Polycystic Ovarian Syndrome - What it Is and What it Means for You
A common endocrine problem with implications for health and performance
Polycystic Ovarian Syndrome (PCOS) is a very common cause of abnormal menstruation. It can become apparent as early as puberty and is characterized by irregular or absent menstrual cycles often accompanied by coarse midline hair growth on the face, chest, abdomen, and buttocks resulting from excess production of androgens (“Male” hormones) from the ovaries and adrenal glands. It is also often associated with insulin resistance and an increased risk of developing the metabolic syndrome (High blood pressure, high cholesterol, and diabetes).
According to the World Health Organization (WHO) PCOS affects an estimated 8-13% of reproductive-age women with 70% of affected women going undiagnosed worldwide. It is the most common cause of ovulatory dysfunction and is a leading cause of infertility.
This condition exists on a broad spectrum of severity and demographics. PCOS can be mild with minimal to no excess hair growth and slightly longer menstrual cycles, or it can be more severe, where menses are completely absent, and with facial hair growth that requires shaving or other modes of mechanical removal. Women with PCOS can be obese or they can be lean. They may have small cysts or other characteristic findings on ovarian ultrasound examination or they may have completely normal-appearing ovaries. This broad range of presentations has posed a challenge for the medical community in agreeing on the criteria for diagnosis.
Today’s post will focus on the “essentials” for understanding this condition and review the implications for overall health and athletic performance.
What Causes PCOS?
The symptoms and physical findings seen with PCOS result from an over-production of androgens by the ovaries and the adrenal glands. Laboratory testing will often show elevated testosterone and/or dehydroepiandrosterone sulfate (DHEAS) levels, and elevated fasting insulin and blood sugar levels, but many times this testing will be normal.
The cause-effect relationship between hormonal aberrations that cause disruption of the menstrual cycles and overproduction of androgens and the physical findings of obesity, leanness, insulin resistance, and metabolic syndrome remains elusive and contributes to the challenge of diagnosing and treating this condition.
How is PCOS Diagnosed?
When a female reports a change in her menstrual pattern or loss of menstrual cycles, the first step is to exclude other causes such as thyroid dysfunction, hyperprolactinemia, premature or perimenopause, and fueling/training imbalances, to name a few.
If you are a recreationally or elite athletic female, the first and most critical step is the assessment of low energy availability (LEA) and relative energy deficiency in sport (REDs) as a cause of irregular or absent menstrual cycles. Truth be told, most mainstream OBGYNs and Primary Care providers are not familiar with these conditions, yet, it is a problem that can range between 20%-70% of competitive female athletes across various sports. It is thus critical to involve coaches, trainers, and nutrition specialists when active and athletic women experience menstrual cycle irregularity.
The Rotterdam Criteria is the most widely used diagnostic guideline for PCOS. The criteria for the diagnosis of PCOS include TWO out of three of the following:
Irregular menstrual cycles - loosely defined as cycles <21 or >35 days for at least three consecutive months.
Clinical or laboratory evidence of hyperandrogenism (elevated male hormone levels) - this can include coarse midline hair growth (face, chest, buttocks), and/or elevated serum testosterone, or adrenal androgens such as DHEAS.
Ultrasonographic findings of ≥ 12 follicles measuring 2‐9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary. This also has been referred to as the “String of pearls” configuration of small follicles within the periphery of the ovaries.
Several other findings are often associated with PCOS that are not part of these criteria for diagnosis including, insulin resistance, elevated serum Luteinizing Hormone (LH) to Follicle stimulating hormone (FSH) ratio on day 3 of the menstrual cycle, and elevated serum anti-mullerian hormone (AMH) levels. Hyperprolactinemia can also be seen in women with PCOS physiology.
Lastly, a rare condition called non-classic congenital adrenal hyperplasia often presents with symptoms nearly identical to PCOS, but is caused by a genetic mutation in genes involved in the steroid hormone metabolic pathway resulting in excessive accumulation of androgens. It is important to identify this condition as it may have implications for pregnancy and the health of the unborn child.
Clinical Implications of PCOS
Prolonged abnormal menstruation has implications for suboptimal bone density, endometrial hyperplasia (overgrowth of the cells of the lining of the uterus), and infertility.
Obese women with PCOS have an increased risk of developing metabolic syndrome. The data are mixed regarding whether lean women with PCOS are also at increased risk, however, consensus favors an increased risk of insulin resistance and lipid abnormalities, but to a lesser extent than the obese population.
Implications for Athletic Performance
There is not a lot of study on athletic performance in females with PCOS, however, the data that is available is mixed. Some studies suggest impairment of cardiorespiratory performance in females with PCOS as compared to females without PCOS while other studies suggest greater athletic performance due to higher circulating testosterone levels, particularly in strength-based sports. These studies, along with our clinical knowledge of PCOS raise several questions relevant to female athletes.
1 - How do we optimize fueling in female athletes with PCOS? If women with PCOS experience a predisposition toward insulin resistance, how does this influence recommended carbohydrate intake? Are fatty acids a more favorable fuel source?
2 - Energy Balance. LEA and REDs are common problems that athletes face across the spectrum of competitive sports. According to the 2023 IOC Consensus Statement on REDs, deficient carbohydrate intake is a major culprit in developing LEA and subsequently REDs. The question arises as to how we best keep our insulin-resistant female athletes in energy balance given the potential differences in carbohydrate processing compared to athletes without PCOS.
The answers to these questions are not straightforward as there is a wide spectrum of degrees of insulin resistance (if any) in these athletes, differences in the types of sports that these athletes engage in, and body type (ectomorph, endomorph, mesomorph). I am told by Dr. Stacy Sims (world-renowned expert in nutrition science and exercise physiology and expert on sex differences in athletes) that she is writing a blog post on this very topic. So we should all stay tuned to learn more about the nutrition science and exercise physiology behind this condition in female athletes from Dr. Sims.
Management of PCOS
PCOS has a broad range of severity, physiologic features, and physical demographics. Some women have more profound elevations in serum androgens. Others have notable insulin resistance. Some women with PCOS have neither of these issues and struggle only with irregular menstrual cycles and infertility. Some women are lean. Many are obese. This necessitates an individualized approach to the management of this condition.
Lifestyle management - In women with PCOS who struggle with insulin resistance and obesity, nutrition management and physical exercise are the foundation for improving symptomatology and reducing the risk and impact of the metabolic syndrome. Implementing a nutrition program focused on low-glycemic carbohydrates and an increase in physical activity can result in weight loss and improve insulin sensitivity leading to more regular menstrual cycles and a lower risk of metabolic syndrome. Lean women with PCOS can also struggle with insulin resistance and lipid abnormalities which may benefit from fitness and nutrition consultation.
Oral contraceptive pills (OCPs) - The need for the exclusion of other medical causes and ensuring that active women are adequately fueled cannot be overstated. Optimization of fitness and nutrition are essential first steps in managing PCOS. However, optimizing fueling balance, nutrition, and fitness alone may not resolve menstrual cycle regularity or the metabolic effects of this condition. For women who are not interested in conceiving, OCPs can be beneficial for providing cyclic estrogen and progestin exposure for bone and endometrial health and creating more predictable bleeding patterns for convenience. The use of OCPs also can reduce hair growth and acne due to the increase in sex hormone-binding globulin production in the liver.
Insulin-sensitizing agents - Metformin (a.k.a glucophage, Axpinet, Diagemet, Glucient, Metabet) is a medication used to treat type 2 diabetes and has decades of safety and efficacy data supporting its use in the treatment of PCOS. The use of insulin-sensitizing agents like Metformin can result in more regular menstrual cycles, improvement in blood sugar levels weight loss, and improved fertility.
Inositol - Inositols belong to the vitamin B complex group and are considered insulin sensitizers. They have a positive impact on menstrual cycle regularity, carbohydrate metabolism, and hyperandrogenism. There are several types of inositols. Myoinositol is the most commonly used and is taken as a dietary supplement. A recent review and meta-analysis of randomized controlled trials showed that inositols were effective in treating symptoms associated with PCOS and showed non-inferiority to Metformin, which is considered the gold standard of treatment.
Female endocrine health is sometimes a complicated landscape to navigate during the normal changes associated with different phases of hormonal life and during times when imbalances in hormone health exist. What is critical regardless of the circumstance is the need for a multi-disciplinary approach to care for athletic women from the avid recreational to the elite professional. Engaging trainers, coaches, nutritionists, and endocrine specialists brings together the needed expertise for optimizing health and athletic performance as women navigate the hills and valleys of their hormonal lifespan.
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Over nearly two decades of medical practice, I am perplexed and disheartened by how mainstream medicine often overlooks the very foundation of good health: nutrition, physical fitness, and mental well-being.
Women of all ages experiencing changing menstrual cycles, fatigue, and even bone fractures are often handed a prescription and sent on their way with not a single question about their training and nutrient intake. Midlife women experiencing menopausal symptoms are met with the mere “you’re getting older” without exploring simple nutrition and movement strategies that could significantly improve their well-being.
Well, help is on the way! Starting in November 2024, I will be launching a women’s specialty telehealth medical practice serving the reproductive endocrine needs of active and high-performing women from puberty through menopause.
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