13: PCOS & Perimenopause with Dr. Sonia Hans
EP. 13
Polycystic Ovary Syndrome (PCOS) is more common than many realize, yet it’s so often misunderstood and misdiagnosed. Frequently called a "disease of exclusion," PCOS is commonly diagnosed only after ruling out other conditions, leaving women to suffer with symptoms like irregular periods, weight gain, acne, and fatigue for years. This delay can lead to serious complications such as obesity, type 2 diabetes, and cardiovascular disease.
Early diagnosis and treatment are crucial for managing symptoms and reducing long-term health risks. In this post, we explore the causes and symptoms of PCOS, its connection to metabolic syndrome, and how revolutionary treatments like GLP-1 medications are changing care. We’ll also look at how PCOS evolves through perimenopause and menopause and why ongoing management is key to lifelong health.
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What is PCOS?
Polycystic Ovary Syndrome (PCOS) is a condition that affects how the female reproductive system functions, particularly the regulation of hormones. At its core, PCOS is a disorder in the hormonal communication between the brain and ovaries. The pituitary gland in the brain sends signals to the ovaries, which in turn produce estrogen and regulate the menstrual cycle. However, in PCOS, there's a dysregulation of this process, leading to an imbalance between estrogen and testosterone.
This imbalance often results from underlying issues with glucose metabolism and fat regulation in the body, which stress the hormonal system. As a result, women with PCOS may experience irregular periods and a variety of other symptoms, such as excess hair growth and acne, due to elevated testosterone levels.
PCOS affects not only the menstrual cycle but also how the body processes insulin and metabolizes carbohydrates, further complicating the condition. The name "polycystic ovary syndrome" can also be misleading, as not all women with PCOS have cysts on their ovaries, which adds to the confusion around diagnosis and treatment. PCOS often doesn’t get diagnosed until a woman is trying to conceive, which is far too late for optimal intervention.
How is PCOS Diagnosed?
Diagnosing PCOS can be tricky, especially because its symptoms often overlap with other conditions. If a patient is suffering from irregular periods, the first step is to dig deeper. While it’s common for teenagers to have irregular cycles during puberty, a 19-year-old woman experiencing cycles every 6-12 weeks would be a red flag. Similarly, symptoms like abnormal weight gain, excessive facial or body hair, acne, and oily skin can signal hormonal imbalances linked to PCOS.
Excess testosterone plays a central role in PCOS, and it’s often elevated in both the ovaries and fat cells, especially for women struggling with obesity. This creates a vicious cycle where excess fat contributes to higher testosterone levels, worsening symptoms. However, it's important to note that not all women with PCOS will have cysts on their ovaries, and cysts alone aren't enough to confirm a diagnosis. The true diagnostic marker is an increase in testosterone levels—either total or free testosterone, depending on a person’s weight.
To better understand the severity of the condition, it's important to check both total and free testosterone levels, as well as sex hormone binding globulin. In cases of overweight or obesity, the total testosterone levels may appear normal due to higher levels of binding globulins, but the free testosterone may still be elevated, indicating a problem.
Ultimately, while the process can be complex, early diagnosis and treatment are crucial in managing PCOS and preventing long-term complications.
The Link Between PCOS and Metabolic Syndrome
PCOS and metabolic syndrome often go hand in hand, with both conditions contributing to each other. Metabolic syndrome involves a group of risk factors like high blood pressure, high blood sugar, excess fat around the waist, and abnormal cholesterol levels, which together increase the risk of heart disease, stroke, and type 2 diabetes. Women with PCOS are at a higher lifetime risk of developing metabolic syndrome due to hormonal imbalances, particularly excess testosterone, and the impact on fat storage in the body.
There are an increasing number of cases where women who were previously thin or of normal weight start gaining weight rapidly after puberty, which can trigger PCOS symptoms like irregular periods and difficulty losing weight. This combination of weight gain and hormonal imbalance is becoming more common, especially as obesity rates rise among teens.
The relationship between PCOS and metabolic syndrome is cyclical: Managing one condition can help control the other. For example, tightly managing PCOS in younger women might prevent the development of weight issues later on. Addressing both conditions early can improve long-term outcomes and reduce the risk of more severe health complications down the line.
Treatments for PCOS and Metabolic Syndrome
The treatment of PCOS and metabolic syndrome requires a tailored approach based on the patient's unique needs and goals. Whether the focus is on controlling symptoms, achieving weight loss, or planning for pregnancy, a combination of lifestyle changes and medical interventions offers the best chance for long-term success.
Lifestyle changes, such as focusing on a low-carbohydrate, high-protein diet, are important because many women with PCOS experience insulin resistance. This is similar to pre-diabetes and can contribute to weight gain and difficulty losing weight. Exercise is equally crucial—not only does it support weight loss, but it also improves glucose metabolism and reduces inflammation, which is common in women with PCOS. Lastly, wellness factors such as emotional well-being, stress management, and adequate sleep are vital for helping the body cope with chronic conditions and promoting overall health.
Medical treatment paths vary depending on the patient’s goals but there are often two main approaches:
For Patients Not Focused on Pregnancy:
Birth Control Pills: Help regulate periods and reduce excessive testosterone production.
Spironolactone: A medication that blocks testosterone receptors, useful for treating symptoms like facial hair, acne, and oily skin.
Insulin Sensitizers: Medications like Metformin or the supplement Inositol can help improve insulin sensitivity, reducing the risk of metabolic syndrome.
Finasteride: For more severe cases, such as excessive hair growth or acne, finasteride can help block testosterone effects.
For Patients Trying to Get Pregnant:
No Birth Control: Avoid birth control if pregnancy is a goal.
Insulin Sensitizers: These remain key in improving glucose metabolism and insulin resistance.
No Spironolactone: This medication is contraindicated during pregnancy.
GLP-1 Receptor Agonists: These medications, like Ozempic and Wegovy, are showing promise not only for weight loss but also for improving glucose metabolism and sensitivity. They help reduce inflammation and can support overall metabolic health, even in PCOS.
GLP-1 receptor agonists (such as Ozempic and Wegovy) are one of the most exciting advances in PCOS treatment. These medications are primarily used for diabetes and weight loss but are also showing promise in improving insulin resistance and metabolic disease in PCOS patients. There is growing evidence of their potential to block inflammation and regulate hormones, which could revolutionize PCOS treatment.
PCOS and Perimenopause
PCOS often starts in younger women, but its impact continues into perimenopause. As women enter this phase, hormonal changes can amplify the existing challenges of PCOS, including weight gain, irregular periods, and insulin resistance. In perimenopausal women, these issues often escalate, particularly in those who are struggling with weight management and metabolic shifts.
Many of these women may not have been properly diagnosed or treated earlier, so by the time they reach their 40s, they are experiencing more pronounced metabolic changes. Their body composition tends to shift, with muscle mass declining and fat increasing, especially visceral fat (belly fat), which is strongly linked to metabolic diseases like insulin resistance, diabetes, and fatty liver disease.
GLP-1 receptor agonists, which help regulate metabolism, reduce body fat, and improve insulin sensitivity, are becoming effective treatment strategies. These medications have shown remarkable results in improving menstrual cycles, and in some cases, have led to unexpected pregnancies!
Monitoring body fat percentage, particularly visceral fat, is key, as well as taking proactive steps to manage weight and metabolic health as women with PCOS enter perimenopause. The earlier we address these issues, the better the long-term outcomes for both overall health and fertility.