Polycystic Ovarian Syndrome Clinic

The exact pathophysiological mechanism leading to the characteristic PCOS phenotype remains unknown. Some investigators explain it as primarily an intrinsic ovarian problem (excess ovarian production of androgens), others as adrenal (excess adrenal production of androgens), and again others as hypothalamic-pituitary dysfunction (exaggerated gonadotropin releasing hormone pulsatility resulting in hypersecretion of luteinising hormone).

Perhaps the most widely accepted explanation is metabolic, with the aetiologic factor being insulin resistance (IR) (defined as a reduced glucose response to a given amount of insulin) and consequent compensatory hyperinsulinaemia. Evidence of decreased insulin sensitivity is seen in both lean (30%) and obese (75%) women with PCOS; but insulin resistance, accompanied by compensatory hyperinsulinaemia, is most marked when there is an interaction between obesity and PCOS.  Hyperinsulinaemia stimulates both ovarian and adrenal androgen secretion directly and suppresses sex hormone binding globulin (SHBG) synthesis from the liver resulting in an increase in free, biologically active androgens. The excess androgen production and hyperinsulinaemia causes premature follicular atresia and anovulation.

PCOS usually presents the following symptoms after puberty begins, It is not just a reproductive issue – it’s a systemic metabolic and endocrine disorder influenced by insulin resistance, chronic inflammation and hormonal imbalances.

• Irregular periods, light periods or no period at all
• Excess body hair in places not normally grown on females; the chest, abdomen. Face and back (hirsutism)
• Excess belly fat and weight gain in the midsection
• Severe acne
• Oily skin
• Male pattern baldness
• Thinning hair
• Skin tags, especially on neck and armpits
• Discolored, dark patches of skin on neck, armpits and under the breasts
• Enlarged ovaries or ovaries containing many cysts (polycystic)
• Fertility complications
• Acanthosis nigricans (velvety, brown skin markings usually on the neck, under the arms or in the groin)
• Mood swings

Diagnosis can be challenging as symptoms vary in severity and it can be difficult to differentiate normal variability from the abnormality of PCOS, especially in young women. Symptoms can also vary by weight and ethnicity and can change across the lifespan of a woman. Given this complexity and uncertainty, it is not surprising that many women report experiencing long delays and seeing many doctors before receiving a diagnosis.

Despite the name, you don’t have to have polycystic ovaries to be diagnosed with PCOS.

Polycystic Ovary Syndrome is diagnosed when a patient meets two of the three criteria (and other potential causes have been ruled out):

• Chronic Anovulation (no ovulation)
• Hyperandrogenism (high levels of male hormones)
• Polycystic Ovaries

In an adolescent or a young women within 8 years of the start of menstruation (periods), neither the appearance of polycystic ovaries nor the use of anti-mullerian hormone are used in the diagnosis of PCOS. This is because the ovaries may contain > 20 follicles and the AMH may be elevated as part of normal pubertal development. If multiple follicles are seen on ultrasound in adolescent women, the ovaries are defined as multi-follicular and not polycystic.

Although obesity is prevalent among women with PCOS and exacerbates the clinical manifestations of PCOS, it must be emphasised that obesity is not essential for the diagnosis of PCOS.

Polycystic ovary syndrome is a disorder of excessive androgen production, which is often aggravated by associated insulin resistance. Although insulin resistance is closely associated with obesity, it can also manifest clinically in lean patients. The prevalence of obesity among PCOS women ranges from 30% to 75%.

It is not known if PCOS causes weight gain or if being overweight leads to insulin resistance and this in turn leads to excess levels of androgens. It’s a chicken and egg scenario. It has been shown however, that the symptoms of PCOS such as menstrual irregularity, hirsutism and acne tend to worsen with weight gain. If lifestyle measures and combined hormonal contraceptive are not enough to help a PCOS patient get to a healthy weight then prescription weight loss medications are now available such as GLP-1 agonists (Ozempic, semaglutide) and Mounjaro (tirzepatide).

Hirsutism is very common, affecting 5% – 10% of all women. It refers to excess dark, thick hair in areas where women usually don’t have much hair (male pattern). Light hair (blonde or white) is not considered to be hirsutism. Many women feel distressed, anxious and depressed if they have hirsutism.

While in the general population, hirsutism affects around 4–11% of women, it is the main manifestation of hyperandrogenism in women with polycystic ovary syndrome (PCOS), with a prevalence estimated at 65–75%.

Hirsutism is generally associated with high androgen levels, but not always.  Sometimes women with PCOS may have clinical hirsutism, but normal androgen levels.  It may be that the androgen receptor on their hair follicles to androgens is more sensitive to androgens.

As well as high levels of androgens it is believed that insulin resistance in PCOS may contribute to the development of hirsutism.

An abnormal scale of hirsutism associated with ovulatory dysfunction or ovarian morphological findings is sufficient for the diagnosis of PCOS, after the exclusion of other conditions. The term idiopathic hirsutism should be applied only to hirsute women with normal ovulatory function and detectable normal androgen levels (testosterone, androstenedione, and DHEAS).  Some experts think that these women most likely have PCOS without all of the usual signs and symptoms.

For treatment of hirsutism is women with PCOS most women will be started on an oral contraceptive (birth control pill) and if they are not pleased with the improvement after six months, a second medication called an antiandrogen can be added. All birth control pills work about the same for hirsutism. Direct hair removal methods like electrolysis or laser removal are also very effective, but more than one treatment is required and it is expensive. Women should stay on their medication when they do laser to prevent the hair from growing back. Laser therapy works best for women with light skin and dark hair.

Women with PCOS suffer from acne long after their teenage years. PCOS isn’t just surface bumps, but rather tender knots under the skin which tend to be along the jawline, chin, cheeks, and neck.

Prescription antibiotics may help, but usually only whilst you are taking the antibiotic as the source of the problem is the hormone imbalance associated with PCOS, especially the raised androgens. Insulin resistance which is normally present in PCOS also contributes towards acne.

Usually the first course of action will be a combined oral contraceptive to balance hormones. If weight, acne and mood are symptoms you have then another type of medication which tends to help are GLP-1 agonists such as Ozempic.

Good skincare and prescription topical skincare such as tretinoin can be helpful, but the mainstays of therapy for PCOS driven acne are medical treatments to optimise your hormonal and metabolic functioning.

Combination birth control is a popular PCOS treatment. Whether it takes the form of the pill, ring, patch or another delivery method, birth control is a first-line treatment for PCOS patients who are not looking to get pregnant. Contraceptives help regulate menstrual cycles and alleviate acne.

Some patients may also choose to pursue treatment for hirsutism such as laser hair removal or electrolysis.

Many people with PCOS also struggle with insulin resistance.  A GLP-1 agonist (semaglutide) or combined GLP-1 and GIP agonist (tirzepatide) is sometimes prescribed to control insulin levels and stimulate ovulation. Because of the increased risk of insulin resistance, women with PCOS may be more likely to gain weight, especially around the midsection. Being overweight can exacerbate symptoms, so encouraging patients to follow a balanced diet and exercise regularly is just as important as medication for managing the condition. Please read our FAQ on lifestyle changes which help manage PCOS.

Women with PCOS often have trouble with ovulation, making it difficult to get pregnant spontaneously. Clomiphene citrate is a common hormonal medication used to stimulate ovulation in women with PCOS. Gonadotropins — injectable hormones commonly used during in vitro fertilisation — are another primary option for inducing ovulation.

We do not provide these treatments at our clinic, but we are happy to refer you to a specialised infertility clinic if you are having problems conceiving.

This is a common concern amongst women experiencing symptoms of PCOS or who have been diagnosed with PCOS and in some women problems with conceiving is how they discover they have the syndrome.

However, the outlook in terms of overall fertility are good and several studies have shown similar live birth rates to women without PCOS (Joham et al., 2014; Holton et al., 2018; Varanasi et al., 2018). This is due to understanding that controlling weight and insulin resistance improves fertility and also a high success rate with clomiphene and other technological advances in fertility medicine.

Some women may believe that they don’t need to be careful with contraception if they have PCOS, but this is not the case and women with PCOS need to take the same precautions as every other woman or they could end up with an unplanned pregancy.

Myo-inosital (MI) and D-chiro inosital (DCI) are sugar molecule supplements which can be taken daily to improve insulin sensitivity and are thus beneficial for conditions associated with insulin resistance such as PCOS.

PCOS patients tend to have a much higher level of DCI and very low levels of MI, leading to an abnormally low MI:DCI ratio of 0.2:1.7

Combined therapy with MI and DCI is more effective than taking either inosital alone. Specifically, research shows a 40:1 MI/DCI ratio is best for restarting ovulation in people with PCOS.

In a study by DiNicolantonio ‘Myo-inositol for insulin resistance, metabolic syndrome, polycystic ovary syndrome and gestational diabetes’ it was found that taking 1200 mg of D-chiro inositol daily for 8 weeks significantly lowered insulin and male hormone levels in obese PCOS patients, also regulating their periods. PCOS patients who weren’t overweight also benefited.

Myo-inositol and D-chiro inositol are the most beneficial types. They can improve egg quality — a critical factor for women trying to conceive. An increase in these types can result in better ovarian response and higher birth rates.

Foods high in myo-inositol include:

• Citrus fruits
• Brown rice
• Nuts
• Rockmelon
• Oats
• Beans
• Bananas
• Pears
• Peaches
• Wheat bran

As well as inosital supplements the following supplements are recommended:

Omega-3 fatty acids: these reduce inflammation and support metabolic health

Vitamin D and Magnesium: Helps balance hormones, reduce inflammation and improve insulin senstivity

Turmeric:

A healthy lifestyle with exercise, healthy nutritious foods and keeping well hydrated are very important in PCOS as it is a disorder characterised by insulin resistance. Consuming more high-fiber foods and lean protein, and limiting refined carbohydrates and sugary foods may be enough on its own to help reduce symptoms especially if your PCOS is mild.  A diet high is sugary, high carb foods means your body needs to produce more insulin and high insulin levels stimulate the ovaries and adrenals to produce androgens, which disrupts the menstrual cycle.

Insulin resistance creates a cycle of inflammation and weight gain. This is why addressing insulin is critical for managing PCOS and why diet and support from insulin lowering medication such as GLP-1 agonists have been found to improve symptoms so much.

Foods to limit

• foods high in refined carbohydrates, like white bread and muffins
• sugary snacks and drinks
• inflammatory foods, like processed and red meats

Foods to focus on:

• Lean proteins, healthy fats and high fiber vegetables to stabilise blood sugar
• Anti-inflammatory foods including omega-3 rich foods like fatty fish leafy green and berries to reduce inflammation

Exercise your body in a way that works for you:

• Incorporate strength training to improve insulin sensitivity and support weight management.
• If high-intensity workouts feel stressful, opt for low-impact exercises like walking, yoga or pilates which can reduce cortisol levels and support hormonal balance. Very high intensity exercise like HIIT workouts can actually raise cortisol.