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ABDOMINAL PAIN

PCOS: Symptoms, Treatment and Diagnosis

Symptom Guides > Abdominal Pain > PCOS: Symptoms, Treatment and Diagnosis

by

Dr. Edo Paz

Edo Paz is VP Medical and Lead Physician at K Health. Dr. Paz has two degrees in chemistry from Harvard and an MD from Columbia University. He did his medical training in internal medicine and cardiology at New York-Presbyterian. In addition to his work at K Health, Dr. Paz is a cardiologist at Heartbeat Health, a cardiology practice located in New York City.

Concerned you might have PCOS?

Use the K Health app to understand your symptoms.

Polycystic ovary syndrome – often abbreviated to PCOS – is a common female health complaint that affects around 10 million women worldwide. While the exact cause of PCOS is unknown, genetics and environmental factors appear to play a part.

 

You may suspect you have PCOS if you have irregular (or non-existent) menstrual periods, are finding it difficult to get pregnant, are overweight and struggling to lose weight, or have excess facial or body hair. These symptoms are caused by an imbalance of hormones, which is characteristic of PCOS.

 

Fortunately, there are many things you can do to relieve both the symptoms and side-effects of PCOS, as you will learn in this article.

 

Read on to find out about: 

• What Is PCOS
• PCOS Diagnosis
• Signs of PCOS
• Conditions Associated with PCOS
• When to Seek Medical Care for PCOS
• How K Health Can Help
• PCOS Treatments
• PCOS Weight Loss
• What You Can Do at Home
• PCOS and Pregnancy (Can I get pregnant if I have PCOS?)
• Medications for PCOS

What Is PCOS

Despite the condition's name, not all women suffering from PCOS develop cysts (small fluid-filled sacs) on their ovaries, however this can be a feature for some women. While symptoms such as weight gain, irregular periods and infertility are the most noticeable and unpleasant features of PCOS, these are just external manifestations of the underlying causes.

 

Here is a run-down of what is actually going on “behind the scenes:”

 

Excess Androgen - Androgens are sometimes referred to as “male hormones” however all females also produce androgens in their ovaries and adrenal glands. PCOS sufferers have higher levels of androgens than the rest of the female population, which causes symptoms such as acne, excess facial and body hair, thinning scalp hair, and irregular periods.

 

High Insulin - The function of insulin, a hormone produced in the pancreas, is to drive glucose from the bloodstream into the muscle cells where it is used to provide the body with energy. PCOS sufferers are less responsive to insulin, which results in elevated blood glucose levels and triggers their body to make more insulin. In turn, the elevated insulin causes the body to release even more androgens, and a vicious cycle begins.

 

Low Progesterone - PCOS sufferers have lowered levels of progesterone—a hormone released by the corpus luteum in the ovaries. Progesterone plays an important role in the menstrual cycle and in maintaining the early stages of pregnancy. Low levels of progesterone lead to irregular periods and explains why many women with PCOS have difficulty becoming pregnant.

 

Low-Grade Inflammation - Research has shown that women with PCOS show low-grade inflammation. This means they have a slightly higher than average level of immune-system markers (substances that the body produces when fighting off infection, virus or toxin) in their blood or tissue. Inflammatory markers can stimulate polycystic ovaries to produce androgens which leads to an increased risk for heart and blood vessel problems.

 

Genetic Factors - Scientists think that certain inherited genes might be linked to PCOS. Studies focusing on the genetics of PCOS are still in the early stages, but are focusing on genes that influence androgen receptors and insulin action and excretion, amongst others.

PCOS Diagnosis

There is currently no single test to diagnose PCOS, however your doctor may order several different tests to help make a definitive PCOS diagnosis. They will likely begin by taking a detailed medical history, asking you about symptoms such as irregular or skipped periods, weight changes, hair changes, and acne.

 

Your doctor may also order a series of lab tests to look at your fasting blood glucose levels, triglyceride, cholesterol and androgen levels, and might refer you for an ovarian ultrasound to evaluate the condition of your ovaries.

 

In order to exclude the possibility that another condition is causing your symptoms, your doctor may order tests to look at pituitary, thyroid and adrenal function. You may also be referred to a hormone specialist or endocrinologist who can perform these additional tests. In very rare cases, if a tumor is suspected, further investigation for this will also be performed.

Signs of PCOS

The signs and symptoms of PCOS often develop after the onset of the first menstrual period at puberty. For some women, PCOS develops later in life and can be triggered by substantial weight gain. The following list of signs and symptoms can help you determine whether you have PCOS, and whether you want to consult further with a medical professional:

 

Irregular Periods / Menstrual Irregularities - If you have PCOS, you may experience no menstrual periods (amenorrhea), frequently missed periods (oligomenorrhea), very heavy periods, or bleeding but no ovulation (anovulatory periods).

 

Difficulty Getting Pregnant / Infertility - Many PCOS sufferers have difficulty getting pregnant. This is because they may not ovulate at all, or ovulate infrequently, which makes for irregular or absent periods and difficulty in becoming pregnant.

 

Hirsutism/ Scalp-Hair Loss - Hirsutism is a condition where excess hair grows on the face, chest, belly, or upper thighs. Younger PCOS sufferers often notice early (pre-pubertal) male-pattern hair growth affecting facial and body areas dependent on androgens—namely mustache and beard, pubic hair, buttocks, and thighs. You may also notice a loss of hair on your scalp resulting from the hormonal imbalance and excess androgen.

 

Acne - Severe or persistently oily skin and acne, which does not respond well to standard treatments.

 

Weight Gain - Up to 65% of PCOS women have an abnormal body mass index. You may be overweight, obese or have excess of abdominal fat. You may also find it extremely difficult to lose weight, even when trying to diet.

 

Prediabetes – People with PCOS have a higher than average chance of getting prediabetes, a condition where your blood sugar level is higher than normal (detected by a blood test) but not yet high enough to be considered type 2 diabetes. Without lifestyle changes (and sometimes, medications), prediabetes will often progress to type 2 diabetes.

 

Pelvic Pain or Discomfort - Lower back pain, sacral pain (the sacrum is the triangle-shaped bone near the bottom of your spine. This is felt as pain in the lower back or butttocks), and lower-quadrant abdominal pain alongside your other PCOS symptoms.

 

Acanthosis Nigricans - These are patches of darkened skin, especially in skin-folds and on the back of your neck, under your arms, on your inner thighs, under your breasts, between your fingers, and in your groin area. These patches may also be thickened and have a soft, velvety texture.

 

Skin Tags - Alongside the darkened skin patches, you may also find a number of skin tags. Doctors are not sure why this happens, but it is a very common symptom of PCOS and not a cause for alarm.

 

NOTE: PCOS symptoms may be that much more severe if you are also obese. For that reason, doctors recommend that you do all you can to lose weight and maintain a healthy diet and lifestyle.

Conditions Associated with PCOS

If you have PCOS, you may be at increased risk of developing other health problems later in life. Arming yourself with knowledge about these risks can help you take steps to better look after yourself and reduce the likelihood of developing a more serious condition.

 

Diabetes - More than half of women with PCOS will already have, or are likely to develop, diabetes or prediabetes (glucose intolerance) before the age of 40. Be sure to ask your doctor to refer you for an Oral Glucose Tolerance Test (OGTT) and a blood glucose test at least once a year, and more frequently if you already have pre-diabetes.

 

High Blood Pressure - You have an increased of getting high blood pressure which is a leading cause of heart disease and stroke. Your doctor should keep an eye on your blood pressure levels at your check-ups.

 

Unhealthy Cholesterol - You may have higher levels of LDL (bad) cholesterol and lower levels of HDL (good) cholesterol, which raises your risk for heart disease and stroke. Ask your doctor to refer you for a cholesterol screening test once a year.

 

Sleep Apnea - This is a condition in which your breathing is repeatedly interrupted while you sleep. Sleep Apnea often occurs in women with PCOS and can be a side-effect of excess weight or obesity. Sleep apnea raises the risk of getting heart disease and diabetes. You may suspect you have sleep apnea if you sometimes wake up abruptly with shortness of breath, wake up choking or gasping or if your partner reports that you occasionally stop breathing when you sleep. Please speak to your doctor as soon as possible if you suspect this is true for you.

 

Depression and Anxiety - Depression and anxiety are common among women with PCOS because the symptoms can affect confidence and self-esteem. If you are feeling low or depressed, make an appointment to discuss this with your primary care provider or visit the K App and, if you need it, ask for a referral to a qualified therapist who can help you work through your feelings.

 

Endometrial Cancer / Endometrial hyperplasia - Problems with ovulation, obesity, insulin resistance, and diabetes increase the risk of developing cancer in the lining of the uterus or womb (also called the endometrium). If you have not had any periods for several years, or have fewer than 3 or 4 per year, you may have a higher than average risk of developing endometrial cancer. Try not to be alarmed as the chances are still very small and can be further minimized by using the contraceptive pill or an intrauterine system (IUS) to regulate your periods.

When to Seek Medical Care for PCOS

If you have concerns about irregular menstrual periods, the signs of excess androgen (worsening hirsutism, acne, male-pattern baldness, darkened patches or skin-tags), you should speak to your doctor who can advise you about appropriate treatments for your symptoms. You should also seek medical attention if you have been having unprotected sex for 1 or more years and are having difficulty getting pregnant (despite not having another underlying cause for infertility). Your doctor can advise on medications that induce ovulation and raise your chances of getting pregnant.

 

You should also see a doctor if you are worried about associated health problems such as high cholesterol or blood pressure, pre-diabetes or diabetes - particularly if you are overweight or have significant abdominal obesity.

How K Health Can Help

Of course, if you are suffering from PCOS symptoms and want to know how to manage your condition, you can use the free K Health app to check your symptoms and chat with a doctor on my team for advice or a prescription.

PCOS Treatments

There is no one cure for PCOS, but your doctor can advise you about some of the available treatments that can decrease or eliminate your symptoms. You can read about these here:

 

Irregular Periods - If you are not trying to get pregnant, hormonal birth control pills are likely to be the first treatment your doctor will offer you. Birth control pills lower androgen levels, help regulate periods, and thus protect the endometrium (inner lining of the uterus) against abnormal cell growth.

 

Infertility - Lack of ovulation (monthly release of an egg from the ovary) is the predominant cause for infertility in PCOS women. Several medications are available to restore ovulation in PCOS women. Oral clomiphene citrate stimulates FSH secretion from a woman’s own pituitary gland to induce ovarian follicle growth. Injections of gonadotropins with FSH and LH can also have this effect. Another medication is metformin - an insulin sensitizer that lowers insulin and androgen levels thus gradually inducing ovulation. Medications that block estrogen production to stimulate FSH secretion (letrozole) may also be helpful.

 

Hirsutism and Hair Loss - Hirsutism can be treated with an oral contraceptive or another medication like spironolactone, which blocks the actions of androgen on hair follicles. A topical cream (eflornithine hydrochloride) can be applied to treat facial hirsutism. As medical therapy only inhibits hair growth without eliminating hair already present, mechanical methods of hair removal, such as electrolysis or laser hair removal might be needed. For hair loss, your doctor can advise androgen suppression combined with antiandrogen therapy and topical means of stimulating hair regrowth.

 

Acne - Acne can be treated with oral contraceptives, topical creams and ointments or antibiotic medications.

 

Diabetes and cardiovascular disease - If you have diabetes or pre-diabetes, your doctor will advise you about lifestyle management including weight loss, diet and exercise. He may also prescribe an insulin-sensitizing medication such as metformin. If you have high triglycerides and cholesterol, your doctor may prescribe oral statins or other medications.

 

Quality of life - There is growing evidence that mood disturbances such as severe depression are common in PCOS women who may suffer body-image concerns related to weight and excess hair, and poor sleep due to conditions such as sleep apnea. If you are struggling in these areas, your primary health care provider can advise you on where to get appropriate help.

PCOS Weight Loss

There are many factors that contribute to weight gain and difficulty losing weight in PCOS sufferers, and one important factor is insulin resistance. This is a condition where the cells in your muscles, body fat and liver resist or ignore the signals sent out by the hormone insulin. When functioning optimally, insulin regulates blood glucose levels by taking glucose out of the bloodstream and putting it into the cells where it can be used for energy. When this mechanism breaks down (as it does where insulin resistance is present) the body tries to fight the rising levels of blood glucose by producing even more insulin. These processes may contribute to the patient putting on weight and make losing weight so difficult. It is also why some people think that managing insulin resistance is often the key to successful weight loss in PCOS sufferers.

 

The following PCOS diet suggestions have proven effective in helping women with PCOS both resolve insulin resistance and regulate their weight:

 

Avoid Refined Carbohydrates - Because women with PCOS have insulin resistance, it is important to lower your overall intake of carbohydrates to better manage blood glucose and insulin levels. Try to eliminate refined sugar from your diet and look out for sugar’s various names – sucrose, high fructose corn syrup, dextrose – on food labels. Sugar also lurks in many drinks, such as soda and juice, so try to limit these as well. Highly-processed foods made with white flour, such as: white bread, muffins, breakfast pastries, sugary desserts, should also be avoided.

 

Choose high quality carbohydrates - Making quality choices when eating carbs will lessen the glucose load. Eating whole grains instead of refined carbohydrates boosts dietary fiber and will allow you to achieve better glucose regulation. Brown rice, whole grain pasta, quinoa, or multigrain bread are better choices than their “white” counterparts. However, even when choosing these foods, its sensible to exercise caution as they are still very high in carbs. Try to fill no more than a quarter of your plate with whole grains and fill the rest with lean protein and plenty of vegetables.

 

Eat more vegetables and pulses (e.g beans, lentils and other legumes) - Be sure to add lots of high-fiber cruciferous vegetables – such as broccoli, cauliflower, and brussels sprouts – into your diet. Vegetables and pulses are extremely high in fiber and high-fiber foods can help combat insulin resistance by slowing down digestion and reducing the impact of sugar on the blood. Substitute beans and lentils for pasta and rice.

 

Eat lean protein - Lean protein sources like tofu, chicken, and fish don’t provide fiber but are very filling and a healthy dietary option for women with PCOS.

 

Meal-timing - Nutritionists recommend that women with PCOS spread their food intake throughout the day and avoid eating very large meals at night.

 

Portion control - You can use a smaller size plate to help guide you towards a sensible portion size. Fill your plate with a mixture of wholegrains, vegetables and lean proteins and do not go back for second helpings.

 

The 80/20 approach - Starting a new diet can be intimidating, however if you follow an 80/20 approach you are more likely to succeed. This approach specifies that you stick to the plan about 80% of the time and feel free to go “off-track” for the remaining 20% which will reduce stress and allows for a splurge on a special occasion.

What You Can Do at Home

PCOS, like many disorders, responds positively to proactive lifestyle choices. Aside from taking steps to improve your diet there are a few other things you can do to help manage your condition.

 

Physical activity - The importance of physical activity cannot be underestimated because in addition to promoting weight loss, exercise helps the body to lower circulating glucose and improve insulin resistance. Going to the gym or a yoga class a few times a week can be enormously beneficial, as can simply increasing your daily physical movement by walking to the bus stop or taking the stairs instead of the elevator. Experts agree that at least 150 minutes per week of exercise is ideal.

 

Self-Care - Making time for things you enjoy will lift your spirits and make it easier to stick to a healthy eating plan or exercise regime. Factor some enjoyable or relaxing activities into your weekly schedule – a walk in nature, coffee with friends – and you will feel better and more able to cope with the stresses of life.

 

Reduce stress - Feelings of stress are common amongst PCOS sufferers. Many have reported significant benefits from learning stress reduction techniques to calm the mind. A relaxing yoga or meditation class will guide you in the best techniques. Speaking with a therapist or other medical professional may also help if you are struggling to cope or are feeling low.

PCOS and Pregnancy (Can I get pregnant if I have PCOS?)

It can be difficult to become pregnant if you have PCOS, as the hormonal imbalance interferes with ovulation. However do not be discouraged as fortunately, there are several things you can do to raise your chances of getting pregnant:

 

Ovulation-tracking - Knowing when you ovulate and are therefore most fertile, can help you plan towards getting pregnant. You can purchase an at-home, over-the-counter ovulation prediction kit which detects the surge in luteinizing hormone (LH) that occurs before ovulation.  Your doctor can also check prolactin or progresterone levels to determine when you are ovulating.

 

Lose weight - If you are overweight or obese, you can boost your chances of getting pregnant by losing weight through healthy eating and regular physical activity. Losing excess weight often helps to regulate the menstrual cycle and improves fertility.

 

Medications - Once your doctor has determined that there is no other cause for infertility in either yourself or your partner, he might prescribe a medicine, such as clomiphene (Clomid), to help you ovulate.

 

In vitro fertilization (IVF) - In cases where medical and lifestyle interventions have not proved effective, your doctor might suggest IVF. This is when your egg is fertilized with your partner's sperm in a laboratory and then implanted into your uterus to grow and develop. Contrary to what you may have heard, IVF actually has a higher success rate for pregnancy than some other medical interventions.

 

Surgery -  In women with PCOS, the outer shell (the cortex) of the ovaries is thickened and this is thought to play a role in preventing spontaneous ovulation. Your doctor can discuss the possibility of undergoing an ovarian drilling operation, during which a few tiny holes are made in the surface of the ovary using lasers or a fine needle heated with electricity. This surgery usually restores ovulation.

Medications for PCOS

There are several medications your doctor can prescribe to help ease the symptoms of PCOS. Metformin and the anti-androgen drug, Spironolactone, are some of the most commonly prescribed drugs. You can read more about them here:

 

 

Metformin for PCOS

 

Sold under the brand names Glucophage, Glucophage XR, Glumetza, and Fortamet, Metformin is actually one of the most commonly prescribed medications in the management of PCOS and is also used for the management of diabetes. Metformin works as an insulin-sensitizer, increasing the sensitivity of cells in the body to insulin and thus moving glucose from the blood and into cells (and thus lowering blood glucose levels). Metformin also suppresses the liver's production of glucose and decreases your intestine’s absorption of glucose from food. With all of these functions, metformin slows down worsening insulin resistance and reduces your risk for diabetes. The average dose of metformin for women with PCOS is 1,500 mg to 2,000 mg daily. Metformin can also enhance ovulation, regulate menstrual cycles, lower cholesterol, and improve symptoms like acne and excess hair growth. Accompanied by a healthy diet and exercise regime, metformin may also assist with weight loss. Taking metformin while pregnant may reduce the risk of gestational diabetes and should be discussed with your physician.

 

Side Effects - When you first start taking Metformin, you may experience gastro-intestinal symptoms like nausea, gas, bloating, abdominal discomfort and diarrhea. Some people find the extended-release version of metformin to be gentler on the digestive system. Eating sugary and processed foods can worsen the digestive side effects of metformin and should be avoided. Metformin should be taken with food to minimize side effects. Slowly increasing the dose over several weeks is recommended for best results. Long-term use and high doses of metformin increase the likelihood of a vitamin B12 deficiency, so supplement your diet with vitamin B12 and have your levels checked annually. Drinking alcohol while on metformin is not recommended

 

 

Spironolactone for PCOS

 

PCOS symptoms like facial and body hair and acne are a result of high levels of male hormones called androgens. Spironolactone (sold under the brand name Aldactone) is a potent antagonist (blocker) of androgen receptors and can significantly lessens hair growth and improves acne by blocking the effect testosterone. It works especially well with women who are also taking oral contraceptive pills. It can take up to 6 months to see an improvement in symptoms.

 

Side Effects - You may experience minor side effects like headaches, nausea, vomiting, diarrhea and dizziness while taking spironolactone. More serious complications like stomach bleeding, bloody or tar black-colored stools, coughing up blood, weak pulse, slurred speech, or confusion are also possible. If you experience any alarming symptoms after beginning a course of Spironolactone, stop taking the drug and get in touch with your doctor immediately.  Doctors will usually prescribe a dosage of 50 – 200 mg per day, either once or divided into two doses per day. Lower dosages of the drug cause milder side effects however higher dosages are more effective in reducing hirsutism and acne.

 

Consult with your doctor about the safety of spironolactone if you have a liver or heart disease or an electrolyte imbalance. You should not be taking this medication if you are pregnant, plan to become pregnant or if you are breastfeeding a child. Spironolactone can interact moderately with NSAIDs so please consult with your doctor as to proper usage.

 

Do you think you might have PCOS?

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"PCOS affects around 10 million women worldwide."

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by

Dr. Edo Paz

Edo Paz is VP Medical and Lead Physician at K Health. Dr. Paz has two degrees in chemistry from Harvard and an MD from Columbia University. He did his medical training in internal medicine and cardiology at New York-Presbyterian. In addition to his work at K Health, Dr. Paz is a cardiologist at Heartbeat Health, a cardiology practice located in New York City.

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