Polycystic Ovarian Syndrome (PCOS) is not what most people think it is. The ovaries are not the cause but a casualty of an endocrine problem.
PCOS is the most common endocrine disorder in pre-menopausal women ~10% will have PCOS
- 50% are not obese
- 50% are not hirsute (hairy)
- 90% of cases will be missed by their doctor.
Primary defect is hyperinsulinemia (too much insulin) and insulin resistance due to genetics .
It is therefore an endocrinopathy not a GYN problem
Signs of PCOs
- Enlarged ovaries and anovulation
- Acne
- Hirsutism (due to hair follicles being hypersensitive to androgens, in spite of normal levels)
- Male pattern thinning in severe cases
- Obesity
- Lipid abnormalities
- Glucose intolerance
Insulin abnormalities precede PCOS. Genetically, some people have insulin resistance (like I do). This means that you make more insulin to reduce the blood sugar to normal levels. The key is the amount of insulin.
The increased insulin makes your ovaries (theca cells) produce increased androgens (predominantly male hormone) and a gland called the adrenal gland, to also produce androgens.
This increased androgen reduces insulin sensitivity, meaning the body needs to make even more insulin which leads to more androgen production, leading to more insulin and more androgen…
This also causes the body to not ovulate. The major hormone produced after ovulation is Progesterone. The has a hormonally calming effect on a gland in the brain called hypothalamus. So, since with PCOS there is no ovulation, there is no progesterone to calm the hypothalamus. As a result, the hypothalamus is constantly telling another gland in the brain, the pituitary, to continue to make something called LH and not FSH (follicle stimulating hormone, without this eggs or follicles are not stimulated for eventual ovulation). Another reason why ovulation does not occur.
As it turns out, LH also stimulates the ovary to produce androgens. This increase in androgens further increases the insulin resistance, so the body needs to make even more insulin, which increases androgens…
All this increase insulin creates yet another problem. It blocks the production of SHBG (sex hormone binding globulin) in the liver. This is a protein that carries hormones around the body. The more SHBG there is, the more hormones are bound. Only free hormones can do things, not bound hormones. When the level is reduced, there is less bound hormone and more free. This creates a situation where this is a lot of free androgens (testosterone) and estrogens. Potentially very bad.
The culprit in PCOS is insulin, not androgens (testosterone)
Remove insulin and testosterone hypersensitivity resolves
Treatment
Treatment of PCOS is particularly important for longevity
Treatment should Prevent:
- Cardiovascular disease (this is caused by insulin resistance and not increased androgens)
- Obesity
- Diabetes and insulin resistance
- Hypertension
- Endometrial cancer (due to elevated estrogen and no progesterone)
- Breast cancer: There is a 5.4% increased risk of breast cancer in patients with PCOS all due to loss of progesterone production and insulin resistance.
Women with PCOS have low SHBG which frees up unbound estradiol and androgens which increases side effects
Need to protect the lining of the uterus (endometrial protection):
Birth control pills:
- Blocks ovarian production of testosterone
- Protect endometrium, ovaries, and heart.
- Stimulates the production of SHBG by the liver and increase of binding of free testosterone.
- Decreases skin symptoms and hirsutism
Treatment:
- is not directed at ovary
- is directed at hair follicle to reduce sensitivity
- is directed at pancreas to reduce insulin resistance
Treatment is multimodal:
- Anovulation (not ovulating) causes endometrial hyperplasia: treatment progesterone or birth control pills
- Lipid lowering by diet, weight loss, exercise.
- Obesity treated with emphasis on exercise and diet
- Insulin resistance treated by diet, low carbs/lectins, weight-loss, exercise, and medication
Metformin 500 mg ER; insulin sensitizers, may need to up Metformin 1000 mg b.i.d. as tolerated
- Thyroid optimization
- Hirsutism treated with spironolactone 100 mg BID
- Treat peripheral androgen hypersensitivity.
- Do not want to lower testosterone level rather wants to lower testosterone hypersensitivity
- Metformin cuts insulin, LH, and testosterone levels by half thereby reducing hirsutism
- Metformin reduces symptoms of PCOS by lowering insulin levels, it treats insulin resistance
- Metformin reduces testosterone hypersensitivity by increasing SHBG
If you or a loved one has PCOS, it is not your fault. Remember, it is a genetic problem that causes the body to produce excessive insulin. All the problems related to PCOS arise from this. It should be treated appropriately.
If you have any questions about this important topic, please feel free to call our expert staff.