Understanding PCOS (polycyctic ovarian syndrome)
You’ve been told you have PCOS & been put on the pill ? to “regulate” your period (which is code for let’s shut off your ovaries until you want to get pregnant & deal with it then). Unfortunately this is a common case & it makes it hard as a practitioner to help until someone is ready to come off the pill.
I’m writing this blog because I want you to be well equipped with the knowledge you need when you do come off the pill. The most common thing I hear from woman with PCOS is that they’ve been told they may not be able to have children & this really upsets me because it’s just not the case. So let’s give you some knowledge so you can advocate for yourself.
Let’s start with what PCOS is & then go into where to start to confirm a diagnosis.
When it comes to PCOS there seems to be little concrete consensus on what constitutes PCOS. Essentially it is an umbrella term like IBS to box a group of signs & symptoms which for different individuals may have varying driving forces behind it.
Currently there are two common diagnostic frameworks for a PCOS diagnosis. They are the Rotterdam & the AE PCOS criteria of which the latter seems to make more sense clinically, & the way Lara Briden, a leader in this field also views it.
The main difference between the frameworks is that AE Pcos criteria is defined by the presence of an excess of androgens whereas Rotterdam sees this as one category which may or may not be present. The AE Pcos criteria also places little importance on the presence of polycyclic ovaries itself, as one in four women tested will have poly cystic ovaries without having the syndrome. Therefore while I have listed it as a category, & pelvic ultrasound as a diagnostic tool, keep in mind this is not a defining factor, it merely gives us more information to work with when treating.
PCOS DIAGNOSIS CATEGORIES:
Clinical (symptoms of) & biochemical (showing on a blood test) androgenism – which means elevated Testosterone & DHEA Anovulation (not ovulating) or oligo anovulation (irregular ovulation) Poly cystic ovaries- this means more than 25 on each ovary
Now before I move on to blood tests etc, I think it’s important to point out that there are different types of PCOS, all fuelled from a different driving force & thus treatment needs to address the root cause of the individual.
TYPES OF PCOS:
Insulin PCOS – this is the most common form of PCOS, where insulin resistance leads to elevated testosterone.
Post pill PCOS – yes, unfortunately it’s a real thing & we see it a lot in clinic. There can be a few factors driving this. The first is androgen rebound, where you’re ovaries start over producing testosterone after coming off the pill. This is because your brain & ovaries are trying to adjust to working again for the first time since starting the pill. The second is insulin resistance from the pill. Yep, the contraceptive pill causes insulin resistance (shaking head). This type of PCOS is often temporary however it can take 12 months for the hormones to self regulate which if you’re trying to conceive can feel way too long. So what often happens is patient are scared into thinking they can’t have children without medication & put on metformin & clomid. Or, if they’re lucky, will find natural means of regulating their cycle (I hear Acupuncture & Chinese herbs can be great ; ).
Inflammatory PCOS – this is where the underlying cause is from inflammation in the body
Adrenal PCOS – where there is adrenal dysfunction driving it.
So now that we know what we’re dealing with, where do we begin?
Well, before we do anything, when you’re ready to come off the birth control pill I typically suggest waiting at least six weeks to let the synthetic hormones leave your system before doing any blood tests, as we may not get a true reading.
When you’re period comes back (or around six weeks if it hasn’t) I suggest a day 3 blood hormone panel (this means testing E2, FSH, LH, testosterone, SHBG & DHEA on day 3 of your period) to see if your hormone levels point to the syndrome. There are a few things we’re looking at here. One of them is the ratio of FSH to LH, which in someone without PCOS should be 1 to 1.
Let’s look at this closer. FSH or Follicle stimulating hormone, is the hormone which tells your ovaries how hard to work. It stimulates the little follicles to grow, until one becomes bigger than the others & tells them to back off & stop growing because it’s his turn to mature into the one that will be ovulated. So the less responsive you ovaries are, the higher the FSH level needed to stimulate your follicles to grow.
LH is Luetenizing hormone which signals the dominant follicle to release the egg, & well, ovulate. When the level of LH in relation to FSH is significantly higher, this can be a good indication of PCOS. This tells us that more LH is needed to try & stimulate the release of the follicle. It’s having to work overtime.
The other two sex hormones we look at & the most important in confirming a diagnosis of PCOS is Testosterone & DHEA which are androgens. Both are often elevated in PCOS but especially testosterone. DHEA is a precursor for Testosterone so excess DHEA can spill over to testosterone, which is why when testosterone is high you may often find DHEA to be too.
Then there is the matter of insulin resistance. In Lara Briden’s book “The Period Repair Manual” she explains how “too much insulin can impair ovulation & stimulate your ovaries to make more Testosterone, which is why insulin resistance is such a driver of PCOS.” A very large portion of women with PCOS have insulin resistance but not all, so it’s important to do the testing to differentiate. Everyone with suspected PCOS should have a fasting insulin & a glucose tolerance test with insulin.
Other blood tests to consider are inflammatory markers such as CRP & ESR as well as basic FBE (full blood examination) thyroid panel & iron panel. Let’s use iron deficiency as an example. If you don’t have enough iron, your body is going to prioritise it’s basic functions over ovulation. Sometimes it’s as simple as that!
Other than bloods I would also look into a pelvic ultrasound to establish whether you do in fact have poly cystic ovaries. As I mentioned earlier however, take this information with a grain of salt.
In addition to a pelvic ultrasound & bloods, body basel temperature ? (bbt) charting gives us a clearer view of how your body’s working. It can tell us if you’re ovulating, when you’re ovulating, if your temperature is rising high enough & holding long enough for pregnancy to occur.
So now that you’re armed with some knowledge, I’m hoping you will have the confidence to advocate for yourself & ask for the various blood tests etc you need to get to your root cause. If you need help navigating changes in your condition that’s what we are here for. Whether it’s helping you to ovulate so you can fall pregnant & have a baby, or you just want to regulate your hormones so you’re not getting androgen dominant hair growth, Chinese medicine really excels at getting to that underlying cause.
Pic by Duvet_days