PCOS: Symptoms, Diagnosis, and Treatment Options Explained

Polycystic Ovary Syndrome (PCOS)

I would like to ask the doctor, I am 32 years old this year.
Three years ago, my menstrual cycle was often late and the flow was light.
I inexplicably gained 20 kilograms, going from 55 kg to 75 kg.
I have been experiencing hair loss and thinning on the top of my head, almost to the point of baldness.
I consulted a dermatologist regarding my hair and had blood tests done, which showed no iron or zinc deficiency; all my levels were normal! Initially, I visited a general clinic for gynecological issues, where the doctor performed an ultrasound and noted the presence of follicles.
Based on my description and the observation of excessive hair growth on my arms and legs, I was diagnosed with polycystic ovary syndrome (PCOS), but no blood tests were conducted.
The doctor prescribed me progesterone and birth control pills (I forgot the names of the medications).
After taking them for six months, my menstrual cycle became regular, and the doctor advised me to stop the medication.
After my periods normalized, my weight gradually decreased to 60 kg, thanks to exercise and dietary control.
I maintained this weight but was unable to lose more, although I also did not gain further weight.
However, my hair remained sparse.
Over the past three years, there were occasional months when my period was late, but it would return to normal afterward.
I did not return for follow-up appointments or continue medication.
Recently, in the past six months, my weight has started to increase again, approaching 70 kg.
My menstrual cycle has become increasingly delayed, and the flow has decreased.
My hair is thinning even more, and I am starting to notice white hairs! This time, I went to a large hospital, Chang Gung Memorial Hospital, and explained my situation from three years ago to the doctor.
The doctor said I needed blood tests to get accurate results (all tests for PCOS were conducted), but when I reviewed the results today, all my levels were normal, including male hormones, and my thyroid function was also normal...
So, doctor, are my symptoms indicative of polycystic ovary syndrome or not? Why am I still gaining weight, experiencing hair loss to the point of near baldness, and developing white hairs without any identifiable cause? What is wrong with me? Why do some doctors say it is PCOS while others say it is not? Is it possible that the blood tests are inaccurate, and should I seek a second opinion? Finally, the doctor prescribed me medication again, this time progesterone (Norethisterone) and birth control pills (Chlormadinone).
Will these medications have side effects? Will they cause weight gain or further hair loss? I am already overweight and experiencing hair loss, so I am quite anxious! (I forgot the names of the medications from three years ago, but I did not experience side effects or weight gain then.)

Kkyy, 30~39 year old female. Ask Date: 2017/06/12

Dr. Zhang Kunmin reply Obstetrics and Gynecology

Hello, the treatment overview for Polycystic Ovary Syndrome (PCOS) is as follows: PCOS is a condition characterized by abnormal hormone secretion, leading to irregular ovulation and the inability of follicles that should develop into eggs to grow properly.
The exact cause is unknown, but it is believed that genetics may play a role.
However, "polycystic ovaries" do not equate to "polycystic ovary syndrome." If an ultrasound reveals multiple small follicles in both ovaries (like a string of pearls, with at least 10 on each side), but menstruation is normal and there are no symptoms, it is clinically referred to as "polycystic ovaries," which is considered a normal phenomenon.
Clinically, it is observed that 30% of normal women may have polycystic ovaries on ultrasound.
Patients with PCOS experience abnormal follicular proliferation in the ovaries, leading to endocrine dysfunction and excessive secretion of male hormones, resulting in irregular menstruation, often experiencing cycles that are 2-3 months apart or only once every six months to a year, and long-term anovulatory cycles or amenorrhea.
In addition to irregular menstruation, patients may exhibit symptoms such as obesity, hirsutism, acne, and alopecia, or may have darkening and pigmentation in skin folds such as the armpits and groin.
However, not everyone will exhibit symptoms; some individuals may have none at all.
It is important to note that conditions such as hypothyroidism, ovarian or adrenal tumors, Cushing's syndrome, and elevated prolactin levels can also present with symptoms of anovulation, acne, and hirsutism due to elevated androgens, necessitating blood tests for further evaluation to rule out other diseases before a diagnosis can be made.
Clinically, the diagnostic criteria for PCOS include three main features: 1) Chronic anovulation, 2) Elevated androgens, and 3) Ultrasound findings of polycystic ovaries.
A diagnosis of PCOS can be made if at least two of these criteria are met.
Typically, other associated issues include obesity, with about 50% of PCOS patients experiencing weight problems.
Not every individual with PCOS will be overweight, but approximately 50-60% may become obese due to increased androgens, metabolic dysfunction, endocrine imbalances, and insulin resistance.
While obesity is not a diagnostic criterion for PCOS, it is indeed one of the contributing factors.
Research has shown that PCOS is closely related to genetics, dietary habits, and lifestyle choices.
If a mother or sister has PCOS or a family history of diabetes or metabolic syndrome, the risk of developing the condition is higher than that of the general population.
There is also an increased likelihood of developing endometrial abnormalities, hypertension, and fatty liver disease.
Women with PCOS may face challenges with fertility due to long-term anovulation, leading to insufficient progesterone secretion, which can result in abnormal endometrial hyperplasia and lesions, as well as a higher risk of depression, obesity, cancer, and metabolic diseases related to high insulin resistance.
Studies have found that most women with PCOS also have issues with obesity and insulin resistance, which can be simply described as a "prediabetic state." Without appropriate treatment, this can pose significant health risks.
Notably, patients with PCOS are more prone to issues such as dyslipidemia, abnormal triglycerides, and elevated blood glucose levels, leading to a higher risk of diabetes and cardiovascular diseases.
Additionally, a study published by the Department of Obstetrics and Gynecology at National Taiwan University Hospital in 2010 found that PCOS affects liver metabolism, with patients exhibiting elevated male hormones having an eightfold higher incidence of fatty liver compared to normal women.
Not only does liver metabolism get affected, but many organs and functions in the body can also be impacted.
Increasingly, research indicates that PCOS is not just about irregular menstruation or infertility; it has significant long-term health implications for women.
It is recommended that individuals with a family history of the condition take early preventive measures and seek treatment.
Treatment approaches vary based on individual needs.
For patients who do not wish to conceive, treatment may include regular administration of progesterone (every 45-60 days) to induce menstruation and reduce the risk of endometrial cancer, or oral contraceptives that suppress gonadal hormone secretion, thereby inhibiting ovarian androgen production and maintaining regular menstrual cycles.
For those with significant masculinization, stronger anti-androgen contraceptives may be prescribed.

The occurrence of PCOS is primarily due to the body's poor utilization of insulin.
Therefore, medications used to treat type 2 diabetes, such as metformin, can be effective for managing PCOS.
Inositol is currently classified as a health supplement and is not a formal treatment option.
For women with PCOS who wish to conceive, the primary issue is anovulation.
The most commonly used medication is the oral ovulation inducer Clomiphene Citrate.
For those who do not respond to oral medications, injectable ovulation drugs such as HMG, FSH, and r-FSH may be considered.

In addition to medication, controlling weight and establishing an exercise routine can improve symptoms.
Lifestyle modifications, including dietary changes, regular exercise, and maintaining a healthy weight, are more effective than medication alone in managing hyperinsulinemia and reducing insulin resistance, thereby improving the clinical manifestations of PCOS and promoting ovulation.
Weight control is particularly important; for obese women with PCOS, weight loss is the first-line treatment, often restoring normal hormonal balance, resuming ovulation, and reducing miscarriage rates.
Exercise not only aids in weight control but also improves insulin sensitivity.

If sudden weight gain or irregular menstrual cycles occur, it is advisable to consult a gynecologist for proper diagnosis and treatment.
Individuals diagnosed with PCOS, even in the absence of symptoms, should not take the condition lightly; they should improve their lifestyle, dietary habits, and exercise routines to enhance their overall health.
Thank you! Wishing you peace and health, Dr.
Zhang.

Reply Date: 2017/06/12

More Info

Polycystic Ovary Syndrome (PCOS) is a common hormonal disorder that affects women of reproductive age. It is characterized by a combination of symptoms, including irregular menstrual cycles, excess androgen levels, and polycystic ovaries. Your symptoms, including irregular periods, weight gain, hair thinning, and increased body hair, are indeed consistent with PCOS, but the diagnosis can be complex and may require a thorough evaluation.

Symptoms of PCOS
1. Irregular Menstrual Cycles: Women with PCOS often experience irregular or absent menstrual periods. This can lead to difficulties in ovulation and fertility issues.

2. Weight Gain: Many women with PCOS struggle with weight gain or obesity, which can exacerbate other symptoms.

3. Hair Changes: This includes thinning hair on the scalp (androgenic alopecia) and excessive hair growth on the face and body (hirsutism).

4. Skin Issues: Some women may experience acne or dark patches of skin (acanthosis nigricans).

5. Infertility: PCOS is one of the leading causes of infertility in women.

Diagnosis of PCOS
The diagnosis of PCOS typically involves a combination of clinical evaluation, ultrasound imaging, and blood tests. The Rotterdam criteria are commonly used, which require at least two of the following three criteria:
1. Irregular or absent ovulation (irregular menstrual cycles).

2. Clinical or biochemical signs of hyperandrogenism (excess male hormones).

3. Polycystic ovaries visible on ultrasound.

In your case, the ultrasound findings of follicles and the symptoms you described suggest PCOS, but the normal hormone levels from your blood tests may complicate the diagnosis. It's important to note that not all women with PCOS will have elevated male hormones, and the condition can present differently in each individual.

Treatment Options
Treatment for PCOS often focuses on managing symptoms and may include:
1. Lifestyle Changes: Weight management through diet and exercise can help regulate menstrual cycles and improve insulin sensitivity.

2. Medications: Hormonal contraceptives (like the birth control pills you were prescribed) can help regulate periods and reduce androgen levels. Metformin, a medication used for type 2 diabetes, may also be prescribed to help with insulin resistance.

3. Hair Removal Treatments: For hirsutism, treatments may include laser hair removal or anti-androgen medications.

4. Fertility Treatments: If pregnancy is desired, medications to induce ovulation may be necessary.

Concerns About Medications
The medications you mentioned, such as norethisterone (a form of progestin) and the contraceptive pill, can have side effects. Common side effects may include:
- Nausea
- Breast tenderness
- Mood changes
- Weight gain
- Headaches
However, many women tolerate these medications well, and they can help manage PCOS symptoms effectively. It's essential to discuss any concerns about side effects with your healthcare provider, especially regarding weight gain and hair loss.

Next Steps
Given the complexity of your symptoms and the varying opinions from different healthcare providers, it may be beneficial to seek a second opinion from a specialist in reproductive endocrinology or a gynecologist with experience in PCOS. They can provide a comprehensive evaluation and may suggest additional tests or treatment options tailored to your specific situation.

In summary, while your symptoms align with PCOS, the diagnosis can be nuanced and may require further investigation. It's crucial to work closely with your healthcare provider to develop a management plan that addresses your concerns and improves your quality of life.

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