Polycystic Ovarian Syndrome (PCOS)

What is it?

Polycystic ovarian syndrome (PCOS) is a common condition affecting roughly 50% of women in their reproductive years. PCOS is an endocrine disorder primarily affecting ovulation, leading to the overproduction of underdeveloped ovarian follicles. In some women with PCOS these follicles are unable to produce an egg (oocyte) and remain in the ovaries as larger fluid filled sacks (which look like cysts with medical imagery). PCOS is one of the leading causes of infertility in woman worldwide and can also increase the risk of cardiovascular disease, type 2 diabetes, and other metabolic disorders.

Not all women will have symptoms in the early stages, which can make PCOS quite a challenge to diagnose. Those that do have symptoms may experience 1 or more of the following:

• Heavy/irregular/missing menstrual periods
• Hirsutism (facial hair growth)
• Acne (particularly around the jaw line)
• Oiler skin
• Scalp hair loss/hair thinning
• Weight gain
• Headaches
• Mood swings
• Dark patches (mostly in skin folds)

What causes it?

It is not clearly understood what causes the onset of PCOS, studies have shown genetics may play a role as women with PCOS often report having a mother or a sister with the same condition. There are several lifestyle and environmental factors which can also drive this condition, such as diet, obesity, digestive issues, stress, and lack of sleep.

Some women can develop PCOS symptoms after stopping the contraceptive pill, known as Post-pill/Pill induced PCOS. This is a temporary issue caused by a rise in testosterone levels resulting from coming off the pill. This is not considered a true form of PCOS.

So, what is happening on the inside to drive PCOS?

Different types of PCOS have been identified over recent years, and the underlying factors associated with the development of this condition can be different from one woman to another.

A smaller percentage of women (10%) may suffer from an adrenal type of PCOS, which is usually caused by an abnormal response to stress. This can be identified by raised blood DHEAs (Dehydroepiandrosterone sulphate) levels, with androgen levels often in the normal range.

For most women, the associated factors involved in the typical pathogenesis of PCOS are:

Insulin resistance

Insulin resistance occurs when cells cannot use insulin properly to metabolise glucose. When cells become resistant to insulin, the pancreas will respond by producing more insulin. The effects of this issue are raised blood glucose, which the body will convert to fat cells. Sustained high levels of insulin results in a condition called hyperinsulinemia (see below).

Hyperinsulinemia (increased insulin levels)

High levels of insulin can cause a number of issues:

• Reduce sex hormone binding globulin (SHBG) levels – This is a protein produced by the liver which binds with androgens (male hormones) in the blood. SHBG has a high affinity for testosterone, so lower levels of this protein can lead to an increase the amount of unbound (biologically active) testosterone in the blood stream.
• Increased visceral fat – Visceral fat is the worse type of fat you can have (the fat you cannot see). It forms around vital organs in the abdomen and sometimes in blood vessels. The presence of visceral fat can worsen insulin resistance, compounding the PCOS issue.
• Ovaries produce more testosterone – Ovaries will produce some testosterone in normal circumstances (its needed for sexual development/function and bone health), but high levels of insulin will cause the ovaries to kick out a lot more testosterone than they should. This can affect ovulation and disrupt the menstrual cycle.

Hyperandrogenaemia (elevated androgens)

As mentioned above, elevated androgens (testosterone namely) is a common feature of polycystic ovarian syndrome. Higher levels of testosterone can prevent normal ovulation and cause irregular menstrual periods or amenorrhea (absent periods). Symptoms of elevated androgens in women can include hirsutism (excess facial hair), acne, mood swings, increased sebum (oil) production, and hair loss/thinning. Elevated androgens may also contribute to insulin resistance in women with PCOS, creating somewhat of an endless cycle.

Inflammation

Many factors can drive systemic inflammation:

• Insulin resistance
• Hyperinsulinemia
• Obesity
• Hormonal imbalance
• Gut dysbiosis (reduced levels of good bacteria in the gut)
• High blood pressure
• Hyperlipidaemia (elevated blood lipid levels)
• Lack of sleep
• Stress
• Some medications

And that’s just the tip of the iceberg!

Inflammation will lead to oxidative stress and increase the number of reactive oxygen species (ROS). ROS can affect mitochondrial function, leading to poor cellular respiration and ATP production (cells energy source). Lower ATP production will affect cellular metabolism and function, potentially causing further weight gain, effectively adding to the PCOS problem.

Hair loss and PCOS

Elevated androgens are usually the driving force for hair loss in women with PCOS and are also responsible for any increased facial hair and acne! The main type of hair loss associated with PCOS is called androgenetic alopecia. The hair loss may start with an increased shedding (beyond what is normal for you), followed by some thinning in the upper regions of the scalp. The central parting may appear wider and the scalp may seem more visible. Some women may also notice some thinning in the crown, recession areas and frontal hair line, although this is less common. Hair loss is typically diffuse in nature (as opposed to the balding seen with male pattern hair loss), although in very rare occasions women may present with a male type of pattern. Hair to the back and sides is usually unaffected.

Thankfully not all women with PCOS will experience hair loss!

Those who do suffer with androgenetic alopecia in PCOS are genetically predisposed with a sensitivity to circulating androgens. Local circulating testosterone binds with receptors of hair follicles which is then metabolised by an enzyme (5-alpha reductase) into a more potent androgen called dihydrotestosterone (DHT). It is believed DHT negatively affects the hair follicles vascular supply of energy and nutrients, as well as a shortening of the growth phase of the hair cycle. This leads to a process called miniaturisation, where the hairs become progressively thinner and shorter with each passing cycle.

Some women may also experience a temporary disruption to the hair cycle, causing an increase in hair shedding throughout the scalp. This is called Telogen Effluvium, and maybe the result of hormonal imbalance, systemic stress, or another underlying health issue.

Can the hair loss be treated?

This type of hair loss cannot be reversed or cured, but there are some medications which can slow the progression of hair loss quite successfully, and in many cases improve density. Some medications used to treat PCOS may also help. Speak to a registered Trichologist or dermatologist who can work with your GP to find you the most appropriate treatment routes to tackle your hair loss.

Low level laser light therapy (LLLT) may also be a beneficial treatment for this type of hair loss, especially when used in conjunction with other medical treatments. LLLT uses laser light at a particular frequency to stimulate cellular energy within the hair follicle. LLLT devices come in many shapes and sizes, from helmets and caps to bands and combs, and cost will vary depending on the type of device.

Hair loss can be a complex issue, and there are often numerous factors contributing to the problem. Blood tests should be carried out as part of a routine investigation, to rule out other common causes of hair loss. Hypothyroidism (as an example) is increasingly diagnosed in women with PCOS, and both share similar characteristics. It is recommended that thyroid function is tested when PCOS is suspected/diagnosed.

Can PCOS be treated?

There is currently no cure for Polycystic ovarian syndrome, but actively taking the following steps can help to improve health and the symptoms associated with PCOS:

• Be more active – this does not mean throwing yourself from the couch into HIIT! If you are not particularly active right now, go for a brisk walk or up your steps. Increase activity gradually, as doing too much too soon will only increase stress levels. Aside from that, getting more exercise can only be a good thing.
• Maintaining a healthy weight – Although there are many factors contributing to weight gain with PCOS, trying to reduce excess weight will also help to reduce androgen production and insulin resistance. A weight loss of just 5% can lead to a significant improvement in symptoms.
• Improve sleep – are you getting enough restful sleep? Inadequate sleep increases stress levels and will make the fight against PCOS much harder. So, look at ways to effectively improve your sleep. If you are exercising more this is a good start! Other things you can do include, reducing exposure to blue light and avoiding heavy meals and caffeine a good few hours before bedtime.
• Manage Stress – Yoga, meditation, mindfulness, exercise, talk to a friend, laugh a little, sing a song in the bath…… whatever works for you!
• Diet – Increasing your intake of high fibre foods can help slow the uptake of glucose, helping to combat insulin resistance. Make sure to also include lean protein, and healthy fats (omega 3). Phytoestrogens can also help to regulate hormone levels, and increase SHBG, found in flaxseed, soy, chickpeas, tofu, hummus, and garlic. Try to reduce starchy carbohydrates (1-2 portions a day), as well as processed/convenience food, and sugar.
• Avoid endocrine disruptors – Endocrine disrupting chemicals such as Bisphenol A (BPA) and phthalates are used widely in food packaging and personal care products to protect the contents from physical, chemical, and microbiological contamination. Unfortunately, these chemicals may also migrate into our food and cosmetics, which can disrupt normal hormonal function. For many of us this may not cause any major issues, but for anyone who has an existing endocrine disorder it is worth keeping an eye on. Where possible minimise packaging with food, and carefully consider your cosmetic choices.

Conventional treatments to help manage PCOS include:

• Anti-androgens
• Oral contraceptives (some oral contraceptives can worsen hair loss, so it is important to speak with your Trichologist/Dermatologist to ensure you are using a ‘hair friendly’ option)
• Metformin
• Clomiphene

Are there any supplements that could help?

I am not an advocate of taking supplements without first establishing if you are deficient/low in anything. Taking a supplement when you do not need it can do a lot more harm than good, so ask your trichologist or GP to run an appropriate set of blood tests to rule out any underlying issues or deficiencies. The same goes for any natural/herbal treatments, they very rarely come with the scientific evidence to back up their super medicinal powers, and when you read a little deeper the safety of these products are typically not well researched either, so please check with your GP before taking anything new. With that in mind, there are several supplements which may help with PCOS symptoms:

• Vitamin D – It is now advised by most GPs that taking vitamin D during the winter months (Oct – March) could help prevent against deficiency and support the immune system. Low levels of vitamin D have been found to worsen insulin resistance in some cases. Vitamin D is also anti-inflammatory.
• Myo-inositol – has been shown to help to regulate glucose levels and increase insulin sensitivity.
• Cinnamon – May help to increase insulin sensitivity by improving intracellular signalling. Cinnamon has also been found to help regulate the menstrual cycle.
• Omega 3 fatty acids – known for reducing inflammation as an anti-inflammatory. Omega 3 also helps to improve lipid levels reducing the risk of cardiovascular disease and type 2 diabetes. Some studies have also shown omega 3 to help reduce androgen levels and regulate the menstrual cycle.
• Alpha Lipoic acid (ALA) – ALA is widely used by PCOS sufferers and may help to improve vascular function and increase insulin sensitivity. ALA is also used as an anti-inflammatory.

There are many other documented supplements and food extracts to help with PCOS, however following a healthy balanced diet will ensure an adequate intake of nutrients such as B vitamins, vitamin C, and magnesium.

Again, it is important to let your doctor know before choosing to start any supplements.