Polycystic ovarian syndrome (PCOS) is the most common hormonal issue among women of reproductive age, occurring in about 7% of this population.1 Typical signs and symptoms include irregular menstrual cycles, hirsutism, acne, and infertility. Since 2003, PCOS has been defined by the Rotterdam Criteria as including at least 2 out of 3 of these factors: 1) Oligo- or anovulation (meaning not ovulating regularly resulting in less frequent menses and insufficient progesterone); 2) Hyperandrogenism; and 3) Polycystic ovaries on ultrasound. Being able to recognize this common condition is essential in order to properly treat these women. Here are three facts that are commonly misunderstood about PCOS.
1. Women with a normal or underweight BMI can have it, too!
Elevated BMI is not included in the diagnostic criteria. Insulin resistance is often present in women with PCOS, which can lead to obesity, but obesity can take time to develop and it doesn’t occur in all cases of PCOS. Between 20 and 60% of PCOS-affected women are not overweight or obese.1 Regardless of body shape and size, the connection between androgen hormones and blood sugar dysregulation is one that is often missed. Elevated testosterone and/or DHEA in women can provide a very important early indicator of insulin resistance, even before changes occur on HgA1c or fasting glucose testing.
2. Testosterone and DHEA levels may not be elevated.
A woman can still have hyperandrogenism, or androgen excess, despite normal hormone results. Hyperandrogenism refers to either androgen elevations revealed by testing or having clinical signs such as male-pattern baldness, hirsutism, and acne. The enzyme 5-alpha reductase converts testosterone to its primary metabolite dihydrotestosterone (DHT). Data from a small study suggests that peripheral 5-alpha reductase activity may be enhanced in PCOS.2 This enhanced conversion may explain why testosterone falls within the reference range in some cases of PCOS, but further research is needed. Additionally, it is possible for hair follicles to have excessive sensitivity to androgens so that even within-range levels of androgens can trigger male-pattern hair growth in some women.3
3. Women with PCOS might not have polycystic ovaries.
PCOS is a syndrome, not a specific disease; therefore, there are multiple contributing factors and also multiple presentations. Some women with PCOS have ovarian cysts. This is likely because hormone imbalance may prevent ovulation leading to the development of multiple (12 or more) small cysts in the ovaries referred to as “string of pearls” cysts, or more formally, polycystic ovaries. These cysts are estimated to be present in only 17 to 33% of PCOS cases.4 The anovulation that can cause cysts will also lead to low progesterone levels in the mid-luteal phase. Salivary hormone testing can offer a less invasive and less costly option to ultrasound when evaluating these patients.
When female patients present with menstrual irregularities, male-pattern baldness, acne, hirsutism, or difficulty conceiving, PCOS is a consideration. Finding no cysts via ultrasound or having a thin phenotype does not exclude the diagnosis! Salivary hormone testing as part of a thorough evaluation can provide information on the presence of progesterone insufficiency or androgen excess. Identifying hormone imbalance is a reasonable first step to developing an effective management strategy for these patients.