PCOS and Insulin Resistance: Part 2 - What is PCOS

In my last blog post, Who am I? I alluded to the connection between PCOS and Insulin Resistance. In this post, I would like to define PCOS (Polycystic Ovary Syndrome).

According to the Mayo Clinic, PCOS is defined as: “…a common endocrine system disorder among women of reproductive age. Women with PCOS may have enlarged ovaries that contain small collections of fluid — called follicles — located in each ovary as seen during an ultrasound exam.

Infrequent or prolonged menstrual periods, excess hair growth, acne, and obesity can all occur in women with polycystic ovary syndrome. In adolescents, infrequent or absent menstruation may raise suspicion for the condition.

The exact cause of polycystic ovary syndrome is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications, such as type 2 diabetes and heart disease.”

The important words to note here are: syndrome, common, cause unknown, and type 2 diabetes.

"Syndrome" is defined as “a group of symptoms that together are characteristic of a specific disorder, disease, or the like”. Often in medicine when something is characterized as a “syndrome” it is also a “diagnosis by exclusion”. A diagnosis by exclusion, is defined as “a diagnosis made by excluding those diseases to which only some of the patient's

symptoms might belong, leaving one disease as the most likely diagnosis, although no definitive tests or findings

establish that diagnosis.” Again, according to the Mayo Clinic, “There's no specific test to definitively diagnose polycystic ovary syndrome. The diagnosis is one of exclusion …”. More on this later.

The other important word to dissect here is that PCOS is a common condition. Most of the medical literature states that 1 in 10 (10%) of women may have PCOS, but “these figures may be higher.”. I actually believe that as many of 1/3 (>30%) of women today have PCOS. Whatever the number, PCOS “is one of the most common endocrine disorders of reproductive-age women”.

Conventional medicine, as you can read above, states that the exact cause of PCOS is unknown. Convention says that insulin resistance is associated with PCOS, and that there may be many other complicated causes. Some epidemiological studies state that 40% of women with PCOS are insulin resistant, others state that “As many as 70% of PCOS women are insulin resistant…” and a few have even boldly stated that maybe ALL women with PCOS have insulin resistance or even that PCOS is CAUSED by insulin resistance. But, as I hope to show you, even if as little as 40% of women with PCOS have insulin resistance, those that do, have associated reproductive issues.

Although some features of PCOS had been recognized and noted since the time of “Hippocrates in the fifth century B.C … Until the 1980s, PCOS remained a poorly understood reproductive disorder … After a series of landmark studies in the 1980s … insulin resistance (was identified) as a cardinal feature of the syndrome”

As it is also illustrated below, “…women with PCOS are at increased risk for the spectrum of disorders associated with insulin resistance , including metabolic syndrome, endothelial dysfunction, nonalcoholic fatty liver disease , gestational diabetes , and pregnancy-induced hypertension .” That is a lot of stuff! And it is all related to insulin resistance.

Figure: Prevalence of different elements of metabolic syndrome in women with PCOS

As you can see from the figure above, there is a prevalence of different elements of Metabolic Syndrome (Obesity, Increased waist circumference, Increased blood pressure, High fasting glucose, Altered glucose tolerance, Reduced insulin sensitivity, High fasting insulin, Increased serum triglycerides and Low serum HDL-C) in women with PCOS. Of these, the most prevalent are Reduced insulin sensitivity (>60%) and High fasting insulin (>50%). This means that over 50% of women with PCOS have been found to have impaired insulin function/levels. Further, it has been found that “Affected women have marked insulin resistance, independent of obesity.” What this is saying is that even lean women with PCOS may have insulin resistance. Insulin signalling “… is important for ovulation and body weight regulation.”

It is important to note that not all women with PCOS are obese, and that not all obese women have PCOS. This becomes relevant when we look at the association between insulin resistance, PCOS and fertility. As noted above, proper insulin levels and function are key for ovulation. “The association between insulin resistance and PCOS has revealed that insulin is a reproductive as well as a metabolic hormone”. PCOS women with normal ovulatory cycles have been shown to have normal insulin sensitivity, regardless of weight. This is where Metformin comes in. As I mentioned in the last blog of this series, Metformin (a Diabetic drug) whose main function is to improve insulin sensitivity, is now part of the adjunct treatment of PCOS and infertility, since “hyperandrogenism and anovulation improve during metformin treatment”. This is the drug I took to help get pregnant with my second child!

Another important note here is that there are other conditions/syndromes of extreme insulin resistance where “Hyperandrogenemia (excess male hormones) and ovulatory disturbances are commonly encountered (even without the diagnosis or presence of PCOS)… This observation has led to the hypothesis that hyperinsulinemia causes hyperandrogenemia and anovulation …”.

Let me summarize this for you. PCOS is a very common endocrine (i.e. hormonal) condition. It affects MANY women! It frequently expresses itself with physical characteristics such as excess acne, hair growth, and obesity. Not fun (I speak from experience). Among its many physiological expressions, women with PCOS have an increased incidence of anovulation (infertility), diabetes, and heart disease. Very serious!