PCOS (Poly Cystic Ovary Syndrome) is a health condition that impacts five million women of reproductive age in the United States — often cited as “one in ten women “— yet, due to the personal nature of its symptoms, a confusing name, and lack of research by medical professionals, it is rarely discussed and is often misunderstood.

PCOS causes a whole host of embarrassing and upsetting symptoms including, but not limited to, irregular menstrual cycles, anovulation, depression, anxiety, excess facial hair, bad acne, sweating, weight gain (especially around the stomach), high risk for a host of diseases, and infertility.

Its name is actually a misnomer — PCOS is not about women having many cysts on their ovaries. It is actually a Metabolic syndrome. And it has nothing to do with ovarian cysts.

So why is it called “Poly Cystic Ovary Syndrome?” Due to rarely ovulating, women with PCOS have a large number of follicles on their ovaries which fail to mature each month. The normal ovary each month has 6 to 12 follicles. Women with PCOS often have more than 12 follicles, yet do not produce the proper hormones to grow one each month into an egg. Even healthy women have cycles where they have excess follicles on their ovaries — normal women “have polycystic ovaries 25 percent of the time” (not to be confused with having PCOS.)

So what is PCOS about? Doctors are still figuring that out. What is known is that it is a Metabolic Syndrome which causes excess androgens and wrecks havoc on a woman’s body.

Diagnosing PCOS is challenging because it appears as a collection of seemingly unrelated symptoms. At the age of 15, when I spoke with a doctor about very irregular cycles, PCOS was not even mentioned. I was not asked about other symptoms which could have helped diagnose this disorder. Instead, I was told, at 15, to “go on birth control [to force bleeding, not ovulation, each month] and just have kids before I turn 30.” (Who wants to hear THAT at 15?)

Had I not found an ad for a Northwestern Study on Craigslist for women with “irregular periods,” I may not have learned of PCOS until many years later when, like many other women, I sought help for infertility and would discover PCOS is the cause. Luckily, at the age of 20, I participated in the study and found out. I was told that it was very hard to get accepted into the study since it was based on free testosterone levels, and even if I did not get accepted I may still have PCOS. I was accepted to the study and suddenly I had answers. I also had many more questions, and no one to ask.

How is PCOS Diagnosed and What is It?

There are three different ways doctors diagnose PCOS. The most common method is the “Rotterdam” method, which requires 2 of the following 3 conditions be met: oligovulation or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound. For teenage girls, it’s quite normal to have irregular periods. Many of the obvious symptoms of hyperandrogenism, such as excess acne, may be a normal part of follicles. And, as I noted previously, many healthy women have cycles with more than the normal amount of follicles on their ovaries.

The two other diagnosis methods are the National Institute of Health method and the Androgen Excess Society. The NIH method requires the woman to have chronic anovulation and clinical/or biochemical signs of hyperandrogenism, and leaves off the “polycystic ovaries” from the diagnosis completely. All three methods agree that “hyperandrogism” is a key criteria for diagnosis.

Excess androgens explain most, if not all of the symptoms women with PCOS have. This causes women to make too much testosterone. In healthy women, the ovaries and adrenal glands produce about 40% to 50% of the body’s testosterone. In women with PCOS, this is higher. These high testosterone levels are associated with obesity, hypertension, amenorrhea (stop of menstrual cycles), and ovulatory dysfunction, which can lead to infertility (I’ll explain more on how, below.)

Hyperandrogenism also causes women to have a high tolerance to insulin, which can lead to type two diabetes. This is extremely important in understanding PCOS. Increasing evidence suggests that hyperinsulinemia plays an important role in the pathogenesis of PCOS.

In other words, there is a clear connection between insulin resistance and PCOS. Theories have proposed that hyperinsulinemia causes hyperandrogenism, that hyperandrogenism causes hyperinsulinemia, or that some unknown third defect is responsible for both phenomena. Not all women with PCOS, especially young women, will test positive for insulin resistance. However, women with PCOS are likely to have insulin sensitivity. It’s important to note that not all women with insulin resistance are hyperandrogenic.

Today, it is thought that PCOS “causes” hyperandrogenism and insulin resistance. Some studies have looked at genetic and generational cases of PCOS, as well as insulin resistance in families. The studies found that PCOS “may involve abnormalities in a single transduction, although it may not involve genetic abnormalities of the insulin receptor.” Women with PCOS have no insulin receptor mutations, according to the study, but have been found to have defects in insulin receptor phosphorylation.

Insulin is a hormone released by pancreatic beta cells in response to elevated levels of nutrients in the blood. When you think of the word “insulin,” you probably think “Diabetes.” Insulin triggers the uptake of glucose, fatty acids and amino acids into liver, adipose tissue and muscle, and promotes the storage of these nutrients in the form of glycogen, lipids and protein respectively. Failure to uptake and store nutrients results in diabetes. Type II diabetes occurs when the body becomes resistant to the effects of insulin, “presumably because of defects in the insulin signaling pathway.” Problems with insulin signaling “can impair the proper management of glucose levels in the blood.”

An insulin receptor is a transmembrane receptor that is activated by insulin. It plays a key role in the regulation of glucose homeostasis, a functional process that under degenerate conditions may result in a range of clinical manifestations including diabetes and cancer. Women with PCOS are insulin resistant “secondary to a post-binding defect in insulin signaling.” Steady-state insulin levels are fine, but insulin-mediated glucose disposal was significantly decreased in women with PCOS.

This is where the clinical literature gets a bit too clinical for me to personally understand (yet), but, the important basic thing to know is that PCOS is indeed a Metabolic disorder, and there are clear connections between insulin resistance an excess androgens, though it is unclear if one causes the other. This all will make more sense in a minute as I review how PCOS causes infertility…

Why does PCOS cause Infertility?

We’ve already gone into a bit of detail regarding the relationship between PCOS and insulin resistance, as well as how women with PCOS have excess androgens. In order to understand why PCOS is a leading cause of infertility in women, we must first briefly review the basics of how a healthy female cycle works.

A healthy woman’s menstrual cycle is split in two phases — the follicular phase and the luteal phase. You can think of this as the first part of the cycle when the woman is getting ready to ovulate, and then the part of the cycle after ovulation has occurred, until menstruation begins, when a new cycle also begins.

Women are born with all the eggs they will have in their lifetime, an as they get older these egg follicles decrease (also known as their “ovarian reserve.” Assuming a healthy ovarian reserve, in any given healthy cycle, a woman will begin to grow a follicle or multiple follicles, and within days one follicle will become dominant and will be “selected” to be released in ovulation (twins can happen if two eggs are released and both fertilized, though this is obviously rare.)

At the beginning of the cycle, in the growth phase, the brain sends signals (due to serum estradiol rising) to the ovaries to grow the follicle(s). These signals are sent due to rising concentrations of gondotrophins, follicle stimulating hormone (FSH) and luteinizing hormone (LH.) LH and FSH are secreted by the pituitary gland in the brain.

By day 7, a dominant follicle is “selected” and continues to mature until about day 14, when the follicle ruptures and release an egg to the fluid surrounding the ovary. LH surges right before ovulation and triggers the rupture. In order to implant, should the egg become fertilized, the woman needs to produce enough progesterone and estrogen.

While the cycle length of healthy women varies, it is usually 28 to 35 days. In the case of a 28-day cycle, a woman would likely ovulate on the 14th day, and be fertile a few days before that up to 24 hours post ovulation. (Side note — for woman trying to avoid conceiving, it’s impossible to know if every cycle will be regular, thus one can ovulate early or late and cannot use this logic as a successful contraception method.)

For women without PCOS, at the beginning of the cycle most women have about equal parts of LH and FSH. Women with PCOS tend to have an LH level of two-to-three times that of their FSH level, which is enough to disrupt ovulation. For a more clinical explanation of this, with illustrations, click here.

Women with PCOS do not have enough FSH on a regular basis to stimulate growth of the follicles, thus they do not release an egg (ovulate), or if they do ovulate it is very irregular and unpredictable based on a variety of factors in the body that are largely unknown.

The first course of treatment for women trying to get pregnant who cannot after a year of trying is to put them on one of two drugs — Clomiphene (Clomid) or Letrozole (Femera.) Both drugs work different ways, but focus on increasing the FSH signals so the follicles grow.

Clomiphene is a selective estrogen receptor modulator (SERM). It acts as an estrogen antagonist in the pituitary, preventing negative feedback effect of estrogen and allowing FSH secretion to increase so that follicle development can be stimulated.

Letrozole (and anastrozole) is an aromatase inhibitor, which is actually approved for the treatment of breast cancer in post-menopausal women. While these drugs are not approved for ovulation stimulation, they are often used off-label and have been found to be an effective treatment. In the case of women with PCOS, Letrozole has been proven to be more effective than Clomiphene (and also causes less side effects in general.) These drugs also prevent negative feedback of estrogen, but they do it by preventing estrogen formation instead of “antagonizing the estrogen receptor.”

Both of these drugs stimulate egg growth (if they work in the particular individual) but they do not actually help in the release of the egg (ovulation.) That takes another drug which requires an injection — although some women may naturally ovulate after having help stimulating the growth of the follicle.

Some women with PCOS do not produce enough Progesterone to help a fertilized egg “stick,” and women with PCOS are much, much more likely to have a miscarriage than the average woman. PCOS has been found in 40% to 80%(!) of women with recurrent miscarriages. Of 134 women in one study on miscarriages, 12 had miscarriages in the first trimester and 10 of those 12 had PCOS. Some studies show the rate of miscarriage in women with PCOS is as high as 50 percent, as compared to the national average of 15 percent.

This can be very frustrating for women who invest in IVF (In-Vitro Fertilization) and/or spend many years trying to get pregnant, only to lose the child early in the pregnancy. Insulin resistance strikes again here, as when the body raises blood sugar, it also raises estrogen and testosterone levels, while lowering progesterone levels, which can cause implementation failure or a miscarriage.

The good news for women with PCOS who are trying to conceive — as long as all the other variables are functional (ovarian reserve/quality is good, your tubes are functional and not blocked, and your man’s/partner’s/donor’s health is good) — it is possible to get pregnant. It’s not guaranteed by any means, but women with PCOS do get and stay pregnant successfully with the right mix of medications, timing, and luck.

The use of Metformin in Treating PCOS and Infertility

Women with PCOS are often also prescribed Metformin (Glucophage), which is a well-known diabetes treatment drug. It is proven that increasing insulin sensitivity in women with PCOS helps to improve ovarian function, as does weight loss. It is not considered a fertility drug as it does not increase FSH nor does it “trigger” ovulation — but in some cases it, along with weight loss, can help women restore a healthy, regular cycle. Since high insulin levels cause an increased production of androgens in the ovaries and adrenal glands, using Metformin to resolve this then reduces the production of androgens which can return the pituitary hormones “back to normal.”

In a sense, one can view PCOS as a disorder caused by insulin sensitivity which generates excess androgens which then messes with the pituitary hormones so a woman does not ovulate. Fertility medications focus on treating the pituitary hormones, whereas Metformin treats the insulin resistance. Taking Metformin takes a long time to get the body into a healthy state, and if a woman is over a healthy BMI or is eating in ways that her body does not “like” (i.e. crash diets), Metformin may not “work” in stimulating follicle growth and ovulation. Thus, reproductive endocrinologists, tasked with “getting a woman pregnant,” focus on fixing what makes a woman get pregnant — increasing FSH and providing a substitute for a lacking LH surge. Some will also prescribe Metformin, but in order to have quick results it is less likely that they will recommend this course of action unless the woman is severely overweight and/or is insulin resistant and pre-diabetic.

While Metformin is considered to be a good drug (in fact, it’s being called a “wonder drug” for numerous conditions and prevention), it doesn’t fixPolycystic Ovary Syndrome any more than it fixes Diabetes. Women with PCOS often see excellent results when they go on a diet recommended for diabetes focused on small portions of “good” carbs (complex carbs and veggies), high protein and healthy fats. While it’s impossible to cure PCOS, if, through diet and exercise, one can get their insulin levels under control over a sustained period of time, it’s possible to restore ovulation. In lieu of a perfect diet and workout schedule, Metformin helps when one eats something sugary or forgets to exercise for a week.

Are All Women with PCOS Overweight? Won’t Losing Weight “Solve” PCOS?

Although obesity is common in women with PCOS, some women have PCOS and are “lean.” Insulin resistance can occur in thin woman. Obesity is common with insulin resistance because one’s blood sugar levels are all over the place, leading to severe hunger and sugar cravings, and it’s a vicious cycle. This is why many women with PCOS opt for keto or low-carb diets, since their sugar addictions are real and “everything in moderation” is a significant challenge.

Thin women with PCOS still struggle with insulin-glucose regulation, even though this is not classified strictly as “insulin resistance.” Thin women with PCOS have higher insulin levels in their blood than thin or normal weight women without PCOS. The ovaries of women with PCOS tend to be over-sensitive to the effects of insulin.

Although lean women with PCOS do not need to lose weight, it is important to look at the diet and remove processed sugars and simple carbs, and to focus on eating healthy, balanced meals.

Overweight (slightly overweight or obese) women with PCOS should lose weight to a healthy range to increase fertility and reduce risk factors for many serious diseases, but it’s important to note that weight loss alone, especially in unhealthy ways or too fast, or yo-yo dieting, will not lead to a restored cycle. And even if one eats extremely healthy and exercises regularly, it may be impossible to increase insulin sensitivity enough without the help of medication, for some women.

Women with PCOS are more likely to have diabetes, heart disease, and stroke because PCOS is linked to having high blood pressure, pre-diabetes, and high cholesterol. The risk of heart attack is FOUR TO SEVEN times higher in a woman with PCOS.

PCOS is a serious syndrome which is often misunderstood and not studied nearly enough. Many women do not even know they have this disorder until they try to get pregnant, and few are educated on how their bodies work outside of what is required to understand to conceive.

An August article from US News and World Report asks bluntly, “Why is PCOS Ignored?”

This sad and scary statistic highlights the need for PCOS education and awareness, not only of the general public, but amongst doctors:

“A recent international survey of over 1,300 women with PCOS showed that 50 percent of women saw three or more health professionals or waited for more than two years before receiving a PCOS diagnosis.”

This is one of the reasons why I’m “coming out of the closet,” so to speak, about having PCOS. It’s certainly not an everyday topic of conversation to discuss irregular periods, my lovely (i.e. painful) trips to the laser hair removal technician to ensure that I don’t have a five o’clock shadow, and infertility challenges, but it’s important that women with PCOS share their stores and educate others on this syndrome. Too many woman have no idea what is going on with their bodies, why they’re gaining weight so quickly, why they’re moods are all over the place, why they suffer depression and anxiety, and how everything can be tied to their blood sugar.

And with that, I’ll conclude with this quote from the US News & World Report article:

“Since its discovery in 1935, doctors still don’t know what exactly causes PCOS or the best ways to manage or prevent it. Unfortunately, advancements in understanding and managing PCOS have been limited, as the National Institutes of Health has instituted budget cuts. Currently, PCOS receives less than .01 percent of funding from the NIH. Without sufficient government funding, researchers won’t have the resources to study PCOS and provide advancements in care.”

PCOS (Poly Cystic Ovary Syndrome) is a health condition that impacts five million women of reproductive age in the United States — often cited as “one in ten women “— yet, due to the personal nature of its symptoms, a confusing name, and lack of research by medical professionals, it is rarely discussed and is often misunderstood.

PCOS causes a whole host of embarrassing and upsetting symptoms including, but not limited to, irregular menstrual cycles, anovulation, depression, anxiety, excess facial hair, bad acne, sweating, weight gain (especially around the stomach), high risk for a host of diseases, and infertility.

Its name is actually a misnomer — PCOS is not about women having many cysts on their ovaries. It is actually a Metabolic syndrome. And it has nothing to do with ovarian cysts.

So why is it called “Poly Cystic Ovary Syndrome?” Due to rarely ovulating, women with PCOS have a large number of follicles on their ovaries which fail to mature each month. The normal ovary each month has 6 to 12 follicles. Women with PCOS often have more than 12 follicles, yet do not produce the proper hormones to grow one each month into an egg. Even healthy women have cycles where they have excess follicles on their ovaries — normal women “have polycystic ovaries 25 percent of the time” (not to be confused with having PCOS.)

So what is PCOS about? Doctors are still figuring that out. What is known is that it is a Metabolic Syndrome which causes excess androgens and wrecks havoc on a woman’s body.

Diagnosing PCOS is challenging because it appears as a collection of seemingly unrelated symptoms. At the age of 15, when I spoke with a doctor about very irregular cycles, PCOS was not even mentioned. I was not asked about other symptoms which could have helped diagnose this disorder. Instead, I was told, at 15, to “go on birth control [to force bleeding, not ovulation, each month] and just have kids before I turn 30.” (Who wants to hear THAT at 15?)

Had I not found an ad for a Northwestern Study on Craigslist for women with “irregular periods,” I may not have learned of PCOS until many years later when, like many other women, I sought help for infertility and would discover PCOS is the cause. Luckily, at the age of 20, I participated in the study and found out. I was told that it was very hard to get accepted into the study since it was based on free testosterone levels, and even if I did not get accepted I may still have PCOS. I was accepted to the study and suddenly I had answers. I also had many more questions, and no one to ask.

How is PCOS Diagnosed and What is It?

There are three different ways doctors diagnose PCOS. The most common method is the “Rotterdam” method, which requires 2 of the following 3 conditions be met: oligovulation or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound. For teenage girls, it’s quite normal to have irregular periods. Many of the obvious symptoms of hyperandrogenism, such as excess acne, may be a normal part of follicles. And, as I noted previously, many healthy women have cycles with more than the normal amount of follicles on their ovaries.

The two other diagnosis methods are the National Institute of Health method and the Androgen Excess Society. The NIH method requires the woman to have chronic anovulation and clinical/or biochemical signs of hyperandrogenism, and leaves off the “polycystic ovaries” from the diagnosis completely. All three methods agree that “hyperandrogism” is a key criteria for diagnosis.

Excess androgens explain most, if not all of the symptoms women with PCOS have. This causes women to make too much testosterone. In healthy women, the ovaries and adrenal glands produce about 40% to 50% of the body’s testosterone. In women with PCOS, this is higher. These high testosterone levels are associated with obesity, hypertension, amenorrhea (stop of menstrual cycles), and ovulatory dysfunction, which can lead to infertility (I’ll explain more on how, below.)

Hyperandrogenism also causes women to have a high tolerance to insulin, which can lead to type two diabetes. This is extremely important in understanding PCOS. Increasing evidence suggests that hyperinsulinemia plays an important role in the pathogenesis of PCOS.

In other words, there is a clear connection between insulin resistance and PCOS. Theories have proposed that hyperinsulinemia causes hyperandrogenism, that hyperandrogenism causes hyperinsulinemia, or that some unknown third defect is responsible for both phenomena. Not all women with PCOS, especially young women, will test positive for insulin resistance. However, women with PCOS are likely to have insulin sensitivity. It’s important to note that not all women with insulin resistance are hyperandrogenic.

Today, it is thought that PCOS “causes” hyperandrogenism and insulin resistance. Some studies have looked at genetic and generational cases of PCOS, as well as insulin resistance in families. The studies found that PCOS “may involve abnormalities in a single transduction, although it may not involve genetic abnormalities of the insulin receptor.” Women with PCOS have no insulin receptor mutations, according to the study, but have been found to have defects in insulin receptor phosphorylation.

Insulin is a hormone released by pancreatic beta cells in response to elevated levels of nutrients in the blood. When you think of the word “insulin,” you probably think “Diabetes.” Insulin triggers the uptake of glucose, fatty acids and amino acids into liver, adipose tissue and muscle, and promotes the storage of these nutrients in the form of glycogen, lipids and protein respectively. Failure to uptake and store nutrients results in diabetes. Type II diabetes occurs when the body becomes resistant to the effects of insulin, “presumably because of defects in the insulin signaling pathway.” Problems with insulin signaling “can impair the proper management of glucose levels in the blood.”

An insulin receptor is a transmembrane receptor that is activated by insulin. It plays a key role in the regulation of glucose homeostasis, a functional process that under degenerate conditions may result in a range of clinical manifestations including diabetes and cancer. Women with PCOS are insulin resistant “secondary to a post-binding defect in insulin signaling.” Steady-state insulin levels are fine, but insulin-mediated glucose disposal was significantly decreased in women with PCOS.

This is where the clinical literature gets a bit too clinical for me to personally understand (yet), but, the important basic thing to know is that PCOS is indeed a Metabolic disorder, and there are clear connections between insulin resistance an excess androgens, though it is unclear if one causes the other. This all will make more sense in a minute as I review how PCOS causes infertility…

Why does PCOS cause Infertility?

We’ve already gone into a bit of detail regarding the relationship between PCOS and insulin resistance, as well as how women with PCOS have excess androgens. In order to understand why PCOS is a leading cause of infertility in women, we must first briefly review the basics of how a healthy female cycle works.

A healthy woman’s menstrual cycle is split in two phases — the follicular phase and the luteal phase. You can think of this as the first part of the cycle when the woman is getting ready to ovulate, and then the part of the cycle after ovulation has occurred, until menstruation begins, when a new cycle also begins.

Women are born with all the eggs they will have in their lifetime, an as they get older these egg follicles decrease (also known as their “ovarian reserve.” Assuming a healthy ovarian reserve, in any given healthy cycle, a woman will begin to grow a follicle or multiple follicles, and within days one follicle will become dominant and will be “selected” to be released in ovulation (twins can happen if two eggs are released and both fertilized, though this is obviously rare.)

At the beginning of the cycle, in the growth phase, the brain sends signals (due to serum estradiol rising) to the ovaries to grow the follicle(s). These signals are sent due to rising concentrations of gondotrophins, follicle stimulating hormone (FSH) and luteinizing hormone (LH.) LH and FSH are secreted by the pituitary gland in the brain.

By day 7, a dominant follicle is “selected” and continues to mature until about day 14, when the follicle ruptures and release an egg to the fluid surrounding the ovary. LH surges right before ovulation and triggers the rupture. In order to implant, should the egg become fertilized, the woman needs to produce enough progesterone and estrogen.

While the cycle length of healthy women varies, it is usually 28 to 35 days. In the case of a 28-day cycle, a woman would likely ovulate on the 14th day, and be fertile a few days before that up to 24 hours post ovulation. (Side note — for woman trying to avoid conceiving, it’s impossible to know if every cycle will be regular, thus one can ovulate early or late and cannot use this logic as a successful contraception method.)

For women without PCOS, at the beginning of the cycle most women have about equal parts of LH and FSH. Women with PCOS tend to have an LH level of two-to-three times that of their FSH level, which is enough to disrupt ovulation. For a more clinical explanation of this, with illustrations, click here.

Women with PCOS do not have enough FSH on a regular basis to stimulate growth of the follicles, thus they do not release an egg (ovulate), or if they do ovulate it is very irregular and unpredictable based on a variety of factors in the body that are largely unknown.

The first course of treatment for women trying to get pregnant who cannot after a year of trying is to put them on one of two drugs — Clomiphene (Clomid) or Letrozole (Femera.) Both drugs work different ways, but focus on increasing the FSH signals so the follicles grow.

Clomiphene is a selective estrogen receptor modulator (SERM). It acts as an estrogen antagonist in the pituitary, preventing negative feedback effect of estrogen and allowing FSH secretion to increase so that follicle development can be stimulated.

Letrozole (and anastrozole) is an aromatase inhibitor, which is actually approved for the treatment of breast cancer in post-menopausal women. While these drugs are not approved for ovulation stimulation, they are often used off-label and have been found to be an effective treatment. In the case of women with PCOS, Letrozole has been proven to be more effective than Clomiphene (and also causes less side effects in general.) These drugs also prevent negative feedback of estrogen, but they do it by preventing estrogen formation instead of “antagonizing the estrogen receptor.”

Both of these drugs stimulate egg growth (if they work in the particular individual) but they do not actually help in the release of the egg (ovulation.) That takes another drug which requires an injection — although some women may naturally ovulate after having help stimulating the growth of the follicle.

Some women with PCOS do not produce enough Progesterone to help a fertilized egg “stick,” and women with PCOS are much, much more likely to have a miscarriage than the average woman. PCOS has been found in 40% to 80%(!) of women with recurrent miscarriages. Of 134 women in one study on miscarriages, 12 had miscarriages in the first trimester and 10 of those 12 had PCOS. Some studies show the rate of miscarriage in women with PCOS is as high as 50 percent, as compared to the national average of 15 percent.

This can be very frustrating for women who invest in IVF (In-Vitro Fertilization) and/or spend many years trying to get pregnant, only to lose the child early in the pregnancy. Insulin resistance strikes again here, as when the body raises blood sugar, it also raises estrogen and testosterone levels, while lowering progesterone levels, which can cause implementation failure or a miscarriage.

The good news for women with PCOS who are trying to conceive — as long as all the other variables are functional (ovarian reserve/quality is good, your tubes are functional and not blocked, and your man’s/partner’s/donor’s health is good) — it is possible to get pregnant. It’s not guaranteed by any means, but women with PCOS do get and stay pregnant successfully with the right mix of medications, timing, and luck.

The use of Metformin in Treating PCOS and Infertility

Women with PCOS are often also prescribed Metformin (Glucophage), which is a well-known diabetes treatment drug. It is proven that increasing insulin sensitivity in women with PCOS helps to improve ovarian function, as does weight loss. It is not considered a fertility drug as it does not increase FSH nor does it “trigger” ovulation — but in some cases it, along with weight loss, can help women restore a healthy, regular cycle. Since high insulin levels cause an increased production of androgens in the ovaries and adrenal glands, using Metformin to resolve this then reduces the production of androgens which can return the pituitary hormones “back to normal.”

In a sense, one can view PCOS as a disorder caused by insulin sensitivity which generates excess androgens which then messes with the pituitary hormones so a woman does not ovulate. Fertility medications focus on treating the pituitary hormones, whereas Metformin treats the insulin resistance. Taking Metformin takes a long time to get the body into a healthy state, and if a woman is over a healthy BMI or is eating in ways that her body does not “like” (i.e. crash diets), Metformin may not “work” in stimulating follicle growth and ovulation. Thus, reproductive endocrinologists, tasked with “getting a woman pregnant,” focus on fixing what makes a woman get pregnant — increasing FSH and providing a substitute for a lacking LH surge. Some will also prescribe Metformin, but in order to have quick results it is less likely that they will recommend this course of action unless the woman is severely overweight and/or is insulin resistant and pre-diabetic.

While Metformin is considered to be a good drug (in fact, it’s being called a “wonder drug” for numerous conditions and prevention), it doesn’t fixPolycystic Ovary Syndrome any more than it fixes Diabetes. Women with PCOS often see excellent results when they go on a diet recommended for diabetes focused on small portions of “good” carbs (complex carbs and veggies), high protein and healthy fats. While it’s impossible to cure PCOS, if, through diet and exercise, one can get their insulin levels under control over a sustained period of time, it’s possible to restore ovulation. In lieu of a perfect diet and workout schedule, Metformin helps when one eats something sugary or forgets to exercise for a week.

Are All Women with PCOS Overweight? Won’t Losing Weight “Solve” PCOS?

Although obesity is common in women with PCOS, some women have PCOS and are “lean.” Insulin resistance can occur in thin woman. Obesity is common with insulin resistance because one’s blood sugar levels are all over the place, leading to severe hunger and sugar cravings, and it’s a vicious cycle. This is why many women with PCOS opt for keto or low-carb diets, since their sugar addictions are real and “everything in moderation” is a significant challenge.

Thin women with PCOS still struggle with insulin-glucose regulation, even though this is not classified strictly as “insulin resistance.” Thin women with PCOS have higher insulin levels in their blood than thin or normal weight women without PCOS. The ovaries of women with PCOS tend to be over-sensitive to the effects of insulin.

Although lean women with PCOS do not need to lose weight, it is important to look at the diet and remove processed sugars and simple carbs, and to focus on eating healthy, balanced meals.

Overweight (slightly overweight or obese) women with PCOS should lose weight to a healthy range to increase fertility and reduce risk factors for many serious diseases, but it’s important to note that weight loss alone, especially in unhealthy ways or too fast, or yo-yo dieting, will not lead to a restored cycle. And even if one eats extremely healthy and exercises regularly, it may be impossible to increase insulin sensitivity enough without the help of medication, for some women.

Women with PCOS are more likely to have diabetes, heart disease, and stroke because PCOS is linked to having high blood pressure, pre-diabetes, and high cholesterol. The risk of heart attack is FOUR TO SEVEN times higher in a woman with PCOS.

PCOS is a serious syndrome which is often misunderstood and not studied nearly enough. Many women do not even know they have this disorder until they try to get pregnant, and few are educated on how their bodies work outside of what is required to understand to conceive.

An August article from US News and World Report asks bluntly, “Why is PCOS Ignored?”

This sad and scary statistic highlights the need for PCOS education and awareness, not only of the general public, but amongst doctors:

“A recent international survey of over 1,300 women with PCOS showed that 50 percent of women saw three or more health professionals or waited for more than two years before receiving a PCOS diagnosis.”

This is one of the reasons why I’m “coming out of the closet,” so to speak, about having PCOS. It’s certainly not an everyday topic of conversation to discuss irregular periods, my lovely (i.e. painful) trips to the laser hair removal technician to ensure that I don’t have a five o’clock shadow, and infertility challenges, but it’s important that women with PCOS share their stores and educate others on this syndrome. Too many woman have no idea what is going on with their bodies, why they’re gaining weight so quickly, why they’re moods are all over the place, why they suffer depression and anxiety, and how everything can be tied to their blood sugar.

And with that, I’ll conclude with this quote from the US News & World Report article:

“Since its discovery in 1935, doctors still don’t know what exactly causes PCOS or the best ways to manage or prevent it. Unfortunately, advancements in understanding and managing PCOS have been limited, as the National Institutes of Health has instituted budget cuts. Currently, PCOS receives less than .01 percent of funding from the NIH. Without sufficient government funding, researchers won’t have the resources to study PCOS and provide advancements in care.”

“Since its discovery in 1935, doctors still don’t know what exactly causes PCOS or the best ways to manage or prevent it. Unfortunately, advancements in understanding and managing PCOS have been limited, as the National Institutes of Health has instituted budget cuts. Currently, PCOS receives less than .01 percent of funding from the NIH. Without sufficient government funding, researchers won’t have the resources to study PCOS and provide advancements in care.”