PCOS and Insulin Resistance: Part 4.3 PCOS Signs and Symptoms

Below I will list the most common signs and symptoms of PCOS presented to clinicians and their prevalence in women with PCOS. As noted before, PCOS is the most common endocrine (hormonal) condition of women of reproductive age, presenting with metabolic and reproductive concerns. Also noted, is the importance of establishing the proper diagnostic protocol to determine who and how many women are afflicted by PCOS, and thereafter the appropriate treatment plan.

In PCOS, “..as many as 85% of women with PCOS have clinical evidence of menstrual irregularities”. Menstrual irregularities include amenorrhea, oligomenorrhea, anovulation and oligo-ovulation. Amenorrhea is defined as the absence of menstruation. “Women who have missed at least three menstrual periods in a row have amenorrhea, as do girls who haven't begun menstruation by age 15.” Oligomenorrhea, on the other hand, is defined as irregular or infrequent menstrual cycles. Although, some variation in menstruation is normal, a cycle longer than 35 days is considered oligomenorrheic. “Periods usually occur every 21 to 35 days.” The diagnosis changes to amenorrhea after more than 90 days without a period. The same goes for the definition of oligo-ovulation vs. anovulation, whereas the former defines an irregular ovulatory cycle and the later the absence of one.

Obesity is one of the most common presenting complaints of women who eventually become diagnosed with PCOS. Figure 1 below demonstrates that the obesity prevalence in women with PCOS is about 25%, whereas central obesity, aka Increased waist circumference, is prevalent in almost 40% of the cases. According to other sources, the prevalence of obesity is recorded as being much higher, at 50 to 80% of all PCOS women. The former, fifty percent, outside the USA and the later, eighty percent, within the United States, alluding to the theory that genes and environmental factors such as lifestyle (diet, exercise, etc) will “… contribute to the presence of obesity in PCOS.” The PCOS Obese phenotype is considered a more “advanced” type with higher metabolic and reproductive implications, and one that responds more poorly to treatment. This theory, “…if true would inform both the treatment and the prevention of the disorder (i.e., treat PCOS with weight loss, and prevent it by trying to keeping adolescents and young adults at a normal weight).” Even though it is not thought that obesity, per se, causes PCOS, the presence of it complicates the syndrome and so its treatment and prevention should be of utmost importance.

Figure 1 Prevalence of different elements of metabolic syndrome in women with PCOS

The other metabolic elements graphed above in Figure 1, are not necessarily signs and symptoms that women initially complain of, or present with, as most of these are largely asymptomatic, but rather those that are most often revealed during the diagnostic investigation of PCOS. In addition to these, Fatty Liver (NASH) is another expression of metabolic syndrome prevalent in PCOS. The most prevalent of them all is reduced insulin sensitivity, aka Insulin Resistance, here illustrated as over 60% of the time, many sources quoting it to be as high as 70%. In another post I indicated the challenges in testing for hyperinsulinemia and insulin sensitivity which undermine the determination of its prevalence.

Figure 2 Physical signs of PCOS

“Approximately 60% of women with PCOS are hirsute, the most common clinical sign of hyperandrogenemia (high levels of male hormones).” Hirsutism presents with excessive hair growth usually on the face, chest, back and buttocks. Acne presents in both adolescents and adults. Androgenic Alopecia, aka male-pattern hair loss, presents as thinning hair or hair loss from scalp. “Acanthosis nigricans is a skin lesion characterized clinically by velvety, papillomatous, brownish-black, hyperkeratotic plaques, typically on the intertriginous surfaces (body folds) and neck.” Interesting to note is that acanthosis nigricans (Figure 3) appears in other insulin resistant conditions, which must be ruled out, and “Its severity is directly correlated with the degree of insulin resistance”.

Figure 3 Acanthosis Nigricans

The signs and symptoms above are the most common physical expressions of the condition and those most often brought forward. Understandably so, these afflictions have a physical and mental-emotional impact on these women. It did for me. Depression and anxiety is a common complaint, in the general population, but “The prevalence of depression and anxiety is higher in women with PCOS than in the general population.” This is a classic, “what comes first: the chicken or the egg?”. The reality is that these “mood disorders, capable of impairing quality of life, can be prominent in adolescents faced with issues of self-presentation”, these physical alterations (obesity, acne, facial hair, dark skin folds) can seriously affect an already debilitated emotional condition and self-esteem. Undoubtedly, the struggle with infertility, causing a further dent. Later, the impending doom of metabolic syndrome: obesity, diabetes, fatty liver, hypertension, dyslipidemia, cancer…and maybe then, and often, the incapacitating side effects of the cocktail of meds to manage these seemingly distinct conditions.

PCOS (Polycystic Ovary Syndrome) is this “group of symptoms that together are characteristic of (this) specific disorder”. As with other syndromes, “a diagnosis (is) made by excluding those diseases to which only some of the patient's

symptoms might belong, leaving one disease as the most likely diagnosis”. This means that for a physician to diagnose a woman with PCOS, he/she must first exclude other conditions that mimic PCOS. This is called Differential Diagnosis.

References:

http://www.dictionary.com/browse/syndrome

http://medical-dictionary.thefreedictionary.com/diagnosis+by+exclusion

http://www.mayoclinic.org/diseases-conditions/pcos/basics/tests-diagnosis/con-20028841

http://press.endocrine.org/doi/10.1210/er.2015-1018

https://www.medicinenet.com/script/main/art.asp?articlekey=2991

http://www.eje-online.org/content/154/1/141.full.pdf+html

http://press.endocrine.org/doi/10.1210/er.2015-1018

https://www.mayoclinic.org/diseases-conditions/amenorrhea/symptoms-causes/syc-20369299

https://www.healthline.com/health/oligomenorrhea

https://www.ncbi.nlm.nih.gov/pubmed/20843954

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393155/