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Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder in young women. Yes, young women, because as women age, their egg reserve decreases, and over time, the number of follicles in the ovaries tends to reduce, even for those who had a very strong reserve. This is a multifaceted condition that also requires mandatory correction of hormonal balance. The prevalence of pregnancy difficulties in women with PCOS is 70-80%.
How is the PCOS diagnosis established?
First, let’s clarify what Polycystic Ovary Syndrome is. Not every woman with a good egg reserve has PCOS. It’s not enough to visualize the multi-follicular structure of the ovaries (an increased number of follicles) on an ultrasound to confirm the diagnosis of PCOS. Often, women come to us with a diagnosis of PCOS, although in reality, they just have a good egg reserve, which is something that makes us, as reproductive specialists, happy.
To diagnose PCOS, we must confirm 2 out of 3 criteria:
- Hyperandrogenism (clinical or biochemical) – increased levels of male sex hormones in a female’s body.
- Menstrual cycle disorders, anovulation (a condition where ovulation does not occur) or oligoovulation (ovulation occurs rarely).
- Ultrasound visualization of more than 12-15 follicles in one ovarian slice, or the ovarian volume exceeds 10 cm³.
Why doesn’t pregnancy occur with PCOS?
The immediate question is, why doesn’t pregnancy occur if there are many follicles and not few? PCOS is a complex hormonal condition: increased insulin levels, decreased sensitivity of cells to it (insulin resistance), elevated androgen (male sex hormone) levels, which leads to ovulation blockage and reduced oocyte quality.
The most common manifestations of PCOS are:
- Absence of follicular maturation – anovulation.
- Hyperandrogenism (elevated testosterone levels). This testosterone suppresses sensitivity to female sex hormones, particularly progesterone.
- Hyperprolactinemia (increased prolactin levels in the blood, often observed with elevated testosterone). High prolactin levels, in turn, suppress ovulation.
- Increased LH (luteinizing hormone) levels. An elevated LH to FSH (follicle-stimulating hormone) ratio blocks ovulation at the pituitary level – the endocrine system regulation center.
- Hypothyroidism (decreased thyroid function). When the thyroid is impaired, it cannot regulate sex hormone activity and often secondary increases prolactin levels.
- Insulin resistance (excess insulin stimulates weight gain and further inhibits ovulation).
- Endometrial hypoplasia (thin endometrium) due to the imbalance of female sex hormones, primarily the lack of cyclic dominant follicle growth.
- PCOS can also lead to endometrial hyperplasia, often seen in women with increased aromatase activity, which converts excess testosterone into estrogen, putting extra stress on the endocrine system with both male and female hormones and promoting excessive endometrial growth.
How does excess testosterone affect reproductive function in PCOS?
One of the main problems in PCOS is elevated testosterone levels. This male hormone is produced by the ovaries, leading to ovulation disturbances and reduced egg quality. High testosterone levels cause:
- Anovulation: testosterone interferes with the normal maturation of follicles, blocking ovulation. It also affects the thickening of the ovarian capsule and makes the rupture of the dominant follicle more difficult, even during ovulation stimulation.
- Hirsutism (excessive hair growth): increased testosterone levels cause unwanted hair growth on the face and body, and active hair loss on the head may also occur.
- Skin problems: acne and oily skin on the face and scalp are common companions of elevated testosterone levels.
- Often, hyperandrogenism leads to the formation of a male body shape, with excessive fat accumulation around the waist.
- Chronic increased androgen levels in women lead to cholesterol buildup in the blood and an increased risk of high blood pressure during hormonal changes (during pregnancy or later in life).
How to normalize testosterone levels in a woman’s body?
- Medication: antiandrogenic drugs can help reduce testosterone levels, normalize skin condition, and restore the cycle.
- Lifestyle changes: regular physical exercises (without excessive strength training) can reduce testosterone levels and improve hormonal balance.
- Proper sleep. Disturbed sleep patterns (especially falling asleep after 11:00 PM or during night shifts) increase cortisol levels, a stress hormone from the adrenal glands, which further stimulates insulin resistance and raises ovarian androgen levels.
Insulin’s impact on PCOS
Insulin resistance is one of the main causes of hormonal imbalance in PCOS. High insulin levels (hyperinsulinemia) stimulate the ovaries to produce excessive testosterone, which in turn leads to anovulation. It is important to know that excess testosterone also causes insulin resistance, forming a vicious cycle.
Insulin resistance often causes weight gain starting from adolescence, with changes in eating behavior (constant cravings for sweets and carbs). Prolonged insulin resistance may lead to gestational diabetes (high blood sugar levels during pregnancy due to the body’s increased demand and hormonal changes).
How to improve insulin sensitivity?
- Exercise: regular aerobic exercises significantly improve cell sensitivity to insulin. Brisk walking increases insulin sensitivity and normalizes insulin levels in the body.
- Medications: insulin sensitizers, especially for those with excess weight, can help normalize insulin levels and improve sensitivity. Adding chromium, berberine, and alpha-lipoic acid can also help increase insulin sensitivity and improve metabolism.
- Intermittent eating (three meals a day without snacks) and
- Weight loss: for overweight women, reducing body weight by 5-10% can significantly improve insulin sensitivity.
The importance of nutrition in PCOS
Balanced nutrition is crucial for improving hormonal balance and insulin resistance in PCOS.
Main nutrition principles:
- Limit simple carbohydrates: reducing sugar and refined carbs helps lower insulin levels and improve sensitivity.
- More fiber: vegetables, greens, and whole grains stabilize blood sugar levels.
- Healthy fats: omega-3 fatty acids found in fish, flax seeds, chia seeds, black cumin oil, and avocado reduce inflammation and normalize hormonal balance.
- Low glycemic index: foods with a low glycemic index, such as vegetables, cereals, legumes, and unsweetened berries, help control blood sugar and reduce insulin resistance.
- Meal intervals (three meals a day with no snacks and a 14-hour gap between dinner and breakfast significantly improves insulin sensitivity and normalizes blood insulin levels).
It is important to avoid products that have an androgenic effect—raise testosterone levels or increase cellular sensitivity to them. Products that may have an androgenic effect include:
- Foods high in sugar and simple carbohydrates (sweets and pastries: cakes, candies, chocolates, cookies, tarts, high-sugar beverages: sodas, energy drinks, juices with added sugar).
Why: consuming large amounts of sugar increases insulin levels in the blood, which can elevate androgen levels, especially testosterone.
- Foods rich in saturated fats
- Red meats: beef, pork, lamb.
- Fatty dairy products: full-fat milk, cream, butter, fatty cheeses, sour cream.
- Processed meats: sausages, hot dogs, smoked meats.
Why: high levels of saturated fats can increase testosterone levels in the blood, overload the liver, and reduce its ability to eliminate excess androgens.
- Alcohol
- Especially beer and beverages with high hops content (e.g., dark beer).
Why: alcohol, particularly beer, contains phytohormones (plant-derived compounds that may increase prolactin and testosterone levels). Interestingly, beer lowers testosterone levels in men by increasing prolactin levels.
- Foods rich in trans fats
- Fast food: chips, fries, hamburgers.
- Processed foods: muffins, crackers, fatty creams, mayonnaise-based sauces, ice cream, baked goods containing trans fats.
Why: trans fats can cause inflammation in the body and disrupt hormonal balance, contributing to elevated testosterone levels.
- Caffeine (large doses) and black tea
- Energy drinks, coffee in large amounts.
Why: excessive caffeine consumption can increase cortisol levels, which in turn can raise testosterone levels and worsen hormonal balance.
Dietary and lifestyle corrections have a positive impact on hormone levels and can significantly improve PCOS symptoms and overall health.
The main challenges faced by reproductive specialists when working with women with PCOS who are planning a pregnancy:
- The possibility of many leading follicles growing at once: this may cause superovulation of several follicles, increasing the risk of multiple pregnancies and removal from stimulation programs.
- Thin endometrium: hormonal imbalance often leads to insufficient endometrial thickness, making embryo implantation difficult.
The main goal of treatment in PCOS is to induce ovulation with the growth of 1-2 leading follicles and to support endometrial growth for a successful singleton pregnancy.
Is IVF used for women with polycystic ovaries?
Yes. There are certain indications for IVF in PCOS patients:
- Fallopian tube obstruction
- Decreased sperm parameters that are insufficient for natural conception with ovulation induction
- Progressing endometriosis
- Failed previous ovulation induction attempts
- More than 3 leading follicles repeatedly growing
Additionally, if a couple plans to have several children in the future, it is very reasonable to undergo an IVF or deferred motherhood program. A good egg reserve is great, but as age increases, egg quality decreases. So, if you plan to have children later in life, IVF could be considered as a strategic step.
By assessing the situation comprehensively and explaining all possible options, we can help you choose the right strategy for achieving pregnancy, giving birth to a healthy child, and planning future children!
