome)

High levels of growth hormones (called acromegaly)

High levels of prolactin

High levels of adrenal hormones because of some congenital enzyme deficiencies known as congenital adrenal hyperplasia (CAH)

High levels of male hormones because of adrenal or ovarian tumor

All these hormones need to be checked before we know that it is PCOS and nothing else. I have come across women who were misdiagnosed as PCOS, but later turned out to be Cushing’s disease or acromegaly. 

On the other hand, once the diagnosis is made, we do not need to regularly keep checking the other hormones, unless there are new pointers to any of those diseases. It’s commonly seen that women keep getting these costly tests every year.

We need more research to figure out the “pathophysiology” of PCOS (this term just means “figure out what’s gone wrong”), but that is scientists’ problem. You should only be concerned about whatever troubles you. 

1.    First and foremost, diet and exercise are the foundation of all other treatments. You may visit the doctor for all your cosmetic (facial hair, acne), gynecological (irregular menses) and reproductive (infertility) issues. However, your doctor may throw on you some bizarre terms like “metabolic syndrome, insulin resistance, diabetes and cardiovascular risk.” From medical point of you, the more serious problems are those that affect your longevity. (The doctors are mostly too boring to focus on the real issues like appearance). Most women with PCOS are overweight. To avoid diabetes in future it is important for them to focus on a “healthy” lifestyle. A healthy lifestyle means eating healthy food and exercising. This might also help in losing weight, but a “healthy lifestyle” is not equivalent to  “weight loss”. (Crazy fact 3: Like anything else in life, the more you pursue the goal of weight loss, the more it eludes you. So ignore weight loss, just focus on your diet and exercise. Once ignored sufficiently, weight will be more under your control. If you focus on the numbers on your weighing scale, it starts playing on your mind.)

If its irregular cycles, then short course (about a week) of progesterone therapy can help, whenever menses are delayed.

If the problem is excessive hair growth or acne or severe hair fall, then it’s a 3-week therapy with estrogen and progesterone, EVERY month. Gradually the facial or body hair becomes finer and lighter and therefore less visible. Acne may subside. It takes at least 3-6 months to discern some effect of the medicines. Crazy fact 4:The effect of the medicine lasts only till the time you are taking them.For how long do you need to take the medicine.…depends on you! Once the medicines are stopped, the effect starts reverting. Just like diabetes, PCOS is a lifelong disease. Does that mean that you will take the medicines lifelong? Answer is no you should not because no medicine is without side effect. Sometimes the side effect can be serious like venous thromboembolism (fortunately, the risk is quite low with new low dose hormone therapy). At some point in time we have to remind ourselves, all this just for looking good. Agreed it’s an important issue in today’s culture and hirsutism can seriously affect one’s self esteem. So while all these therapies would be discussed with you, don’t shift your focus from “who you are” to “how you look”. You are much more than just your looks ALWAYS.

If the hormone pills are not showing much results OR to begin with the hair growth over face is excessive, one can consider antiandrogen therapy. Again more pills, additional side effects to be monitored, but mostly these medicines are safe. Don’t ever forget the choice is yours-if you want to take the medicines or not.

Nowadays effective laser therapy is available (albeit at a cost) which is effective and very often shows permanent facial hair reduction. Find a good cosmetic surgeon or dermatologist.

In 25% women, getting pregnant may be a challenge and some medicines to help in the formation of egg may be needed. A good lifestyle may be helpful in management of infertility.

All females with PCOS should check their glucose levels annually, now just fasting but also 2 hours after 75 gm glucose (the test is called oral glucose tolerance test. Crazy fact 5: Well, it does test your tolerance because the glucose water can be pretty nauseating…so remember to use a pinch of lemon and drink slowly). If it suggests abnormal glucose values, its time to start metformin, a drug for diabetes also useful in PCOS mostly to normalize glucose levels, but may help in egg formation (alas, scientists are not too sure how much metformin helps with egg formation, hirsutism or irregular menses). 

To conclude, PCOS is a disease of women, and like the layered persona of women, PCOS also remains an enigma. Reminds me of Oscar Wilde:

“Women are to be loved, not understood.” 

So love yourself the way you are!