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Polycystic ovary syndrome: PCOS is more than a reproductive condition

Polycystic ovary syndrome, or PCOS, is the most common hormonal condition in women of reproductive age, affecting between five and 10 per cent of women.

PCOS is the most frequent cause of irregular periods, and one of the condition’s defining features – as the name suggests – is multiple cysts on the ovaries. However, PCOS is more than a reproductive condition. It’s a metabolic condition that is linked to health issues such as insulin resistance, diabetes and sleep apnea.

“Insulin resistance is what underlies PCOS,” says endocrinologist Dr. Sheila Laredo, chief of staff at Women’s College Hospital. “Women with PCOS have a four to five times increased risk of developing diabetes. They have an increased risk of high blood pressure, abnormal cholesterol, fatty liver, sleep apnea, and probably increased risk of cardiovascular disease. Not all women have evidence of insulin resistance with PCOS, but most do.”

Diagnosing PCOS

To be diagnosed with PCOS, a woman must have at least two of the three key symptoms. In addition, other possible causes that can mimic PCOS must be ruled out. The three key symptoms of PCOS are:

  1. abnormal periods: either absent periods (three to six months with no period), or irregular periods (periods that start more than 35 days apart on average)
  2. evidence of high male hormones: this can be either elevated male hormone levels on tests, or physical symptoms of high male hormones such as acne, loss of hair on the scalp, or male-pattern hair growth on the body or face
  3. polycystic ovaries seen on ultrasound

While absent periods can be caused by many factors, irregular periods are very often the result of PCOS.

“When you have irregular periods, it turns out that probably 85 to 90 per cent of those women are going to have PCOS,” Dr. Laredo says. “So it’s a very easy single question to ask, and for that reason it’s very useful for many different healthcare providers.”

It’s also important to note that the cysts that define PCOS are actually egg follicles – not cysts.

“In PCOS what we say is polycystic ovaries is just little undeveloped follicles, and by definition they’re under a centimeter. They look like cysts on the ultrasound but they’re just follicles,” Dr. Laredo explains, adding that a woman can have large cysts on her ovaries that have nothing to do with PCOS.

“You can have large ovarian cysts, and if you have more than one of them, people think they have polycystic ovaries. But it’s not the same thing.”

Risk for PCOS is higher in women with a family history of the condition. Women who have a first-degree relative (a sister, mother or daughter) with PCOS have a 35 to 40 per cent chance of developing the condition, Dr. Laredo says.

“We typically see that there’s also a family history of insulin resistance,” she explains. “Because the insulin resistance doesn’t always come down the maternal side. It can come down the paternal side. So what you’ll see in Dad is maybe a history of diabetes or high blood pressure or cholesterol.”

PCOS and fertility

PCOS can affect fertility, and women who have the condition may take longer to get pregnant than other women. For that reason, Dr. Laredo talks to her PCOS patients about family planning as early as possible so they can make informed decisions about timing pregnancy. Declining fertility after age 35, in addition to the extra time it may take a woman with PCOS to conceive, may make it increasingly difficult to get pregnant as they get older.

However, it’s also crucial for women with PCOS to be aware that they can become pregnant.

Although some women with PCOS may struggle to conceive, others have the reverse problem: undiagnosed pregnancies. Because some women with PCOS believe they can’t get pregnant, they may not use appropriate birth control. Then if they do get pregnant, they don’t realize it: their irregular cycles mean they aren’t surprised if they don’t get a period for three or four months. They don’t know they are pregnant, and don’t get appropriate prenatal care. 

“That’s a really important message: PCOS doesn’t mean you can’t get pregnant,” Dr. Laredo says.

PCOS is also linked with pregnancy complications.

“Women with PCOS have a higher risk of gestational diabetes, which means developing diabetes during pregnancy,” Dr. Laredo says. “That creates risk for bigger babies, and also indicates higher risk for future Type 2 diabetes in the mother. They are also at increased risk for pregnancy-induced hypertension, which can lead to preeclampsia and eclampsia.”


Treatments for PCOS may address specific symptoms. Because it is a life-long condition, the needs and priorities of women with PCOS change over time.

“There’s no one-size-fits-all treatment,” Dr. Laredo says. “Some women are trying to get pregnant, so we try to give them more regular periods. Some women have major concerns about acne or facial hair that they find really distressing, so we treat that by reducing male hormones. Some women are just trying to prevent diabetes and prevent health complications down the road.”

Treatment can also be important to protect uterine health.

“Having no periods over long periods of time in PCOS can increase the risk of endometrial abnormalities and endometrial cancer,” Dr. Laredo explains. “So for some women we’re just trying to give them cycle control to promote uterine health.”

Sleep apnea is also more common in women with PCOS: studies have found their risk of sleep apnea to be as high as one in six.

“That’s about 30 times higher than the general population,” Dr. Laredo says. Treating sleep apnea can have a profound effect on well-being.

“If you’re not exhausted all the time, it has a big downstream effect,” she explains. “Now you’re actually interested in doing that program at the gym. Now you’re interested in going for walks with your kids. You have the energy to actually cook a healthy meal rather than do takeout.”

Metabolic issues

PCOS treatment often means addressing the underlying metabolic condition. It’s important for women with PCOS to be screened for diabetes more aggressively than the rest of the population.

“In women under 45 with PCOS, the risk of having either prediabetes or diabetes is almost 40 per cent,” Dr. Laredo says.

Women with PCOS have the same options for managing metabolic issues as other patients.

“The best treatment we have for insulin resistance continues to be lifestyle: diet and exercise,” Dr. Laredo says. “Some of the drugs that we use in PCOS and in diabetes and insulin sensitivity are still not as good as lifestyle in terms of the outcome. So we always talk about lifestyle.”

Lifestyle changes may sound challenging for the many women with PCOS who struggle with weight issues. But Dr. Laredo stresses that the goals for treatment are achievable: losing five to 10 per cent of body weight.

“Five to 10 per cent weight loss in women with PCOS is often enough to improve regularity of periods,” she says, adding that diabetes research has shown that losing a similar amount of weight can help prevent diabetes in those prone to it.

“Medically, we’re not looking for the amount of weight loss that women think they need to be successful. Women think they need to lose 30, 50 or even 100 pounds. We’re looking for five to 10 per cent, so in a woman who weighs 200 or 250 pounds, we’re talking about 10, 12, 15 pounds. If you can do it and sustain it, it can have a big impact.”

PCOS after menopause

Unlike some other gynecological conditions, PCOS does not end with menopause.

“After menopause, women sometimes lose track of the fact that they have PCOS because they’re not dealing with periods,” Dr. Laredo says. “They forget about the other things they need to deal with including things related to insulin resistance.”

Women with PCOS continue to have a higher risk of diabetes after menopause. It’s recommended that they continue to be screened more regularly than standard guidelines suggest.

“They should think of themselves as higher risk, and their physicians should think of them as higher risk,” Dr. Laredo says.

Although the metabolic issues underlying PCOS affect women’s health risks through their whole lives, those risks – and the symptoms of PCOS – are manageable.

“The predisposition to PCOS is always there, but for most women we can find a way of managing the different issues at different times,” Dr. Laredo says. “You can’t cure the underlying disposition but you can address a lot of the symptoms very, very well.”


This information is provided by Women’s College Hospital and is not intended to replace the medical advice of your doctor or healthcare provider. Please consult your healthcare provider for advice about a specific medical condition. This document was last reviewed on: Dec. 4, 2014

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