Polycystic ovarian syndrome (PCOS) is probably one of the most common disorders affecting women in Singapore. As an endocrinologist, I've seen many women who complain of symptoms suggestive of PCOS, such as:
- Facial hair growth
- Scalp hair loss
- Menstrual irregularities
Many Singaporeans are not aware that their symptoms are due to PCOS, and spend a lot of time and resources on managing these individual symptoms, instead of targeting the underlying cause.
It's common too for women to be given the oral contraceptive pill (OCP) for PCOS, which they end up taking for many years. This tends to help their symptoms to a certain degree, but doesn’t tackle the underlying cause. It may also have serious side effects like thrombosis, particularly in women who are obese.
In this article, I’ll be addressing the common concerns that women with PCOS may have. The beauty of PCOS (as with most things in endocrinology) is that it's a readily treatable condition.
You may not be completely cured of your symptoms, but there's always something to be done that can significantly improve your symptoms and quality of life.
What is PCOS?
Intuitively, when you think of PCOS, you think of polycystic ovaries.
Well, what does that mean?
A normal ovary contains about 5 follicles on average, and is about the size of a walnut.
A polycystic ovary contains 12 (or more) small follicles, and is much larger, about the size of an egg. This just describes the appearance of the ovary.
You don’t need to have polycystic looking ovaries to have PCOS, and conversely, having polycystic ovaries does not mean you have PCOS.
PCOS is a syndrome that involves some form of “hormonal imbalance” which leads to certain signs and symptoms - I'll be explaining more below!
Why do you get PCOS?
There are many theories as to what the underlying cause of PCOS is, including genetic inheritance and environmental influences, but the 3 common theories involve:
- Hormone imbalance (hypothalamic-pituitary dysfunction)
- Insulin resistance
- Excessive male hormone production (ovarian hyperandrogenism)
Basically, the pulse generator in your brain is “switched on” to a mode where it favours production of luteininzing hormone (LH) over follicle stimulating hormone (FSH).
Your ovary then responds to this by making more male hormones, giving rise to symptoms such as acne and unwanted facial hair.
Furthermore, many women with PCOS have insulin resistance, (ie. they require high levels of insulin to keep their blood glucose levels in check). This high level of insulin acts synergistically with LH to enhance male hormone production by the ovary.
PCOS treatment is therefore targeted at:
- Suppressing the excessive LH
- Improving insulin resistance
- Blocking the effects of testosterone
What symptoms do women with PCOS experience?
1. Irregular menstrual cycles
Women with PCOS tend to have irregular menstrual periods, ranging from slightly delayed periods to no periods at all.
Many of my patients notice that this tends to occur at certain points in their lives, which includes:
- Going to university
- Getting married
- Moving out of their parents’ houses and getting new jobs
During these periods, there's often a change in their dietary habits and lifestyle. Weight gain is the common denominator for these patients.
2. Acne, excess facial/body hair and scalp hair loss
Acne on the face and/or back is one of the common issues my patients complain about. In fact, the majority of young women over the age of 20 suffering from acne will have PCOS.
This often results in scarring, and can get patients feeling very down.
Women with PCOS generally have difficulty conceiving because of the infrequency and unpredictability of ovulation.
Ovulation (when the egg is released) generally occurs 14 days before the menstrual period.
If you’re having irregular cycles, you'll not be able to predict when the egg will be released. This makes it tricky to time intercourse.
4. Being overweight/obese
The symptoms of PCOS tend to manifest when the weight goes up. This is likely the result of increased insulin levels, which drives the ovary to make testosterone.
The cause of the weight gain/obesity is not clear, but the consequence of obesity is well established. As women with PCOS gain weight, insulin and testosterone levels rise.
Who should you see in Singapore for PCOS, and what can you expect at the first visit?
To best manage your PCOS in Singapore, consulting with an endocrinologist or gynecologist with a special interest in PCOS would be ideal.
If necessary, he or she will also refer you to the appropriate specialist to help co-manage other specific symptoms.
At your first visit for PCOS, I generally:
- Ask you questions about your menstrual history
- Explore any particular problem you may be facing, such as acne or unwanted facial hair
- Look for metabolic complications like diabetes
- Address fertility concerns
Additionally, I also perform a physical examination. This includes:
- Looking for signs of insulin resistance. This manifests as darkened/black velvety skin at the back of your neck/in the armpits. You may have noticed it, and tried unsuccessfully to scrub it off. This skin condition is called acanthosis nigricans.
- Looking for signs of excess steroid hormone production. This manifests as central obesity, with thin skin and dark livid stretch marks on the abdomen.
- Examining for signs of other conditions that may mimic PCOS, but in fact signify other more concerning medical conditions. Examples would include shrinking of the breasts or an enlarged clitoris, both of which may suggest the presence of a testosterone-producing tumour.
How is PCOS diagnosed in Singapore?
PCOS can be diagnosed based on history and examination alone.
We use the Rotterdam criteria to diagnose PCOS. This requires a person to fulfill 2 out of 3 of the following conditions:
- Symptoms/signs of excess male hormones (acne, unwanted facial hair, scalp hair loss)
- Menstrual irregularities
- Polycystic ovaries seen on ultrasound scan
Laboratory tests are not essential for the diagnosis, but can help to exclude other conditions that may mimic PCOS. They also help to look for associated complications like diabetes.
What tests are done in Singapore for PCOS?
I request for specific blood tests, depending on my clinical findings. These may include:
- Human chorionic gonadotropin (hCG). To find out if you are pregnant.
- Testosterone. At high levels, it blocks ovulation and causes acne, male-type hair growth on the face and body, and hair loss from the scalp. If significantly elevated, warrants searching for a testosterone producing tumour.
- Prolactin. High prolactin levels are another cause of irregular periods.
- Cholesterol and triglycerides. Some women with PCOS may have obesity and the metabolic syndrome.
- Thyroid-stimulating hormone (TSH). Check for an overactive or underactive thyroid, both of which can cause irregular periods.
- Adrenal gland hormones, such as DHEA-S or 17-hydroxyprogesterone. An adrenal problem can cause symptoms similar to PCOS.
Besides these blood tests, I also tend to do an oral glucose tolerance test (OGTT) during the first few visits in all women diagnosed with PCOS, because we sometimes pick up undiagnosed diabetes. It's particularly important to get diabetes under control before conceiving.
Also, if the corresponding insulin level during the OGTT is not high (i.e. no evidence of insulin resistance), I would consider alternative diagnoses.
Lastly, an ultrasound scan may be performed to look at the ovaries, and the thickness of your womb lining.
How is PCOS treated in Singapore?
Treatment depends on whether or not you’re pursuing fertility.
If fertility is not a current concern, priority is given to the symptom that causes the most distress. For all women who are overweight, dietary and lifestyle advise is key.
Sometimes, simply losing weight can improve most of your symptoms. This is easier said than done - most Singaporeans are too busy with work/home commitments to do regular exercise!
Knowing what foods to eat to lose weight is one thing, but finding affordable healthy options is another.
If your BMI is >25, you should lose 5 - 10% of your body weight.
If your BMI is < 25, you should aim to avoid gaining weight.
What medications are used to treat PCOS?
The majority of my patients are unable to lose weight/maintain weight loss. Metformin is a drug that's commonly used in diabetes. It can help with weight loss to a certain degree, and improves insulin resistance.
It has also been shown to improve the regularity of the periods in women with PCOS. This doesn’t occur overnight, and I would recommend taking it for at least 6 - 12 months to see some effect.
In the meantime, if you’re not having at least 6 periods a year, I would give some progesterone tablets. After a course of progesterone, you should have a resultant withdrawal bleed.
My general rule of thumb is to keep some of these tablets in hand, and if you haven’t had a period in 2 months, do take a course of progesterone. This ensures regular shedding of the womb lining, and reduces the risk of womb cancer later on.
If you’re troubled with acne or unwanted facial hair, there are certain medications that you can take to reduce the effects of testosterone.
I use Spironolactone as it effectively blocks the effect of the male hormone. Because of the long life cycle of the hair follicle, any effect on facial hair will take at least a few months to be apparent.
Do note that because it blocks the effect of the male hormone, you must NOT take this medication if you plan to get pregnant!
Hence, I always recommend some form of contraception whilst you’re on this medication. In my experience, if a woman is not obese, Spironolactone together with an OCP is pretty well tolerated, and has good results.
In view of the thrombosis risk associated with OCP use, I avoid it in women with milder symptoms, smokers and those with a BMI of over 30.
This helps to induce ovulation in women with PCOS who desire fertility. With Clomiphene use, studies have shown ovulation rates of 60 – 85%, and pregnancy rates of 30 - 50% after six ovulatory cycles.
How does PCOS affect my fertility?
Fertility is often the biggest thing on my patient’s mind. Many women in their 20s and 30s are not ready to get pregnant yet, but are worried about putting it off for too long in case they have difficulty conceiving later on.
In actual fact, the pregnancy rate in women with PCOS (including PCOS women who have received treatment such as ovulation induction) is excellent, and is similar to that of the general population.
You may require some help along the way, but the outcomes are generally positive.
What can I do to increase my chances of getting pregnant with PCOS?
It's well established that the single most important factor predicting the success of fertility treatment is body weight. All treatments are less successful if you’re overweight.
In the first instance, if a woman is overweight, I would advise her to lose weight - this may be all that's needed to restore fertility!
Many of my patients do find that their periods become more predictable and regular after they’ve lost weight.
The other main issue in PCOS is the infrequency (or absence) of ovulation. However, weight loss, metformin and medications such as Clomid can result in ovulation in the majority of women with PCOS.
I would usually advise my patients to monitor their periods to find out their cycle length, and from there, estimate the date of ovulation. This occurs 14 days before the start of the next period.
Knowing exactly when you ovulate will allow more accurate timing of intercourse. If, despite all treatment options, pregnancy is still not achieved, I would then refer to my gynecology colleagues for consideration of IVF treatment.
I hope these anecdotes have helped you to better your understanding of PCOS. If you’re experiencing any of these symptoms, I would suggest sending an enquiry to a few endocrinologists or gynecologists.
This will allow you to discuss your concerns and find a treatment plan that is most suitable for you.
Dr Marilyn Lee served as Adjunct Assistant Professor in Medicine at Yong Loo Lin School of Medicine (NUS), and is currently a committee member of the Chapter of Endocrinologists (Academy of Medicine Singapore). Dr Lee previously set up the reproductive endocrine service at Khoo Teck Puat Hospital. She deals with all aspects of endocrinology, and has a special interest in reproductive endocrinology. Dr Lee has 2 young daughters, and they enjoy traveling and exploring new places.