September was the PCOS (Polycystic Ovarian Syndrome) awareness month, so I’d like to wave goodbye to September by shedding some further light on the syndrome and sharing with our readers some information that might help ladies reach an early diagnosis as well as some skin related management tips for this difficult multisystem disease. It’s a grim fact that worldwide PCOS affects 6% to 10% of women, making it the most common endocrinopathy in women of childbearing age. Early diagnosis and establishing a good management plan are key to managing cosmetic issues and preventing long term health consequences, as there is no cure for PCOS.
PCOS At A Glance
Common symptoms of PCOS include irregular or no menstrual periods, acne, obesity/weight gain/inability to lose weight, breathing problems while sleeping, depression, oily skin/acne, infertility, skin discolorations, high cholesterol levels, elevated blood pressure, excessive/abnormal hair growth and distribution, pain in the lower abdomen and pelvis, multiple ovarian cysts, and skin tags. Some women have only a few symptoms, while others have several.
How Do You Know If You Have PCOS?
You can be diagnosed with PCOS if you have at least 2 of the following 3 criteria
- Irregular or absent periods,
- Blood tests or physical signs that show high androgens,
- Polycystic ovaries.
Health Risks With PCOS
Women with PCOS have greater chances of developing several serious health conditions, including life-threatening diseases. Recent studies found that:
- More than 50 percent of women with PCOS will have diabetes or pre-diabetes (impaired glucose tolerance) before the age of 40.
- The risk of heart attack is 4 to 7 times higher in women with PCOS than women of the same age without PCOS.
- Women with PCOS are at greater risk of having high blood pressure.
- Women with PCOS have high levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol.
- Women with PCOS can develop sleep apnea. This is when breathing stops for short periods of time during sleep.
- Women with PCOS may also develop anxiety and depression. It is important to talk to your doctor about treatment for these mental health conditions.
- Women with PCOS are also at risk for endometrial cancer. Irregular menstrual periods and the lack of ovulation cause women to produce the hormone estrogen, but not the hormone progesterone. Progesterone causes the endometrium (lining of the womb) to shed each month as a menstrual period. Without progesterone, the endometrium becomes thick, which can cause heavy or irregular bleeding. Over time, this can lead to endometrial hyperplasia, when the lining grows too much, and cancer.
Skin & PCOS
Being a dermatologist I’d like to focus on the skin-related symptoms of PCOS, which include oily skin, adult acne, increased/abnormal hair growth, skin tags, and dark velvety skin patches on neck known as acanthosis nigricans.
Acne and oily skin:
One of the earliest signs of PCOS is acne and oily skin which are primarily the result of hormonal disorders caused by androgens (male hormones). PCOS-related acne tends to flare in areas that are usually considered “hormonally sensitive,” especially the lower third of the face. This includes your cheeks, jawline, chin, and upper neck. Ladies with PCOS tend to get acne that involves more tender knots under the skin, rather than fine surface bumps, and these acne lesions tend to flare before the menstrual period. This type of cystic acne doesn’t resolve quickly and takes time to go away.
Unwanted Hair Growth:
Unwanted hair growth is also triggered by an excess of male hormones leading to excessive growth of facial hair, as well as hair on the abdomen and around the nipples. The same hormones are also responsible for hair loss on scalp, which is why ladies suffering with PCOS struggle with thinning hair on scalp and increased hair on face and body at the same time. Shaving, waxing, depilatories, and tweezing are all options, but each has its limitations and each demands ongoing efforts. Vaniqa cream has shown promising results to reduce facial hair growth. Laser hair reduction is another good long-term option.
Medications called anti-androgens may reduce hair growth and clear acne. Spironolactone (Aldactone), first used to treat high blood pressure, has been shown to reduce the impact of male hormones on hair growth in women. Finasteride (Propecia), a medicine taken by men for hair loss, has the same effect. Anti-androgens are often combined with birth control pills. These medications should not be taken if you are trying to become pregnant.
Metformin (Glucophage) reduces insulin levels, and this change, in turn, reduces the ovarian testosterone levels by competitive inhibition of the ovarian insulin receptors. This drug is effective in treating increased hair in women with PCOS.
The type of hair loss women with PCOS experience is directly related to the excess production of male hormones caused by the disorder. Referred to as male-pattern baldness, it can be successfully treated with over-the-counter medications containing Minoxidil or Saw Palmetto.
The brown skin discolorations that occur with PCOS are unique, and are called “Acanthosis Nigricans”. They appear as darkened, velvety swaths of dark brown patches that most often develop on the nape of neck, armpits, inner thighs, or under the breast areas. Although these discolorations are not related to sun damage, the treatment is the same: daily exfoliation, sunscreen, and use of a topical over-the-counter skin-care product with 2% hydroquinone or other skin lightening agents. For stubborn cases, you may need a prescription-strength skin lightener that contains 4% hydroquinone.
Fleshy skin growths in the armpits and neck regions are commonly spotted in PCOD. Once the hormones are fixed we can surgically remove or cauterize these growths.
Lifestyle modifications are considered first-line treatment for women with PCOS. Such changes include the following:
- Diet – Low-fat, high-carbohydrate diets may increase insulin levels, so you may want to consider a low-carbohydrate diet if you have PCOS. Don’t severely restrict carbohydrates; instead, choose complex carbohydrates, which are high in fiber. The more fiber in a food, the more slowly it’s digested and the more slowly your blood sugar levels rise. High-fiber carbohydrates include whole-grain breads and cereals, whole-wheat pasta, bulgur wheat, barley, brown rice, and beans. Limit less healthy, simple carbohydrates such as soda, excess fruit juice, cake, candy, ice cream, pies, cookies and doughnuts.
- Exercise – Exercise helps lower blood sugar levels. If you have PCOS, increasing your daily activity and participating in a regular exercise program may treat or even prevent insulin resistance and help you keep your weight under control.
- Weight loss – Obesity makes insulin resistance worse. Weight loss can reduce both insulin and androgen levels and may restore ovulation. No single specific dietary approach is best, but losing weight by reducing how many calories you consume each day may help with polycystic ovary syndrome, especially if you’re overweight or obese. Use smaller plates, reduce portion sizes and resist the urge for seconds to help with weight loss. Ask your doctor to recommend a weight-control program, and meet regularly with a dietitian for help in reaching weight-loss goals.
Medications used in the management of PCOS include the following:
- Oral contraceptive agents (eg, ethinyl estradiol, medroxyprogesterone)
- Antiandrogens (eg, spironolactone, leuprolide, finasteride)
- Hypoglycemic agents (eg, metformin, insulin)
- Selective estrogen receptor modulators (eg, clomiphene citrate)
- Topical hair-removal agents (eg, eflornithine)
- Topical acne agents (eg, benzoyl peroxide, tretinoin topical cream (0.02–0.1%)/gel (0.01–0.1%)/solution (0.05%), adapalene topical cream (0.1%)/gel (0.1%, 0.3%)/solution (0.1%), erythromycin topical 2%, clindamycin topical 1%, sodium sulfacetamide topical 10%)
The optimal management for PCOS is a multi-factorial approach involving diet and lifestyle modification along with appropriate medication. If you think that you have any symptoms which point towards PCOS speak to your GP as soon as possible.